FYI. Good info found in the George Town Exuma Sailors and Cruisers Facebook forum
Originally posted by Dale Phillips
· February 24, 2020 ·
A huge gift from Donna and Patrick from Jersey Girl
Shipboard Emergency!
1. Introduction:
a. Who am I
i. Retired Emergency Physician. License un-renewed 2018
ii. 35 years in rural ER’s
iii. Wilderness survivalist and instructor
iv. Wilderness awareness and tracking instructor
v. As a physician I was not at the top of my class nor did I seek extra letters to place behind my name. In general I was a
rogue who looked for the simple way and who distrusted anyone who was being paid as a sales person, which, toward the
end, was pretty much everyone.
b. Considerations for sourcing medical information
i. Despite quite a few years of scientific investigation there is
very little that is known for a certainty, much less than you would imagine. Certainty means multiple well-designed
scientific studies done by persons and institutions that do not have a financial connection to the process or product being
studied and agree on the same outcome. This is class A information.
ii. Class B information is when multiple but poorly designed studies that may have been done by interested parties that
don’t study exactly the same subject in the same way but never-the-less seem to generally agree at least according to
some people who often are ‘experts and leaders with a lot of letters behind their names but are also likely to be paid to
say what they say even while they vehemently deny it.
iii. Class C information, the most common, is what a bunch of white haired doctors have always thought was true.
1. Which has been proven wrong often unfortunately.
iv. Class TV is where most lay people get their actual information.
1. Despite the fact that it could be good information delivered by a powerful medium it isn’t and the creators of it feel it is
their first amendment right to mislead you for laughs.
c. So, when you are trying to understand something medical it is important to at least give some thought to where the
information is coming from.
d. What is the point of a little bit of knowledge?
i. My purpose in making information available in this form is to
help you find the confidence to know when to act and what to do. My father, a physician of profound wisdom said. “Most
of what a doctor does is to try to stay out of the way while the body heals.”
ii. That said, as an emergency physician I did come across a few situations where it was better to do something. It helped if
that something was the correct thing to do and was confidently done.
iii. Even if you have the knowledge, if you do not have the confidence to help someone then you are not really able to help.
iv. At times helping means causing some initial pain. This will be especially problematic if you are out of sight of land and
there are no other options.
2. Eric Weiss MD has written “A Comprehensive Guide to Wilderness and Marine Medicine” He is very experienced in
supporting groups in the wild and has done a good job. This outline is not meant to be quite as comprehensive. He does
speak in terms of ‘worry’ ‘what to worry about’ Personally, I have never found worrying to be of much use. It is like telling
someone to ‘be careful’. If you need to say that the jig is probably already up. I prefer to focus on what to do next.
a. Except when specifically stated the following assumes a normal person before the injury happened or symptoms began.
3. Trauma
a. General stuff regardless of the type of trauma
i. Assessing for stability and sensation
1. In any traumatic injury this is an essential step
2. It means seeing if the nerves, tendons and muscles work
a. So basically see if it works
b. For stability move it around and make sure it
doesn’t move in ways it isn’t supposed to.
i. This is whether it is stable not does it hurt
to move it. It is going to hurt to move it.
a. If a wound or injury is not mechanically stable and awake to sensation
then this means it is going to have to go to the doctor. Ice and Elevation
a. Every body writes it that way ... it should be Elevation and more elevation and elevate it higher for longer and then, oh
yeah, you could put some ice on it too. Elevation means above the heart. Think of a plumbing pipe and you want the
circulation to passively drain back to the heart.
b. Ice constricts the blood vessels, which slows down swelling which is desired but also the general circulation, which is
not desired. Ice is also harder to come by at sea.
b. Splints
a. All the trauma kits seem to hold a large variety of these. Your
kitchen does too and they have at least two purposes, eating and splinting.
i. A serving spoon for the wrist
ii. A small spoon for the finger.
b. Ankles, knees and elbows are best splinted with rolled up towels held with duct tape. The tighter you roll it the stiffer it
is. You don’t need board ridged and you don’t want pressure points that can damage skin.
c. A splint should hold the joint in the middle of its range of motion.
d. If a splint is hurting it has to be removed and looked at. If the skin is getting red from pressure you have to fix that.
e. A skin infection over an injury is bad and avoidable.
