Was it hearing, at the inquest into the drowning death of their five-year-old boy, that the lifeguard at Margaret Grant Pool did not ask the St. Adolphe schoolteachers to come out on the deck to help supervise the 40 to 50 five- and six-year-olds heading into the shallow end? Or was it when this young man, 22 now, testified Josh Harder had a weak pulse when the paramedics raced him off to hospital?
Both points are terribly painful. Had there been more adults on the pool deck, more eyes on the crush of children celebrating the end of school almost a year ago, perhaps Joshua's pulse might never have become an issue.
The first that lifeguard, Matthew Rice, saw of Joshua was from the deck, after his gaze returned to the pool, having been momentarily distracted by two girls who needed lifejackets and then couldn't get them zipped and buckled.
Joshua was floating, face down. His pint-sized schoolmates assured Mr. Rice he was just playing, the way kids do.
"What we call possum in the pool, when they float on their stomachs, holding their breath," explained Mr. Rice. But something about the way the boy was floating didn't look right. Mr. Rice tapped him on the back, and got no response.
Mr. Rice's instincts, having guarded at various pools in various cities, were right. He jumped in and, turning the boy over, noticed Joshua was not breathing. He could not find a pulse and so concentrated, airway clear, on getting him breathing again. The boy repeatedly vomited, and the ABCs -- airway, breathing and circulation -- of respiratory assistance had to start over again each time.
By this time, the three lifeguards were calling upon their lifesaving training, going through the right paces with practised efficiency. Mr. Rice was the first rescuer, turning the body with precision so as to secure each side of the torso with his forearms and the head and neck with his hands. The second guard on the scene, Sean Robert, helped to put Josh on the spine board while the third -- acting-acting supervisor Christa Buccini -- told the pool receptionist to call an ambulance and, once the boy was on the pool deck, began artificial respiration as Mr. Rice did chest compressions.
A missing valve meant oxygen equipment couldn't be used.
When the ambulance arrived, the paramedics detected a faint pulse, Mr. Rice said. So Joshua's heart, though weak, was beating. In the cramped courtroom yesterday, mom Kristin Harder began to cry. Matthew Rice was swallowing hard, his youthful face flushing.
The burning question is not whether any of the young people, just out of their teens, in charge of watching the young kid, knew how to respond to the emergency. Lifeguarding is about preventing incidents, as Mr. Rice noted in court.
To that point, it must have been excruciating for Kristin and Rudy Harder to hear again yesterday, as they did Monday from Ms Buccini, that neither lifeguard had seen the city's pool rules for school groups. This document -- and, boy, the city is very good at writing letters and memos, Ms Buccini noted in testimony -- required one adult per four children younger than six, and within arm's reach if the child can't swim. Children had to be taller than 42 inches (107 centimetres) and have a basic swimming ability for less supervision.
In all, Josh was among 95 kids on the celebratory trip last June 27, although 108 were supposed to go. Neither guard knew the kids' ages, heights or swimming abilities. The kids got pool safety lectures when they arrived, older kids first, at the pool. Five- and six-year-olds were left to decide for themselves if they needed lifejackets. The five teachers and one parent went to the pool's observation room -- they have said they were told they were not welcome on the pool deck -- leaving three guards on their own.
The striking contrast to Ms Buccini's and Mr. Rice's command of lifeguarding skills and emergency response is the fact neither had seen the city's rules about supervision -- although Mr. Rice knew, from previous experience, that the one-to-four ratio was standard. Both assumed the teachers would stay on deck. When the kids got in the water, both said they were too busy to leave their stations to ask teachers to come to the poolside. Yet neither, constantly scanning the pool and counting heads, felt the situation was dangerous.
Everyone knew that little people who can't swim and stand chest-high in water at the lowest part of the shallow end need special supervision, including Kristin Harder, who had asked if she could help chaperone but was told there were enough adults along.
It wasn't Mrs. Harder's job to ensure city employees read and followed safety manuals.
The city says now pool staff will be "encouraged to familiarize" themselves with the manual and reread it regularly. City bureaucrats have not testified yet, but I'm sure someone will say all pool staff were expected to know the rules.
The difference is made, though, in enforcing the rules. Clearly, no one made the lifeguards read the manuals; the lifeguards did not insist that the teachers stay close to watch the kids.
And the difference there, you see, can be the one between life and death.