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Injury on Board
Posted: Monday, April 25, 2011 4:03 PM
Joined: 01/05/2008
Posts: 65

Dockwalk magazine’s new column, Worst Case Scenario by Kelly Sanford, highlights a hypothetical situation that captains may experience and offers advice from experts on how to handle it. The May 2011 column is about impact injuries on board. We’re republishing it here for your comments.

While M/Y Bogus is anchored out beside Imaginary Glacier, Alaska, Deckhand John Doe dutifully begins washing down the radar mast, which has become encrusted with eagle excrement. Unbeknownst to Doe, the owners’ teenage son is in the pilothouse engaged in an esoteric debate with his cousin about whether the yacht’s radar can distinguish glacial ice from seawater. They decide to switch on the radar to settle their argument. The radar begins to spin, knocking Doe, who slips and falls headfirst to the deck below.

“Impact injuries are one of the most common types of injuries aboard boats, and can come from a number of events: Jet Ski accidents, falling down stairs, slipping on a wet deck or being struck by unsecured equipment, just to name a few,” says Lin Gholson, RN, maritime instructor and client support administrator with MedAire’s office in Antibes. “It is so important that crew know the right way to react to an impact injury because the decisions made immediately following the incident can mean the difference between the injured person making a full and complete recovery or suffering long-term (possibly permanent or fatal) neurological damage. What all crew need to know is that any time there is a fall or a crash injury, you should always assume there is a spinal cord injury until a physician has ruled it out. We tell our clients to call our MedLink Global Response Center right away whenever there is a collision or fall — our motto is call early, call often. That is why we are here.”

Spinal cord injuries typically begin with a blow that fractures or dislocates the vertebrae. Even minor knocks can damage vertebrae, causing tears to cord tissue or affecting the nerve components that carry signals. The most severe injuries sever the spinal cord, resulting in paralysis when the brain no longer can relay messages below the point of the injury. Any head or neck injury is a potential medical emergency and the moments immediately following the injury are critical in reducing long-term effects.

“Ideally when doing dangerous work, a crewmember would not be working alone and someone would witness the fall,” Gholson says. “After a fall, many people instinctively try to get up. The danger is that symptoms of neurological damage may be delayed beyond the time of injury. They think they are fine, but by getting up they could be making matters much worse.” Let’s assume Doe remains conscious after the fall. “He should be encouraged to lie down and stay still until a physician has been consulted; the doctor is going to want to check for signs of damage before [he gets] up,” Gholson says.

Keep the injured person calm and still, make note if there is any loss of consciousness or signs of shock. Ask the injured if they are feeling any pain, numbness, tenderness, tingling or loss of feeling. Other than pain, additional warning signs of an under- lying serious injury are difficulty breathing, unequal pupils, immobility, an unintentional erection or if the person has lost bladder or bowel control. “These are all very bad signs that the injury is serious,” Gholson says.

If the person insists on getting up, pay close attention to their sense of balance, check for dazed behavior or if their lips are changing color. Even if they get up, appear fine, laugh it off and are ready to go back to work, they should not do so until you have the doctor’s approval.

Realistically, in the fall scenario presented, there would be a very serious injury. “Though we hope there would be a witness to such a fall, there are circumstances where that may not be the case,” Gholson says. When you discover a person after a fall, triage starts with the fundamentals. Unless the injured is in immediate danger, assume there is a spinal cord injury and do not move the patient until you are under the direction of a physician. Check for the ABC’s — airway, breathing, circulation. “If the victim is facedown and unconscious, the proper way to check for breathing is to place your hand gently on their back and feel for the rise and fall of breathing,” Gholson says. If they are not breathing, then you will have to reposition them to start CPR.

If the victim is stable, he needs to be kept immobile, calm and safe. While the physician is being contacted, someone needs to collect as much information for the doctor as possible, which includes using a cell phone camera or the onboard telemedicine device to provide visual information. “Treating a spinal cord injury is something that is going to require a team effort and it is a drill you need to practice often and in different scenarios,” advises Gholson. At sea, you may be performing triage in the water, on the deck or in a confined space like a stairwell or in the engine room. If your crew has not regularly practiced how to properly use the head immobilizer or cervical collar, it’s time for a refresher course. If the crew has not drilled for a spinal cord injury since a new crewmember has come aboard, it’s time. Crew need to practice the techniques they are taught in their STCW medical training so it comes naturally in an emergency.

“It’s not a matter of if you will ever be confronted with an impact injury while working on a yacht, it is really a matter of when,” Gholson says. “Head and spinal injuries should always be taken seriously; they are complex in nature, sometimes difficult to diagnose but extremely dangerous.”

Posted: Tuesday, April 26, 2011 5:06 PM
Joined: 21/06/2008
Posts: 17

Sound advice on the medical side if the crew were well trained.