4. Cuts: If it is bleeding what do I do? Answer: Push on it.
i. Bleeding is when the red stuff leaks out. Everybody gets
excited when that happens but a little bit of bleeding can be a good thing. It is the only way to wash out an injury from the
inside. That said some bleeding is going to happen with a cut anyway and you don’t have to encourage it. Still, you don’t
have to jump up and down as if there is a timer on a bomb (or as if you are filming a sit-com). Covering it with a handy
(dirty) rag might save your rug but it doesn’t do anything good for the cut.
ii. So the answer for bleeding is always the same. Push directly down on where blood is coming out. If you can find the
spot where, when you push the least hard, it stops the bleeding then that is great but there is nothing wrong with pushing
over a larger area. Push just hard enough so that the blood stops coming out. If it won’t stop push over a larger area and
harder.
iii. Since you are doing this to stop blood from leaking out it is best to push with something that doesn’t act as a sponge.
Despite TV and what is often done in real ED’s this is not a series of sterile cotton squares. You are better off with your
bare thumb or hand. It doesn’t look so cool and gets you covered in blood but it is quick and efficient.
b. What is actually happening?
i. Bleeding happens when blood vessels are damaged. Either cut
or crushed. Partially damaged vessels bleed more than completely cut ones. Either way you are pushing until the body’s
natural process plugs the hole. This is done first by the sticky part of the blood called the platelets. They very quickly
begin to stick to the edges of the cut and if you are slowing down the current (the rate of bleeding) they can stick better. In
a normal healthy person a platelet clot takes at least 10 minutes of constant pressure. If you let up too soon to see if it is
“still bleeding” then the blood pressure blows off the partially formed platelet clot and the body has to start over. Over the
next few hours 4 to 8 hours or so a fibrin clot will form. This is the stronger clot.
c. When do I wash it and how?
i. If it is a small-ish cut and isn’t bleeding too fast and you are in a
place where you can just wash it out immediately just do it before you stop the bleeding. There is a lot of disagreement
between folks selling product as to how to wash and ‘disinfect’ a cut. The following is my view, which does happen to be
backed up by non- profit research. First let me say that any bacteria in a cut come from what ever made the cut in the first
place and how much dirt it has been exposed to since it happened. The salient fact is that when considering washing
methods the number of bacteria in a cut is inversely proportional to the amount of clean-ish fluid you run through it.
Water is the most commonly available fluid even on a boat. Fresh water is way better than salt water but if there is only a
little fresh and the wound is very dirty for some reason, like you fell on some sandy coral, rinse it with salt water then
follow with as much fresh water as you have. Remember that most salt water has bacteria in it and some of those bacteria
are nasty and poorly understood. There is a risk in using salt water, however, if the cut occurred in salt water this risk is
already taken. Personally, if I have fresh water I’m going to use it (probably not if I only have a little and I’m thirsty). It is
also important to gently agitate the wound to get the water to flush out all the little pockets and spaces. This might sting.
Well, this will sting but it really should be done.
ii. If the wound is contaminated with motor oil use soap and be generous. Oil doesn’t contain bacteria necessarily but the
body can’t heal through it so the body will wall it out and heal from the bottom up which, isn’t bad but does leave more
scar and takes longer.
d. Personally, I do not believe in ‘disinfecting’ a wound. The reason is that a fresh cut is not actually infected yet by
definition, it might be contaminated but it is not infected as yet. When you use Iodine, Betadine, peroxide or the like they
do kill the contaminating bacteria but they also kill the first layer of normal cells. These dead cells then become vulnerable
to other bacteria that inevitably get in there and feast on the dead cells creating an actual infection.
e. How to dress the wound?
i. The best initial dressing is one that continues to put a bit of
pressure on the wound during the next few hours while the fibrin clot is forming. A straightforward band-aide won’t do
this. This is the place for your medical duct tape = Coban. Wrap this on with a few layers. If it is a finger and it is still
bleeding wrap it a little tight. It will throb but you can loosen it an hour or so after the bleeding stops. Don’t leave it tight
enough to be throbbing all night. When it bleeds through the dressing just put a bit more on top without taking the
original off. If you do the platelet clot will be blown off and you start over.
ii. Change the dressing every two days. Soak it off. Don’t pull it off. If you dip it in motor oil you have to remove it. Wash it.
And redress. Keep it covered at least 5 days, longer if you want
f. Does it matter where the cut is?
i. Not for the basic stuff above. Soft places are harder to push on
effectively. To deal with that push over a larger area.
g. What if blood is continuing to squirt out even after I have pushed for a
long time like an hour?
i. That could happen if it is in the area of a major blood vessel. Make sure you are pushing in the right place, sometimes
you have to move toward the heart a little but just keep pushing and seek help unless you are prepared to find and tie off
that vessel in which case you don’t need this book. Ultimately, it doesn’t matter even the largest vessel vein or artery will
stop bleeding if you push long enough and don’t take breaks. So, if it is still bleeding (if you know this you must have let up
to take a look) just push on it more consistently and longer.
ii. What about tourniquets? This is basically applying pressure closer to the heart than where the bleeding happening.
