Would You Recognize an Emergency on Anyone?
Are we teaching people to recognize emergencies, or are we teaching them to recognize what we expect emergencies to look like?
Before someone can perform CPR, activate an emergency action plan (EAP), enter the water for a rescue, call 911 or provide first aid, something else has to happen first: they have to recognize that an emergency is occurring. That sounds obvious, particularly in aquatics, where we spend enormous amounts of time teaching recognition. Lifeguards scan their zones. Staff learn signs and symptoms of common medical emergencies. We show videos of drowning and aquatic distress. We teach people how a stroke, seizure, diabetic emergency or heat-related illness might present. Then we create scenarios to see whether staff can correctly identify what is happening and respond.
But recognition is more complicated than simply seeing something. A staff member can look directly at someone and still misunderstand what they are seeing. A person who appears intoxicated could actually be experiencing a stroke, hypoglycemia or a head injury.
Someone who isn't following directions may not have heard or understood them. A disabled person communicating pain differently may have their distress attributed to their disability. An autistic person experiencing sensory overload could also be injured or ill. A swimmer whose movement looks unusual to an unfamiliar lifeguard may simply have a different swimming style, while another swimmer whose movement looks completely typical may suddenly be experiencing a medical emergency.
A note on language: Throughout this article, I use autistic person rather than person with autism. This is identity-first language, and it is preferred by many autistic people because autism is understood as an integral part of identity rather than something separate from the person. Language preferences are not universal, however, and individual preferences should always be respected.
The question, then, isn't only whether our staff are paying attention. It is whether we have prepared them to correctly interpret what they see, particularly when the person or situation doesn't resemble the examples they encountered during training.
Seeing Something Is Not the Same as Recognizing It
I think we sometimes use seeing and recognizing as though they are interchangeable, particularly when we talk about surveillance and emergency response. They aren't. A lifeguard can visually encounter a swimmer during a scan without recognizing that the swimmer's behavior has changed. A camp counselor can notice that a child is unusually quiet without considering that the change might indicate illness. A fitness attendant can hear someone slurring their words and immediately assume alcohol is involved. A front-desk employee can notice someone lying on a bench and conclude that the person is sleeping. In every one of those examples, the employee technically saw what was happening. The potential failure occurred during interpretation.
There are several cognitive steps between encountering another person and responding to an emergency. We have to notice them, interpret what we are seeing, decide whether intervention is necessary and then act. Aquatic training spends significant time on the first and last parts of that sequence. We teach surveillance so lifeguards will see what is happening in their zones, and we repeatedly practice rescue and first aid skills so staff know what to do once they recognize an emergency. There is an opportunity to spend considerably more time on what happens in the middle.
Stage | What is happening | Where recognition can break down |
See | I encounter the person or behavior. | I don't notice them, my view is obstructed or my attention is elsewhere. |
Interpret | I decide what I think I'm seeing. | I rely on an assumption, familiar pattern or incomplete information. |
Decide | I determine whether intervention is needed. | I minimize the situation, wait for more information or assume someone else will respond. |
Act | I respond. | I hesitate, lack confidence or don't know what to do next. |
The interpretation stage deserves particular attention because sometimes the problem isn't that nobody saw the emergency. It is that someone saw it and gave what they were seeing the wrong meaning.
When "Behavior" Could Be a Symptom
There is a concept in healthcare called diagnostic overshadowing, which broadly describes situations in which symptoms are attributed to a person's existing disability, mental-health condition or diagnosis instead of adequately considering whether another medical problem may be occurring. Research examining emergency medical care for people with intellectual disabilities has identified communication difficulties and diagnostic overshadowing as potential barriers to care, including situations in which behavior may be interpreted as part of someone's disability rather than as a possible expression of pain, illness or another acute problem. (Emergency Medical Care of People with Intellectual Disabilities)
The research is more nuanced than simply saying that diagnostic overshadowing always happens to disabled people. A systematic review published in 2024 found mixed evidence and assessed the overall quality of the available evidence as low. That is important context because we shouldn't take a useful concept and turn it into a universal explanation for every interaction involving disability. (Systematic Review on Diagnostic Overshadowing)
Still, the concept gives recreation professionals something valuable to consider because, although we aren't diagnosing people, we are constantly interpreting their behavior. A staff member may decide that someone is drunk, difficult, noncompliant, having a behavioral issue, playing around or simply acting strangely. Sometimes that interpretation will be accurate. The problem occurs when the interpretation becomes a conclusion before we have considered whether something else might be happening.
