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I want to first acknowledge those still working on the frontlines. Not just doctors and nurses, but the ancillary staff, housekeepers, delivery persons, grocery store workers, and many other minimum wage workers who face the choice every day of infection or further economic uncertainty and inability to provide for themselves or their families. As of the afternoon of May 15, 2020, there were 4.48 million cases of COVID-19 worldwide and 303,825 deaths. The United States alone accounted for 33% of the cases and 29% of the deaths. As striking as these numbers are, they are likely a vast under-count and are more than a statistic. Every single one of those numbers is a person like you or I, with a life story and a family. Even more heartbreaking is that this illness has preferentially affected at-risk communities and populations. It is not clear if this is due to the pathophysiology of the illness or if it is highlighting the social determinants of health that affect outcome.

These are certainly unprecedented times and the degree of confusion and misinformation is staggering. Most importantly, we are all looking for messages of hope. Those messages of hope mean different things to different people. To some, hope is staying closed, to others, it means opening. As we watch this unfold in real time, I think it is fair to say that everyone is looking for concrete, definitive guidance and reassurance.

I spoke recently to Justin Scarr, CEO of Royal Lifesaving Society Australia. He reflected that the rapid evolution of information in the age of COVID-19 has created a new reference for hindsight. While big decisions by leaders used to be measured in terms of months or years, it is now in hours and days. The statements we make today may need updating even later today. By the time this goes to print, the information may be obsolete.

The aquatics industry ranges from law enforcement, EMTs, and ocean lifeguards, to recreational waterparks, municipal aquatic centers, gyms, backyard swim programs, whitewater sports, beaches, and everything in between. In addition to the physical and mental health benefits of aquatic recreation, we know that early swim lessons saves lives and can help prevent drowning later on in life. Like most industries, aquatics is seeking guidance on how to safely open and operate. Appropriately, the recommendations will require vastly different strategies and practical realities for implementation.

The role of government as the primary source of guidance has been relegated to localities. National leadership from the top down has adopted an approach of allowing individuals states, counties, cities, and businesses to develop their own plans. We will see this play out in businesses that choose to open or stay closed in contradiction to state or city guidance. We will see federal and state agencies allowing for reopening, but there is appropriate fragmentation in implementation across communities as local governments and businesses conduct their own risk assessments. This has created significant confusion and interpretation of guidance that is heavily dependent on local expertise. There is not going to be a one-size –fits-all approach to reopening and agencies will have to consult with their local health authority. Unfortunately, many local health authorities may not have aquatics in the front of their mind.

The American Heart Association, the International Liaison Committee on Resuscitation, and the International Drowning Researchers' Alliance have published updates on the performance of cardiopulmonary resuscitation (CPR) for both the lay public and professional rescuers for persons with known or suspected COVID-19. This pandemic has highlighted a longstanding shortcoming in the aquatics industry - a lack of medical direction. For decades, our colleagues in EMS have recognized the need for local variation in protocols and practices that best suit their unique circumstances. These variations are vetted and implemented by physician medical directors with an understanding of the medicolegal risks and the role of patient and provider safety and medical best practices.

So you may ask, what does this mean for me? Whether it is the lifeguards at your community pool or the swiftwater rescue team at your favorite kayaking spot, the responding rescuers may have different and varied protocols or resources for performing rescues or resuscitations in the era of COVID-19. Protecting the rescuers from infection with COVID-19 will take priority over jumping into a rescue. As we all itch to get back out into world and get wet, we have to consider not only the risk of spreading infection, but the strain that may be placed on the local emergency services. The Wilderness Medical Society has had an active discussion on responsible recreation.

You may also decide to recreate or start training at your local aquatic center, waterpark, or swimming pool. The CDC and StarGuard Elite have each published guidelines for the aquatics industry. There is no evidence that COVID-19 can be spread to humans from pools, hot tubs or spas, or water playgrounds so long as the disinfectant (chlorine or bromine) levels in the water are maintained at the usual, appropriate levels. The bigger challenge for the industry is maintaining physical distancing and disinfecting surfaces that are not in the water. It is impractical and unsafe to wear a cloth face covering while in the water, but their use will be a reality in the rest of the facility while out of the water.

Before you head out, check with local agencies to ensure that trail and water access is open and inquire about the status of rescuers. Consider whether you need to pack in additional rescue equipment and practice radical self-reliance. Both nationally and internationally, many recreation sites are in resource deficit communities that may not have the infrastructure to handle additional visitors, rescue or not. Contact the aquatic center to see if they require reservations, have limited capacity, or require the use of masks.

As aquatic recreation facilities and rescue teams move towards reopening, all decisions come down to an acceptable degree of risk management and risk mitigation. Best practices must be implemented in the context of local guidance and resources and do not represent a one-size-fits-all approach. Staff and visitor safety are the top priorities and must not fall prey to the tension between public health and economics.

Stay safe out there, wash your hands, wear sunscreen, use a lifejacket, swim in front of a lifeguard, provide uninterrupted supervision of your kids, and take care of each other.

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