This is good but the problem is it only works on an arm or a leg where you can get around it and it also cuts off the blood
supply that is likely flowing through other blood vessels that are not cut. So, basically tourniquets are ok when you don’t
have extra hands to push or if you have to move the person or if it is you that is injured and you can’t stop to push. But,
you have to release the tourniquet after some period of time that is vague, an hour, some say 30 min, and you might blow
off the clot when you do. Direct pressure is preferred to tourniqueting if at all possible.
iii. Or it could be that there are drugs involved that are slowing down the platelets; aspirin Ibuprophen some others that
basically contain aspirin or ibu. Interestingly, the “blood thinners” that older people with stroke risk are taking don’t
affect the platelets but do affect the fibrin formation. However, many of them are also taking some aspirin. So the answer
is keep pushing till it stops. It doesn’t matter what the reason is.
h. What about nerves and other stuff?
i. Depending on where the cut is and how deep it is this can be
important but it only really comes into play if you are considering never seeking help. If you are going to see a medical
professional as soon as practical then this consideration can wait. If you are thinking of going on your own judgment then
it is pretty simple. Everything has to work. And, you have to test it all to make sure. You have to test it enough to be really
confidently sure regardless of how much that hurts.
ii. Watching a wound over time where you are trying to avoid going to the doctor.
1. My opinion is that changing dressings every two days is the most you need. Clean it well and then let it heal. I’ve
personally left a wound 4 or 5 days when I know for sure it is clean. The only real reason for taking down a dressing is to
see if it is getting infected. The first sign of infection is increasing pain so in-fact you don’t really
need to look at it but you do have to have good information. When the cut is on someone else I have learned that you can’t
trust what they are saying and looking every two days is the best you can do.
2. All that said, if the wound is getting splashed with salt water just assume it is getting infected and wash it at least every
day.
i. If a wound is becoming fire engine red with shinny skin around it or becoming increasingly painful and or tender,
swollen or draining, not clear yellow fluid but cloudy thick fluid, or any one or two of these, it is infected and you need
help. Antibiotics are likely required. If you have some start taking them (Cephalexin if the cause is suspected to be dirt,
Doxycycline or both if seawater is involved, pretty much any antibiotic is going to be better than none). Until you can get
help soak the wound in warm to hot water three times a day with 50% peroxide if you have it, for at least 30 minutes and
elevate the wound above the heart when not soaking to increase circulation. This may slow things down and buy time but
probably won’t fix it. Plan to see a doctor asap.
5. Whacks and bumps: Straight forward impact without skin injury.
a. A whack against soft tissue that is hard enough generally breaks the
blood vessels beneath the skin causing bleeding and the classic discoloration of bruise. If the bleeding is fast you get more
of a bump as in a bump on the head. In the first hour or four it will flatten out as that blood spreads out. Hitting a nerve
hurts but isn’t treated differently. Hitting a bony prominence like the skull or an elbow hurts because the nerves by the
bone are sensitive and without padding but if you don’t break anything it is not special. Put elevate it and ice on it.
b. Important bumps or whacks by location:
i. Head, The head is the scariest bump of course but it is also one
of the simplest. Much is made on TV and news about head injury in the modern world but if you are not near a large city
and trauma center it is not so complicated. This is because there is only one treatment for head injury besides rest and
that is surgery. If you personally are able to refuse surgery, even if you are in a city, you probably should. It is one of the
oldest forms of surgery because if you need it you are still alive but you are unconscious so people around you can do
whatever they want, hence all the holes drilled in skulls of antiquity. What I’m saying is; surgery is generally a last resort
for the very badly injured and everyone else should just use ice and rest there is no middle ground.
ii. All other things besides severe obvious brain injury don’t really matter.
1. Like, did you break your skull? No treatment. We don’t care.
2. Or do you have a concussion? No specific treatment, just rest and if your head hurts rest some more. If you get tired
early just rest. Just rest and don’t drink alcohol because if you pass out someone might come by and operate on your head.
iii. And then from TV there is “you have to stay awake,” which is the opposite of rest and is only good for sit-com plots.
Yes, it is good to have someone check to see if you are asleep or unconscious every once in a while so they can cut on your
head if they want. Or more likely arrange for someone else to do that.
iv. So Ice and rest. Elevation too of course but generally your head is already elevated. That is pretty much it outside of a
trauma center.
v. If it is bleeding we already covered that.