There is an important difference between observing behavior and assigning meaning to it. Pacing, slurring speech, refusing to answer a question, repeatedly submerging, covering the ears, crying, moving unusually in the water or suddenly sitting down are observations. Describing someone as intoxicated, defiant, attention-seeking, disruptive or "behavioral" adds an interpretation to what staff have observed. Once that label is applied, it can become harder to remain curious about other explanations.
What we observe | An easy interpretation | What else could be happening? |
Slurred or unusual speech | Intoxication | Stroke, hypoglycemia, neurological event or disability |
Confusion | Drugs, alcohol or unusual behavior | Stroke, diabetic emergency, head injury or heat illness |
Not following directions | Defiance or noncompliance | Hearing difference, language barrier, processing delay or panic |
Sudden behavior change | Behavioral problem | Pain, illness, injury or neurological event |
Repetitive movement or visible distress | "They're having a meltdown" | Sensory overload, pain, injury, illness or multiple things at once |
Not responding to staff | Ignoring staff | Hearing difference, seizure, shutdown or medical emergency |
Lying on a bench or ground | Sleeping | Syncope, cardiac arrest, overdose or diabetic emergency |
Sitting down suddenly | Tired | Presyncope, heat illness, cardiac symptoms or hypoglycemia |
Erratic movement in water | Playing or poor swimming | Aquatic distress or medical emergency |
Unusual swimming movement | "That's just how they swim" | Typical movement, fatigue, distress, seizure or another meaningful change |
Consider stroke as a simple example. The CDC identifies sudden confusion, trouble speaking, dizziness, difficulty walking, loss of balance and lack of coordination among potential stroke symptoms. To someone who begins the interaction with a different assumption, several of those symptoms could look like intoxication. Recreation staff do not need to diagnose a stroke, but they do need enough recognition skills to consider that something may be medically wrong and activate an appropriate emergency response. (CDC: Signs and Symptoms of Stroke)
This is why one of the most useful questions we can teach staff may be incredibly simple: What else could this be? The goal isn't to turn every unusual behavior into a medical catastrophe or encourage employees to endlessly second-guess themselves. It is to interrupt premature certainty long enough to recognize when another explanation needs to be considered.
Disability Can Complicate Recognition Without Being the Emergency
This conversation becomes particularly important when we think about disability because disabled people do not stop having ordinary injuries and medical emergencies because they have disabilities. An autistic person can experience hypoglycemia. A person with an intellectual disability can have appendicitis. Someone with cerebral palsy can experience a stroke. A nonspeaking person can have severe pain. A person who regularly communicates distress through movement or behavior can also experience an entirely unrelated medical problem.
Emergency-care research involving people with intellectual disabilities has identified communication as an important issue in recognizing symptoms and has highlighted the value of information from people who know an individual well. A family member, caregiver or familiar staff member may notice changes in behavior, ability or function that are meaningful precisely because they understand what is typical for that individual. (The Need for FASTER CARE in the Diagnosis of Illness in People With Intellectual Disabilities)
That idea translates remarkably well to recreation. Instead of asking only whether someone's movement or communication looks different from everyone else's, staff may need to consider whether it looks different for that person. A swimmer with cerebral palsy may have an asymmetrical stroke every day, so the asymmetry itself is not automatically distress. An autistic swimmer may regularly vocalize, repeatedly submerge or move in ways that are unfamiliar to a new lifeguard. A child with an intellectual disability may communicate discomfort differently than another child. Inclusive emergency recognition requires us to avoid treating difference itself as pathology while still noticing meaningful changes that could indicate something is wrong.
In other words, we need to become better at distinguishing difference from change. That is a much more useful skill than simply teaching staff that certain behaviors "look like" disability or "look like" an emergency.
Are We Teaching Lifeguards to See Drowning or to See What They Expect Drowning to Look Like?
Aquatics gives us an especially interesting case study because lifeguards are, in many ways, professional recognizers. Long before a lifeguard enters the water or performs a rescue, they are expected to identify behavior indicating that a swimmer needs assistance. We teach them that real drowning often does not resemble the dramatic version portrayed in movies and television. A person who is drowning may not wave, yell or visibly thrash because maintaining an airway and attempting to breathe take priority. Drowning can be quiet and difficult for an untrained observer to recognize. (University of Utah Health: What Does Drowning Look Like?)
