TM

Date: November 2009

To: NASCO CLIENTS

From: NASCO

Subject: In Water Intervention (IWI)

Last season, misleading media reports were circulated about NASCO's protocol for in
water intervention (IWI). In today's sensational news market, even the most well-
researched and unbiased reporting can lead to inaccuracies, fabrications or false
information.

For 35 years, the National Aquatic Safety Company (NASCO) has provided a logical and
reasoned basis for the procedures that are trained by our program. It is our hope that the
attached position response document, which is based on data collected over the past ten
years, will help clarify the IWI procedure.

Should you have any questions please do not hesitate to contact us. We thank you for
working so hard to accomplish our mission ofReducing the Loss of Life Due to
Drowning.

©NASCO 2009
National Aquatic Safety Company
1002 Ave. L, Dickinson, Texas 77539
(281) 337-5628 Fax (281) 337-0043
Our Missum: Vo Reduce Fhe l,m,% of Ufa Due to B
 TM

John L. Hunsucker, PhD., PE

President, NASCO
The National Aquatics Safety Company
1002 Ave. L
Dickinson, TX 77539
Phone:(281)337-5628
Fax:(281)337-0043
Email: johnnasco@aol.com

NASCO lifeguards 100 times more effective at safe-guarding human life compared
with national statistics and still lead the aquatics industry in the development of
safety systems and protocols

There were several misleading and prejudicial statements made during the last season by
the media about NASCO and its training program.

Since 1999, NASCO guards have guarded millions of swimmers each year, have
performed many thousands of rescues, but have had only 32 victims who lost respiration.
Of these, 28 survived, 14 revived with just the abdominal thrusts, eight required rescue
breathing after the abdominal thrusts with two to eight breaths given, an additional two
victims required CPR after receiving rescue breaths and abdominal thrusts. Of the four
victims who did not survive, only one had abdominal thrusts administered, but for this
victim, two paramedics on the scene could not obtain an airway after multiple attempts.
The fact that we are quick to identify and reach the victim and very aggressive in our
intervention protocols no doubt accounts for why our safety record is among the best in
the nation.

The Center for Disease Control statistic for drowning in pools is approximately 0.6
per 100,000. A previous survey, which includes all public guarded pools in Texas,
not including NASCO guarded pools, is about 0.7 per 100,000. The NASCO statistic
for fatalities in NASCO pools is 0.006 per 100,000. Roughly, our clients are 100
times more effective at safeguarding human life.

NASCO wants to make its position clear that we support the American Heart Association
(AHA) 2005 guidelines. NASCO protocols follow AHA guidelines for a victim on the
deck. However, it is our opinion that these guidelines are unclear for In Water
Intervention (IWI), particularly in deep water. We are unaware of any AHA testing for
IWI protocols. In fact, IWI may be thought of as a special intervention for drowning and
not part of CPR.

We also strongly support the position, shown by numerous studies, that the quicker
normal respiration can be reestablished in a drowning victim, the better the chance of
recovery for that victim. That is why NASCO supports IWI in the form of abdominal
thrusts. Over the last 10 years, we have seen numerous times when abdominal thrusts as
an IWI caused a spontaneous resumption of respiration under the following special
circumstances:

1. The drowning took place in an enclosed, guarded aquatic facility.

2. The rescue was done by trained lifeguards.
3. The drowning victim was spotted within a minute of drowning, and the lifeguard
made contact with the victim within seconds or very quickly.

To answer the question of why abdominal thrusts are not being used in aquatic facilities,
the following occurrences were contributing factors. The use of abdominal thrusts as an
IWI had just begun when several events caused arguments as to the effectiveness of the
technique. First, Henry Jay Heimlich MD, inventor of the Heimlich Maneuver, was felt by
some authorities to be using questionable data and making claims that were scientifically
debatable about the scientific basis for the use of abdominal thrusts in the case of
drowning. Then, several cases of injuries from the use of abdominal thrusts appeared in
medical literature so concerns were voiced about unnecessary procedures being
potentially harmful. Finally, the AHA was concerned that there was no clinical support
for the effectiveness of abdominal thrusts and that doing them according to Dr.
Heimlich's directions was delaying CPR being initiated. It should be noted that NASCO
protocol differs from Dr. Heimlich's in that he advocates doing thrusts until water no
longer comes out of the victim. We administer only five thrusts that are only done in the
water. After that, we follow AHA guidelines for out of the water CPR.