1. And yes, it is a BAD idea to take aspirin Ibuprofen ie
Motrin and the like. You can take Tylenol
(acetaminophen) If you take prescription blood thinners skip a dose or two at least.
a. A note: One of the latest feeding frenzies in US medicine is the person who is on a blood thinner and hits his head. More
and more people are on them and the definition of ‘hit your head’ is getting pretty silly. The frenzy is about Mandatory CT
scans! Observation not good enough. Lots of little bleeds are found stimulating lots of transfers and lots of
hospitalizations. There are some but not so many surgeries. Lots of liability issues. Lots of money changing hands.
vi. Questions:
1. “But it he might need surgery shouldn’t we get him to a
hospital where they can (and here the euphemism) “make sure.” I never really understood “make sure.” It means turn the
responsibility over to someone else who supposedly knows something. But since there is no magic it means do a scan for
lots of $$. It is helpful to remember that the decision to operate is clinical, meaning it depends on what is happening to the
patient. It is not scanned based. So the scan helps you to decide how to observe the patient not what else to do. So if you
have a CT scanner on your boat using it would be cool but otherwise it is just ice elevation and rest.
a. If you hit your head and don’t get knocked out, your likelihood of needing surgery is very, very low, as long as you are
normal and stay that way. I’m not going to quote numbers. For some people any number above 0 is too much. These
people don’t understand numbers. For others a 50/50 chance is fine. These people don’t understand consequences. I can’t
help.
b. If you hit your head and do get knocked out or are otherwise not normal for a short while but now you are awake and
normal the likely hood of needing surgery is very, very low. Pretty close to if you didn’t get knocked out at all as long as
you stay normal.
c. If you hit your head and you are not normal, even if you were normal for a while then there is probably big trouble. But
still, there is nothing new to do except arrange to go see if they want to operate on your head. Usually, if you get worse it
is in the first 24 hours (~90%).
d. Not normal can mean anything like drunk walking, slurring speech numbness and weakness, real confusion getting
worse, (not ‘he is acting funny’). A little bit of nausea or vomiting only once is unlikely to require surgery. These situations
where the person is not normal are significant head injuries where it would be good for you to move toward medical care
while resting and hoping for the best. In this setting in a US hospital we do lots of images and watch for progression of
injury but it is the person who continues to get worse who really benefits from surgery.
vii. Top of the head
1. A hard blow to the top of the head is worrisome if it has
significant force like falling down the gangway. All of the above applies plus the possibility of having broken the first
cervical vertebrae, which is a good road to paralysis. You might even feel Ok for a while, well not OK but not paralyzed
because there is quite a bit of room in there for swelling before the spinal cord gets crushed.
a. Luckily there has been some very good research into this. The Nexus trial produced the “Nexus decision rule”.
Specifically this is the question: Do I need an image? These days that means CT or MRI but in small hospitals a regular x
ray. So if there is any risk of a break we need an image. The rule has five parts.
i. Patient is not drunk.
ii. Patient doesn’t have some other painful
injury that is distracting from examining
the neck.
iii. There is no alteration of consciousness
from head injury.
iv. There is no neurologic problem present,
no numbness, weakness, visual problem,
or ANY other problem.
v. There is no tenderness when you touch in
the exact middle of the back of the neck. This is the important one.
1. The person should be on their back on a flat surface.
2. Touch and press in the groove in the center of the back of the neck
3. There should be no pain with pressure. There can be tenderness in the muscles to the side but not in the center groove.
b. If there is tenderness then you have to stabilize the neck as best you can. A rolled up towel and duct tape can work well.
It has to be snug so you need a beach towel size. Think of a big collar that keeps the person from moving the head. The
swelling comes, (24 to 48 hours) the swelling goes, (can be a long time) hopefully without causing so much pressure that
it blocks the blood inflow. Surgery early is for the relief of pressure. Usually 24 hours, if not immediate due to bleeding
and this usually doesn’t turn out so well. Surgery late is for stabilizing the bone but usually we will do some kind of
external stabilization and let it heal. Either way if the neck is tender in the midline they need professional help a.s.a.p.
viii. Side and back impacts.
1. Hitting the side of the head is not special. Just usual
head bonk info. Same with the back.
c. Neck
i. Pretty much covered this in the last section on a blow to the
top of the head. Striking the neck directly is unusual and is generally just a muscular impact. So Ice and contusion stuff.