That is precisely why lifeguards receive specialized recognition training. We teach patterns, show videos, describe body positions, demonstrate behaviors and repeatedly practice surveillance. Those mental models are necessary because a lifeguard cannot respond quickly to something they have no framework for recognizing.
At the same time, those frameworks can become limiting if the examples are too narrow. Real swimmers do not all move the same way. Age, disability, body composition, swimming technique, fatigue, injury and medical conditions can all influence movement in the water. A swimmer with a physical disability may move very differently from the swimmers represented in a training video. An autistic swimmer may display movement that is unfamiliar to a guard. An older adult may experience a medical emergency while swimming slowly and competently. A strong swimmer may suddenly experience a seizure, cardiac event or another acute medical problem.
This creates an important tension in recognition training. We need to teach lifeguards patterns because pattern recognition helps people make fast decisions, but we also need enough variation in training that guards don't become dependent on one narrow mental picture of what distress or drowning is supposed to look like.
If lifeguards have only practiced recognizing one presentation of distress, are they actually practicing recognition, or are they practicing pattern matching?
The difference matters because a real emergency may share some characteristics with a training example without matching it perfectly.
A Lifeguard Can Look Directly at Someone and Still Miss the Emergency
Aquatic professionals spend enormous amounts of time talking about scanning, and appropriately so. We think about head movement, blind spots, glare, chair placement, zone coverage, water clarity, bottom visibility and whether lifeguards can effectively see every portion of their assigned area. All of those factors matter because a lifeguard obviously cannot recognize an emergency they cannot see.
Research from the Lifesaving Society illustrates how environmental conditions themselves can affect recognition. In research examining submerged manikin visibility, pool-bottom color and water depth affected lifeguards' ability to see and recognize a submerged target. Visibility was better against a white pool bottom than darker blue backgrounds, and recognition became more difficult as depth increased. (Lifesaving Society: Color Does Make a Difference)
But visibility only solves part of the problem. A lifeguard could physically look directly at a swimmer and still interpret what they see as playing, fatigue, unusual swimming technique or something that doesn't require intervention. This is why I think vigilance training needs to explicitly distinguish between seeing a swimmer and understanding what is happening to that swimmer. A guard can succeed at the first and still fail at the second.
That distinction also changes how we evaluate scanning. Instead of focusing exclusively on whether the guard's eyes or head moved through the appropriate area, we should be interested in what information they are extracting from that scan.
Who changed position?
Who stopped progressing?
Whose behavior is different from thirty seconds ago?
Who disappeared from where they were previously swimming?
Who looks different from their own previous pattern?
Those questions move surveillance from simply covering space toward actually understanding the people occupying it.
Our Expectations About "Who Looks Like a Swimmer" Matter
There is another layer to recognition that aquatic professionals should be willing to examine. We make predictions about people constantly, often without realizing it. An older adult entering a lap lane may trigger different assumptions about swimming ability than a teenager. A person with a visible disability may receive extra attention even when they are completely competent in the water. A larger-bodied swimmer may be assumed to be less skilled. Someone who looks athletic may be assumed to be a strong swimmer. A child wearing flotation equipment may receive different attention than a child without it.
Some predictions can be useful when they are based on observable risk factors. Lifeguards need to continuously assess risk. The problem comes when identity or appearance begins substituting for observation.
A person who looks like an excellent swimmer can experience cardiac arrest. A disabled swimmer can be completely independent. A larger-bodied swimmer can be highly skilled. An older adult can swim miles. A young athletic person can experience a seizure. Risk assessment should ultimately be based on what the person is actually doing and what is changing, not on who we assume they are.
This is also why representation in training matters. If every person shown swimming confidently in our materials looks similar, and every "victim" looks similar, we may inadvertently create narrower mental models than we intended. Representation is not simply about whether someone feels included in a training video. In recognition-based professions, varied examples can help learners build broader categories of what normal, distress and emergency can look like.
What About Skin Tone and Underwater Recognition?
Skin tone deserves careful attention here because it would be easy to make claims that go beyond the available research. We know that underwater visibility is affected by water depth, lighting, glare, surface agitation, water clarity, background color and contrast. Research such as the Lifesaving Society's work on pool-bottom color demonstrates that environmental contrast can materially affect whether a submerged target is visible. (Lifesaving Society)
What we should not do is take that research and leap to a universal claim that a particular skin tone will always be easier or harder for a lifeguard to recognize underwater. There are too many interacting environmental variables, and the research needed to support broad claims about skin tone and drowning recognition is much more limited.
