Choking, or airway obstruction, is the most common breathing emergency. The types of airway obstruction lifeguards will encounter are either mechanical or anatomical. It’s imperative that once the airway is clear, getting oxygen into the victim’s body system is the priority — through resuscitation mask, BVM, or a supplemental oxygen delivery system. Rescuers should act with a sense of urgency and proficiency. This article covers areas that rescuers often skim over during in-service training, including rescuer foot placement and body position while giving care to the victim, dealing with atypical body sizes and conditions, and the transition from a conscious victim to an unconscious one. Drills deal with an airway obstruction that is mechanical, not anatomical.

Rescuers often get caught up in the moment, wanting to assist the victim, and they overlook their own safety, especially when presented with a frantic conscious victim unable to breathe. Rescuers can be injured by a conscious victim who becomes unconscious due to poor ergonomics or unequal center of mass as the victim suddenly becomes limp. If you can’t control a victim's descent without compromising your own safety, let them drop to the ground, then continue to provide care. Remember: An injured rescuer helps no one.

When providing back blows to a conscious victim, the rescuer must be slightly behind their side, placing one foot onto the front and one foot to the victim’s back. One arm supports the victim’s chest while the other administers back blows. The rescuer’s legs need to be bent and spaced at least a hip-width apart, if not wider. The victim’s airway needs be parallel to the ground, if not angled slightly downward.

When providing abdominal thrusts to a conscious victim, the rescuer should place themselves directly behind the victim. If needed, kick the victim’s feet to shoulder width apart. The rescuer then places one foot between the victim’s legs. The rescuer should put their dominant leg behind their body as an anchor point, which also widens the victim’s center of mass and, if the victim goes limp, reduces the chance of the victim and the rescuer falling down. This stance also provides the best chance of lowering an unconscious person to the ground without injury. Again, personal safety is paramount. If the victim looks like they could compromise the rescuer’s safety due to size, weight and girth, call for help to assist if the victim becomes unconscious.

Proper hand position during abdominal thrusts is critical. A common mistake is not utilizing the navel as the landmark for placement of the rescuer’s fist for abdominal thrusts. This step is easy to overlook and results in the rescuer providing ineffective thrusts that connect with the victim’s lower ribs rather than the abdomen.

Along with proper hand placement for abdominal thrusts, if the rescuer is unable to reach around that victim due to the victim’s size or condition (obesity or pregnancy), the rescuer should move their hands into position to provide chest thrusts. Hand placement should be practiced for effective delivery.

Lastly, changes in patient care when transitioning from a conscious to an unconscious victim should be reviewed. Remember, if the victim becomes unconscious while the rescuer is providing care, lower the victim to the ground, and begin providing chest thrusts. Don’t delay in providing care by doing a primary assessment, as this step was already completed when the victim was conscious.

Prequel to Conscious Choking Drill

Lifeguards pair up into two-person teams, (rescuer/victim) on land facing each other. 

Objective: Rescuers will go through the sequence steps prior to providing care for an active choking victim. 

Steps include: • Confirm the victim is choking

• Identify yourself as a trained rescuer

• Get consent to provide care

• Activate the EMS system for additional resources.

The victim should act appropriately as a conscious choking victim.

Timing goal: 8-10 seconds to complete the objective. Each step should be distinct. Switch roles when the rescuer has demonstrated proficiency.

Rescuer Body and Hand Position Drill

Lifeguards pair up into two-person teams, (rescuer/victim) standing on land. 

Objective: The rescuer will move into proper position to provide back blows, abdominal thrusts, or chest thrusts. 

Timing goal: up to 5 seconds to get into position.

Once proficient, move into the variations:

• Rescuer segues smoothly through all the positions (10-15 seconds)

• Rescuer demonstrates correct hand placement for each position (no change).

Choking Complications Drill

Two-person teams (rescuer/victim), and each rescuer will have a fanny pack, gloves and pocket mask. The trainer will cue the rescue teams on the complication that is being presented by the victim. Rescuers need to perform the proper skill sequence depending on the complication.

Objective: Rescuers complete correct skills sequence based on the complication. 

Timing goal: Depends on complication.

Here is the list of complications:

• Conscious victim who becomes unconscious (Rescuer safely brings the victim to the ground — up to 15 seconds.)

• Unconscious victim brought to ground with rescuer continuing care for an obstructed airway (chest compressions, look for an object in the mouth, gives two ventilations. Repeat. Object is found in the mouth on third cycle and airway is cleared — up to two minutes)

• During the unconscious choking sequence, the victim vomits (clear airway, attempt two ventilations, chest rises, remove mask and check for breathing and pulse for no more than 10 seconds. If unsuccessful at making the chest rise during ventilations, then continue unconscious choking cycle — up to 1 minute)

Once proficient, move to variations:

• Victim vomits multiple times within the sequence (add up to 30 seconds per vomit episode)

• During rescue breathing, victim vomits and compromises resuscitation mask, new mask is needed (add up to 30 seconds)

• Unconscious choking victim — once the airway is clear, it is determined that the victim has no pulse. Rescuer(s) need to transition to CPR/AED (1 minute).