The exam and the decision rule is the same as before and revolves around tenderness in the midline.
d. Clavicle impact
i. The clavicle or collarbone is a common place to hit when you
fall shoulder first. Broken collarbones are painful and hurt with direct pressure over the injury. They heal well and don’t
require any special treatment. Bone doctors argue about use of slings or braces to hold your shoulders back etc. There
should be no numbness in the arm or hand. If there is and it doesn’t go away in a day or so off to the nearest doctor you
should go.
e. Ribs
i. You can’t tell a broken rib from a bruised rib by anything other
than an x-ray. And even in an ED the x-ray is just for curiosity and billing purposes. If you have trouble breathing not just
pain that is a problem. Perhaps there is a lung injury. Injured ribs just hurt. They hurt a lot so sometimes it is hard to
separate difficulty breathing from it just really hurts a lot.
f. Finger nail bash with blood under nail
i. This is when you smash your fingernail and there is blood under it and it is throbbing to beat the band. Letting that
blood out will help with the pain but is otherwise optional. A non oily wood drill that is nearly new and about 1/16 or less
in size can be spun BY HAND right over the blood spot until you get a drop of blood out.
ii. Purists wouldn’t do this without an x-ray to make sure there is no broken bone under the nail because by drilling a hole
you would introduce the possibility that said broken bone might get infected. Personally I have never seen this happen
but, of course, it could and you could get sued for it.
6. Joint injuries
a. These come in two categories.
i. It looks Ok in the beginning... but then a question arises.
ii. It looks funny right off, that is crooked, out of shape or doesn’t
work right.
1. Easy ones
a. Fingers and toes
i. Broken or dislocated it doesn’t matter the
answer is pull on it longitudinally that is, along the direction the end part is pointing to. Once you get it pulled then move
it to its normal position. Often it will snap into alignment. Then splint it.
ii. There are times when it won’t come straight. In this case you have to actually re create the injury by bending it
backwards a bit while pulling.
iii. This is difficult to put into words perhaps but all you have to do is think of a green stick that you have broken. The
break is not straight across but rather jagged and having splinters that are still holding it partly together but also keeping
it bent. To get this to go straight you have to bend it more to the opposite direction (that broke it in the first place) then
pull and try to get the broken pieces to slide back together. Doing this with a wooden stick is actually good practice.
b. Knee cap
i. The knee cap can break by direct impact
and there is nothing to do but splint the knee fairly straight and then verify it with
an x-ray. It generally heals but often requires a wire. So seeing a doctor is a good idea but a few days won’t matter. I won’t
say that some Ortho guy won’t disagree with me so make the call a.s.a.p.
ii. Or the knee cap can be dislocated or slid to the side, usually it goes to the out side of the knee. This hurts a lot and is
easy to fix. You simply straighten the leg. It hurts like blazes for a second and then becomes almost normal. No splinting is
required.
2. Medium hard: Deciding what to do with these depends entirely on where the boat is. Even two days from help it might
be Ok to splint in place and head for help but if it is longer, if there is numbness or if the extremity becomes pale and cool,
in other words it isn’t getting enough blood then your hand is forced whether you like it or not.
a. Shoulder dislocation and break
i. The way to tell if it is dislocated or broken
is to slide your fingers along the top of the shoulder from the neck town the trapezius to the curve of the deltoid. So down
the top of the shoulder. If there is an abrupt drop or step off, where the shoulder should be rounded it is very likely
dislocated. The person will also be holding the arm against their body and having pain with any movement.
ii. If the shoulder is broken the symptoms depend on whether it is broken in the upper arm bone or on the clavicle or
body side.
1. The body side often doesn’t hurt as much as you might think but it pinches with movement and just doesn’t feel right.
Sometimes after the swelling occurs in a couple hours the swelling presses on nerves and causes tingling or aching in the
lower arm or hand.
2. If the upper arm bone or humerus is broken it will hurt with any movement like a dislocation but there will be no step
off and there will be grinding that you can feel
b. What i.
ii.
with your hand at the elbow when there is any movement. It will hurt when you push up on the elbow while holding the
shoulder that is, compressing the humerus bone.
3. Dislocations also produce fullness in front of the shoulder relative to the un injured side.
4. Of course it can be both dislocated and broken. Not an easy situation to be sure about without an x ray.
to do.
The safest thing especially when you can’t tell if it is broken or dislocated is to lay the person down on a table or high
bunk where their injured arm can hang off the side. You then tie a 5 to 10 lb. weight to their wrist, not more, and wait.
Alcohol as a relaxant can actually help here but you wouldn’t want them to get nauseous. Often, after a while which can be
an hour or so, a dislocation will simply slide into place. A Humerus break will straighten as much as it is going to and
sometimes these remain rather crooked but ultimately heal well regardless. A proximal or body side break to the
olecranon or styloid, which are parts of the wing bone, won’t really be affected by this procedure.