The better operational question is whether our facilities have actually validated visibility under realistic conditions and whether the tools we use for that validation represent the people who use our pools.
What skin tones do our rescue manikins represent?
What clothing colors are used during drills?
What happens to visibility as depth changes?
What happens during glare, heavy attendance or surface agitation?
Are there portions of the pool where contrast becomes poor?
Have we actually tested those conditions, or are we assuming that because a lifeguard's zone technically includes an area, every person in that area will be equally easy to detect?
Inclusive surveillance is not about creating a different scanning system for every identity. It is about refusing to assume that one training target, one environmental condition or one body represents every person we are responsible for seeing.
Stop Giving Away the 'Diagnosis' in Training
One of the simplest improvements we can make to emergency-response training is to stop announcing the answer before the scenario begins. If an instructor says, "This person is experiencing a diabetic emergency. Show me what you would do," we may be evaluating first aid technique, but we aren't really testing recognition. The learner already knows what is happening.
A more realistic scenario might tell the employee that a patron finished a fitness class ten minutes ago and is now sitting against the wall, sweating, confused and not answering questions normally. The learner then has to identify the observable information, recognize that something could be medically wrong and determine an appropriate response. They do not need to correctly diagnose hypoglycemia. In fact, insisting on a precise 'diagnosis' reinforces the wrong objective for many recreation employees. Their responsibility may simply be to recognize that the situation could represent a medical emergency, activate the appropriate response and provide care within their training.
The same principle applies to aquatics. Instead of telling a lifeguard that there is a distressed swimmer somewhere in the zone, create scenarios in which swimmers are playing, resting, moving in different ways and engaging in normal activities while one person's behavior gradually changes. Recognition becomes considerably more realistic when the guard doesn't know exactly when the scenario starts or what type of emergency to expect.
We should also vary the people represented. Disability does not always need to be the point of the scenario involving a disabled person. A wheelchair user can experience hypoglycemia. A Deaf patron can experience cardiac arrest. An autistic swimmer can sustain an ordinary injury. A larger-bodied person can be the strongest swimmer in the scenario. An older adult can be the rescuer rather than the victim. When identity only appears in training when identity is "the issue," we unintentionally teach people to associate difference with problems rather than simply with people.
A note on language: Throughout this article, I use identity-first language such as autistic person and Deaf or hard of hearing person. Many autistic people prefer identity-first language because autism is understood as an integral part of identity rather than something separate from the person. I capitalize Deaf when referring to people who identify with Deaf culture and community, while deaf may be used more broadly to describe hearing status. Language preferences are not universal, and the best practice is always to respect the language an individual uses for themselves.
Debrief the Interpretation, Not Just the Response
Scenario debriefs are another place where relatively small changes could improve recognition skills. We commonly ask staff what they did, whether they followed the emergency action plan, whether their rescue was appropriate and what they would do differently next time. Those are valuable questions, but they primarily evaluate action. We should also ask how the learner understood what was happening.
Traditional Debrief Question | Add a Recognition Question |
What did you do? | What did you initially think was happening? |
Did you activate the EAP? | What made you decide this was an emergency? |
Did you recognize the person needing help? | What almost made you overlook them? |
Was your rescue appropriate? | What other explanations did you consider? |
Did you follow the correct sequence? | Did any assumption influence your first interpretation? |
How quickly did you respond? | At what point did you realize intervention was necessary? |
What would you do differently? | What information would have changed your interpretation? |
Those questions give instructors access to something we rarely see when we evaluate only the final action: the reasoning that produced it. Two employees can perform exactly the same rescue while arriving there through completely different thought processes. One may have recognized distress almost immediately. Another may have spent thirty seconds assuming the swimmer was playing before something finally changed their interpretation. If we only evaluate the rescue itself, we miss the opportunity to train the skill that preceded it.
"What Else Could This Be?" May Be One of the Most Useful Questions We Can Teach
None of this means staff should become afraid to interpret anything they see. Emergency response requires decisions, often very quickly, and there is a point where continued analysis becomes hesitation. The goal is not to teach people to distrust their judgment. The goal is to make their judgment more flexible.