It would have been nice to assume that John Doe is smarter that this and works for a smart crew. One that is professional and follows procedures and codes.  As in most of chapter 15 of the MCA code for safe working practices for merchant seaman. There are pages of code written to stop this type of incident from happening.

But since this is Imaginary let's make it more interesting and ask the now what question, as it seems that M/Y Bogus' crew are not well trained as a team.

John Doe knows he has broken something. His fellow crew mates (not the brightest)  follow few policies (they are all watching the latest DVD that arrived with the owner's teen son) and do not notice John missing for well over an hour.

John lies there for a few minutes getting his breath back not sure what is going on, he can move his right arm but not his left and his head hurts.He is in an awkward position and when he touches his head he finds blood on his hand. He starts to panic and tries to get up, but the pain from his left arm and lower back is excruciating.

He had fallen awkwardly and hit first his back on a rail and then his head on the deck, or something; he can't remember. He needs help but no one is around. He tries his radio but no reply......he feels tired and drifts of to sleep.

Two hours later John wakes to the owners’ teenage son trying to get him up ( he cries out in pain and is dropped back down, John passes out from the pain.

M/Y Bogus is in Alaska and fictitious 'Med Everywhere' service they subscribe to does not have satellite service in this area.

John is wedged in between a tender and the rail, he is unconscious, bleeding from the head, has at least a broken arm, and seemed to be in a lot of pain before he passed out.

He is in an awkward position and it would would be hard to get him out from where he is without getting him vertical, he is somewhat wedged in behind a tender on the top deck. Night will be here soon and the temps will drop close to freezing, and to add to it all it has just started to rain.

Now what ?

Paulo Alves, MD, MSc
Posted: Wednesday, April 27, 2011 3:54 PM
Joined: 07/02/2011
Posts: 3

This is a perfect example of the value of telemedicine. Telemedicine requires three elements: local resources (training and equipment), remote expert advice, and a communication link between the two. In this scenario, there is no possible communication, so expert advice cannot be reached—but will eventually as they move into another geographical area. Therefore, the only elements available are the first: local resources. If they don’t have any training/equipment on board, then we are living in the Dark Ages and the only resource is to pray. Poor John Doe will be paying a high price for working for such a lousy company. Now, if they have some training, there is no mystery… 1) The rescuer should evaluate the safety of the scene and protect him/herself to approach the victim (gloves at least…). In the proposed scenario John is reachable and the scene is apparently safe. 2) The rescuer will conduct the primary survey: Is the victim responsive? Is he breathing normally? John is not responsive, but is breathing. Our rescuer should shout for help at the same time he proceeds to the secondary survey. He identifies the bleeding in the head and the possible fracture by inspecting the victim from head to toe. He knows (because he is trained) that the goal is to stabilize the patient while waiting for advanced care/advice. In doing so, he will prevent things to deteriorate even further. 3) He will try to stabilize the neck with pillows. 4) He will look for the bleeding in the head. In the scenario given, most of the times it would be a superficial bleeding from the scalp, which typically bleeds significantly, but will resolve by compression alone. 5) He will check for a pulse in the fracture limb and will try to immobilize the affected limb in the position he finds it. 6) He will closely monitor the situation for further deterioration that could eventually require CPR. With the situation more stable, it is time to try to contact expert advice at the same time they are already diverting to the closest port. In other words, this is a typical basic life support (BLS) scenario. One can speculate about internal cranial bleeding and other complications, but, again, the goal is to provide BLS until further advice/care is reached as they arrive in a port or within the reach of telecommunication. If there is a major internal bleeding “alea jacta est”, there is very little that can be done since the actual treatment of this sort of complication would require a hospital environment. This is what we teach in our classes and this is what evidence shows that is the best approach. Keep it simple, straightforward, and do the basics well. But, if they don’t have training or equipment, yes let’s hope they have the common sense of not trying to invent anything and compromise even further this poor man’s situation. My two cents… Paulo Alves, MD, MSc, MedAire
Posted: Wednesday, April 27, 2011 8:49 PM
Joined: 13/03/2011
Posts: 6

Out of interest; if applying compression to stop bleeding on the top of the head, how do you minimise pressure against the neck? It would seem if you push, even gently on the top of the head you would put some pressure on the spine which would complicate any spinal issues mentioned??? Just a random thought, it may not be an issue at all? Or all about priorities?
Paulo Alves, MD, MSc
Posted: Thursday, April 28, 2011 5:51 PM
Joined: 07/02/2011
Posts: 3

That’s an important point, no doubt. That’s why you should stabilize the neck first (see item 3 in my previous post). It will also depend on the exact location of the bleeding. But one can certainly apply local pressure carefully. When holding the victim’s head, be sure not to twist or overextend the neck. Paulo M Alves, MD, MSc MedAire
Posted: Saturday, April 30, 2011 6:04 PM
Joined: 13/03/2011
Posts: 6

Ok thanks for the feedback will keep that in mind!
 Average 5 out of 5