Next see if the person can bend the elbow 90 degrees and bring it elbow over in front of their body. If so the dislocation
has been relocated and splinting in this position is best. Check to see that the step off is gone.
If it is still dislocated they really won’t be able to get into this position and will resist moving their elbow over in front of
their belly.
There are a lot of other methods to relocate a shoulder but all require some hands on teaching or at least u-tube-ing If it is
a humerus break in front of the body with the elbow bent is still the best place to splint.
iii.
iv.
v. vi.
vii. In both cases a sling around the wrist and a band around the body keeping it next to the body is best. A dislocation can
reoccur if the arm goes out 90 degrees or over head even in sleep
c. Shin bone
i. This bone is large and strong which
doesn’t mean you can’ t break it. If it is broken you can’t bear weight. But just because you can’t bear weight doesn’t mean
it is broken. Some of this has to do with your pain tolerance. Being too macho isn’t good. Elevate it and put ice on it and
see what happens. A bruised Tibia will feel better in a while a broken bone won’t. If it isn’t getting better splint it and stay
off of it till you can see a doctor. Obviously elevate it and use ice if you want.
d. Ankle breaks and dislocations
i. An ankle that can bear weight now and
right after the injury occurred even if it hurts to do so and that does not have any tenderness on the tip of the outer ankle
bone is unlikely to be broken
ii. The only ankle fracture or break (they are the same thing) that doesn’t produce a floppy ankle is a break of the outer
fibula bone. This is the bone that forms the outside anklebone. A break of this bone hurts but generally heals well and
splinting is just as needed to reduce pain. A fibular break feels pretty much the same as a bad sprain and can be treated
very much the same. If you absolutely have to you can bear weight on this as tolerated but it will swell more and you will
pay.
iii. Ankles generally don’t dislocate without breaking. Such an ankle is floppy.
iv. A floppy ankle is just that; it’s loose. It can be loose and crooked. If it is crooked it is important to pull on it directly
down or away from the knee, by cupping the heel and holding the fore foot pulling directly away from the knee. No
twisting is
required. Once you have it straight have someone place a rolled towel under the arch and up the sides of the ankle and
wrap it with duct tape. Sometimes it is helpful to lay it in a second towel folded around the calf down to the foot to create
even more bulk is helpful. Don’t wrap anything round and round except the tape holding the towel, which shouldn’t be too
tight.
v. A round and round ace bandage is not for a floppy ankle but rather a sprain where there is pain on the outside but no
deformity or instability.
vi. An ankle, like any other injury that is getting worse and worse needs more rest and more professional doctoring.
e. Wrist
i. Broken wrists hurt quite a bit and can be
deformed by rapid swelling due to bleeding or the actual bones being crooked. It is pretty hard to get these straight
without anesthesia. You have up to a week or so before anything absolutely has to be done.
ii. A dislocated wrist is rare but in line pulling or laying over the edge of a bunk with weight tied to the fingers may help.
Mostly, you won’t be able to be sure with out an x ray. A situation of a funny looking wrist that hurts really bad often with
increasing numbness in fingers where splinting and elevation isn’t helping much needs a doctor but you have time, days
not weeks. Head to port and your nearest x ray.
iii. Splinting with a large kitchen-serving spoon wrapped with a small towel and duct tape seems to work better than
something flat. Splinting in the position that the person is holding it is usually Ok.
iv. If it is really crooked some in line traction or weight hanging is in order and getting to the doctor faster.
v. If there is numbness or tingling in the fingers swelling may be pushing on the
nerves traversing the wrist. Elevation is
the answer.
vi. Any crooked wrist should see a doctor
eventually.
3. Hard ones where it would be asking a lot for a nonmedically
trained person to have a clue what to do or how to do it much less have the confidence to actually make it
happen. They all require significant relaxation or anesthesia. All these should see a doctor a.s.a.p. That said:
a. Elbow: Dislocation is where the forearm bone is forced rearward from the upper arm bone. The elbow is fixed at 90
degrees usually. The move is to pull hard away from the shoulder and gradually straighten the arm.
b. Knee (Not knee cap). This is where the lower leg usually goes forward relative to the knee but it can be the other way
around. The danger is stretching of the blood vessels and nerves. Pulling hard and a long time in line with the leg is the
move but to pull hard enough the person’s upper body would have to be tied in place and you would have to be able to
use your body weight not arm strength. It is a slow constant increasing pull. It is possible to do it wrong and cause damage
so if you are anywhere near help working on getting that help is probably better. If the foot is white and cold meaning
getting no blood your hand is forced and you have to try.