When a person appears intoxicated, staff can ask themselves what else could produce the symptoms they are observing. When a swimmer appears to be playing, they can consider what would distinguish play from emerging distress. When a child isn't following directions, they can consider whether the child heard, understood and was able to process the instruction. When a disabled participant begins behaving differently, staff can ask whether the behavior is typical for that individual or represents a meaningful change.
That brief mental check interrupts one of the biggest risks in recognition: deciding too quickly that we already know what is happening. Sometimes the first explanation will be correct.
Sometimes asking "What else could this be?" will lead someone to notice the piece that doesn't fit.
Building Better Recognition Into Everyday Training
Improving recognition does not require turning every in-service into a medical lecture or purchasing an entirely new collection of training equipment, and it shouldn't! Much of this work can be incorporated into training programs facilities already have. Scenarios can begin before the diagnosis is obvious. Staff can receive observable information rather than being told exactly what emergency is occurring. Training videos can show multiple presentations of the same emergency. Aquatic scenarios can vary swimmers, movement patterns, body types, ages, disabilities, locations, crowd conditions and environmental conditions so staff do not develop a single mental image of what distress is supposed to look like.
Facilities can also spend more time validating actual visibility rather than assuming that theoretical zone coverage guarantees effective surveillance. Guards can practice identifying changes in swimmer behavior rather than simply locating planted rescue manikins. Staff who work with recurring participants can be encouraged to notice meaningful changes from an individual's baseline without treating disability itself as a problem. First aid training can include situations in which medical emergencies initially resemble intoxication, behavioral concerns, fatigue or confusion.
Most importantly, instructors can explain why the variation exists. We are not trying to trick employees. We are trying to build recognition skills that survive contact with the real world.
Instead of only training... | Also practice... |
The textbook presentation | Multiple reasonable presentations |
The correct response | Recognition before response |
A clearly announced emergency | Ambiguous situations |
One generic "victim" | Different ages, bodies, disabilities and identities |
Identifying a diagnosis | Recognizing that something may be medically wrong |
Looking throughout the zone | Identifying meaningful changes within the zone |
Rescue technique | The interpretation that triggers the rescue |
What staff did | Why they decided to do it |
This kind of variability can also make training more interesting. Staff aren't simply repeating the same rescue for the tenth time. They are solving a problem, noticing details, explaining their reasoning and learning how easily two situations that initially look similar can require very different responses.
An Emergency Does Not Have One Look
In the CPR conversation, the central question is whether someone who knows how to help will actually intervene. This conversation starts one step earlier. Will they recognize that help is needed?
The person experiencing hypoglycemia may appear intoxicated. The person experiencing a stroke may simply seem confused. A nonspeaking person experiencing severe pain may communicate through behavior. An autistic person experiencing sensory overload may also be experiencing an unrelated medical problem. A disabled swimmer may move differently every day, which means staff need to recognize when something is different for that swimmer rather than simply different from everyone else. A competent swimmer can experience a sudden medical event, and a person who is drowning may not perfectly resemble any example a lifeguard saw during certification training.
We cannot train staff for every possible human presentation, and trying to create a checklist for every type of person would miss the point entirely. What we can do is expose people to enough variation that they stop mistaking familiarity for certainty. We can teach them to describe what they actually observe before assigning meaning to it. We can teach them to recognize meaningful changes. We can make our scenarios less predictable, our examples more representative and our debriefs more interested in how people arrived at their decisions.
Most of all, we can teach people that the first explanation their brain produces is not necessarily the only explanation available. Maybe the goal isn't simply teaching staff what an emergency looks like. Maybe it's preparing them for how many different ways an emergency can look.
Resources & Further Reading
This open-access review examines barriers people with intellectual disabilities may encounter in emergency medical care, including communication, symptom recognition and diagnostic overshadowing. It is useful background for recreation professionals considering how disability and communication can affect the interpretation of distress.
This review is especially useful because it adds important nuance to the discussion of diagnostic overshadowing. The authors found mixed evidence and identified limitations in the existing research, making it a good resource for understanding both the concept and the limits of what we currently know.
This article discusses changes in behavior, function and ability as potential indicators of illness and highlights the value of information from people who know an individual well.
An accessible explanation of why drowning frequently does not resemble the dramatic struggling and yelling portrayed in popular media and why a person who is drowning may be unable to call for help.
Research examining how pool-bottom color and water depth affected lifeguards' ability to see and recognize a submerged manikin. The findings are useful for broader conversations about visibility, environmental conditions and the importance of validating surveillance conditions in actual facilities.