There is still a lack of clinical data that describes the actual mechanics of drowning. Since
the use of clinical studies on actual victims is limited the most effective means will have
to be observational data collection. Most emergency intervention protocols are developed
through observational methods and sound reasoning. Many of the studies do not factor in
the ability of the lifeguard to perform the intervention. There is a wealth of differing
opinions about what occurs during drowning and what intervention techniques are
effective.

To address the legitimate concerns of the AHA and the medical establishment, yet still
take advantage of the ability of an abdominal thrust to restart respiration, NASCO has
adapted its protocols in the following ways. We have developed our training to make sure
the possibility of delay if CPR is needed is minimized, and the possibility of injury from
the abdominal thrust is minimized. We train our lifeguards to do only five abdominal
thrusts that take four to six seconds in the pool during rescue. The guards also are
required to participate in in-service training each month and complete refresher training
during the season to make sure that their skills are current. As far as the fear of a victim
vomiting during a rescue is concerned, many people receiving artificial respiration or
CPR (approximately 86%) will vomit during those procedures. Our lifeguards are trained
to position the drowning victim to reduce the chance of vomit being aspirated.

One additional consideration must be taken into account in order to do any IWI. At
NASCO, we have shown over years of experience that any IWI has to meet the following
criteria:

1. The procedure has to be one that can be learned and retained.

2. The procedure has to be one where the proper safety equipment is immediately
available or no equipment is needed.
3. The procedure has to be one that a 16 to 17 year old lifeguard can be expected to
perform.
4. The procedure has to be performed immediately upon contacting the victim.
5. The procedure has to be effective.

Unfortunately, experience has shown that many interventions such as mouth-to-mouth,

mouth-to-mask or Bag Valve Mask (BVM) respiration will either not occur in a timely
manner, won't be performed by the guards or requires a guard who is a very strong
swimmer and specially trained.

The time required from the identification of the victim to the rescue, extrication,
obtaining equipment and positioning the victim on the deck can take between two to four
minutes. This amount of time makes early intervention imperative. Our experience has
shown that abdominal thrusts can and will be performed as an IWI under all
circumstances within 15 to 20 seconds of bringing the victims head above water.

NASCO feels that the benefit of performing abdominal thrusts, where results show that at
least half of our drowning victims start breathing on their own and don't need more
extreme interventions such as artificial respiration or CPR, far outweighs the risk of
delaying CPR by four to six seconds or the extremely low percentage of injuries arising
from abdominal thrusts. As with any medical procedure and drowning, we strongly urge
the victim to go to a hospital for a foil examination.

In summary, we at NASCO know that our protocols support our motto, "To Reduce the
Loss of Life Due to Drowning." While any drowning is a tragedy, our protocols have
been proven to be uniquely effective in fulfilling our mission.

The drowning data NASCO has collected has been summarized and submitted for
publication in a peer reviewed journal.
Abstract:

NASCO lifeguards have guarded millions of swimmers and make thousands of

rescues each year. The fact that we are quick to identify and reach the victim and
very aggressive in our intervention protocols no doubt accounts for why our
safety record is among the best in the nation.
Our survival rate is roughly 100 times higher than the national average reported
by CDC for pool drownings.
The NASCO protocol includes only five abdominal thrusts done only in the
water. It takes four to six seconds to perform all the thrusts.
NASCO strongly supports the position, shown by numerous studies, that the
quicker normal respiration can be reestablished in a drowning victim, the better
the chance of recovery for that victim.
NASCO feels that the American Heart Association's (AHA) position on In the
Water Intervention (IWI) is unclear and has not been tested by AHA.
NASCO follows the AHA protocols for CPR when the victim has been extricated.
A typical rescue of a submerged victim can take between two to four minutes
before the victim is positioned on the deck and CPR is started. This makes IWI
critical.
During the last 10 years, NASCO has seen numerous times when abdominal
thrusts as an IWI caused a spontaneous resumption of respiration.
Of the techniques available for IWI, NASCO's experience has shown that
abdominal thrusts are the most effective.
The knowledge that NASCO has obtained by analyzing our data has been
summarized and submitted to a peer reviewed journal.