c. Hip. Here the ball of the hip usually winds up behind the socket. It happens most often in people with artificial hips and
some of these folks have learned what to do. The person is usually holding the leg up at 90 degrees. The move is to weight
down the pelvis and pull up on the leg with the knee bent. It takes a lot of force even with anesthesia but there is less
likelihood of causing more problems than with the knee. So it is not unreasonable to try since the person will be
immobilized and in pain until it gets fixed. Tying the legs together in the flexed position is as good as you can usually do
for stabilization while you head for help.
d. Fore Foot. This is usually a fracture dislocation from getting the foot caught and then falling one way or another. The
foot will be floppy below the
ankle and it will swell al lot. The best you can do is stabilizing it with towels and duct tape, elevate it constantly and use
ice while heading for help. This can be a debilitating injury even with help and time does matter.
7. Eyes
a. Tangent lighting,
i. Spot on the cornea
1. Having a something lodged on or in the cornea is
painful. It is very hard to get this out without anesthesia and a very confident stable hand. Washing with lots of water is
second best. The cornea can scar from a foreign body that stays too long. However, while you are heading in the thing
often will pop loose and the eye may heal in 24 hours. If the eye doesn’t hurt sees well and looks normal with tangent
lighting it is probably normal but if you are worried and have access having a professional look is a good idea.
ii. Blood layering out over the iris
1. This is bad go to the doctor.
8. Swallowed a fish bone
a. The problem with this is that if you really do have a fishbone stuck in
your throat it can cause infections and hurt basically till it comes out but most of the time when you think you have one
you really have a scratch caused by a fish bone. There is no practical way to look down there without special equipment
and knowledge much less pull anything out. So, the best you can do is sip on soothing fluids like milk not whiskey and see
what happens. If it is a scratch it will be better tomorrow and gone in two days. If it is a persistently caught bone it will get
worse and worse. Both can be pretty uncomfortable in the first hour or so and making your self cough or gag doesn’t help
and may make it worse.
Medical issues
1. Headache: While painful most headaches are do not cause lasting injury. The exception is the Headache due to bleeding
in the head.
a. While quite rare the most reliable characteristic of this headache is that it comes on suddenly and is maximally painful
in the first minute. It is diagnosed with a CT or MRI scan of course and making way to the nearest medical facility that may
have one is worthwhile though there is no easy treatment. In a modern center with up to date neuro- surgery a procedure
to stop the bleeding by going through the vessels and planting a coil is done but it needs to be accomplished quickly. It is
not likely that you can get a crewmember to an advanced center quickly enough without helicopter transport.
b. Baring advanced treatment rest is the best you can do. Maintain fluid intake and lying down with no exertion is best. I
think if I was alone and I could I might just drift for a while. This headache is pretty incapacitating. Any lessor degree of
headache is unlikely to be due to a bleed. Bleeds are quite rare.
2. Difficulty swallowing
a. Choking. Heimlich maneuver is fairly well known now. Even if you
have only seen photos you can probably do it. Failure is more likely if you don’t try. There might not be much time. This is
a good thing to look up on You Tube and at least know what it looks like.
b. The child who swallowed something.
i. Small children; those that can be held in one hand can be
turned upside down and a couple of sharp raps on the back. This is stuff you can learn in a emergency course but even
watching You Tubes can be better than nothing.
ii. Children who are too big to hold can be bent over a knee or any way to get their airway upside down. But another
school of thought is that if they are not infants they are just small adults and Heimlich is the best.
c. If this is a chronic problem that has gotten worse but fluids can still be swallowed waiting is best. I wouldn’t try to ‘force
it down’ with bread or whisky.
d. If this is a sudden problem and nothing, not even saliva, can be swallowed you will need to head for port. It is likely that
the obstruction will resolve on the way but that can’t be known. A bit of steak not chewed well is most likely to be the
problem and although it is uncomfortable it is not life threatening unless it goes on for a day or so. Most people with this
problem have had it before and know what to do. If it is the first time waiting it out will likely work. Afterward they still
need to see a GI specialist at their next opportunity and chew well until then.
3. Sore throat
a. These are common of course and most are viral, which as everyone knows do not respond to antibiotics. Of course lots
of people think they are different and only get better with antibiotics. How special.
4. Sore throat that gets worse and worse.
a. It is important to look in the throat. White spots really don’t mean
anything, viruses and bacterial throats have white spots. This is the
body fighting the infection.
b. A bad case of halitosis, green pus and large tender nodes under the
jaw... I would take the antibiotics. Most strep throats come on faster than viral throats and are bad in a short time. Where
the pain of a viral throat plateaus the strep throat keeps hurting more. Often fever is more prominent but viruses can
cause fever too.
c. The decision to take an antibiotic is thus not clear. If you know you tolerate the drug well, and you have some and you
are worse trying it is Ok with me. I might try in for 48 hours. If the results aren’t dramatic it is probably a virus and you
are wasting your pills. If the results are good take the drug for at least two days longer than you have any symptoms. No,
this is not what the AMA says.
d. One sided swelling with pus pushing the Uvula (thingy that hangs down in the middle) over to the side. This can be a
peri-tonsilar abscess and can grow to close the airway. You need help pretty quick. Take the antibiotics if you have them
but it probably won’t fix it. Head in.
5. Chest pain
a. Most chest pain is not from the heart. Most of it is sharp, well
localized, and doesn’t last too long (less than 5 min.) This type of chest pain is from the esophagus or the chest wall well
over 90% of the time. It can be recurrent and pretty severe but goes away with rest and calming down.
b. Cardiac pain, pain from the heart, is typically poorly localized, dull, and associated with at least one secondary symptom
such as nausea, shortness of breath, (not panting), radiating pain (though esophageal spasm can also radiate.
i. If you think it is cardiac put the person at rest, give an aspirin and drink water not alcohol. If you can head for port great
but when the pain goes away, even if it was a heart attack the person is going to look pretty normal afterwards which
doesn’t change the risk that it is going to happen again so once you decide to seek help stick with it.
c. Hyperventilation and panic
i. These problems are perhaps the most common medical
problems and quite difficult to deal with. Seasickness can be combined as well. The important thing to remember is
although the crewmember may be panicking it is very important that others do not. A calm demeanor in the presence of
the panic is essential to the boat and the patient.
ii. Alcohol does not help.
iii. Hyperventilation symptoms are a cascade of symptoms
depending on the severity of the problem. Symptoms range from; the sensation of shortness of breath or ‘can’t breathe’
even though in truth they are breathing too much, next tingling, then dizziness, next tetany or involuntary contractions of
first hands then face then the rest of the body and finally passing out. At that point breathing will normalize and the
person will wake up in a few minutes but may repeat the entire thing.
1. Breathing in a paper bag is hard to do because the bag has to be sealed to the nose and mouth for at least 10 minutes
without ever letting go. Every time you let go you start over.
2. I have had better luck with
a. Have the person count their respirations against
a clock for a full minute and then repeat to see if their rate is decreasing. Often the mere distraction of this helps.
b. If they are getting through the counting then have them try slow their breathing for the next two minutes counting each
respiration to see if they are speeding up or slowing down.
c. Breathing too deep can also cause hyperventilation even if it is only 8 per min.
d. Hyperventilation usually lasts less than a half hour so you can often just wait it out. Sitting with them and doing the
counting with them often helps.
e. This can be a problem in rough seas a problem that is best known before leaving the dock but that is not always
possible.
6. Shortness of breath (not related to hyperventilation, note that if there is tingling of the finger tips the likelihood of
hyperventilation is near 100%)
a. This is generally a problem that the person knows about and has medication for so it is nice to know that all your crew
has their meds and is taking them.
b. So Shortness of breath not related to hyperventilation is about the heart or about Allergy or Asthma. Asthma essentially
always has a history so the person knows. New Shortness of breath can be allergy or heart. If there is a suspected allergy
give 50mg oral Benadryl (diphenhydramine). If it is heart give Aspirin. Allergy should be better in an hour and you can
repeat the dose or half the dose in 30 min if needed. If you think it is heart then treat it like chest pain.
7. Abdominal pain: In general abdominal pain without tenderness is less likely to be something bad than pain with
tenderness even if the tenderness isn’t so
severe pain wise. Tenderness means it hurts worse when you press on it. The less pressure it takes to make it hurt worse
the more likely it is to be something where you need to abort and head for help. Note that it is not the severity of the pain
that matters but whether it is tender or not. Often really bad pain is not tender and not associated with the need for
intervention while moderate to mild tenderness can be very important.
a. Upper center: This means pain in the very top of the abdomen between the junctions of the ribs.
i. First, this can be chest pain and especially if there are other symptoms as stated in sections 4 and 5 above it should be
considered cardiac until proven otherwise.
ii. However if it is pain with tenderness, that is it hurts more to push on it then it is less likely to be from the heart and
more likely to be stomach or pancreas. This is especially true if there was preceding alcohol involved.
iii. In either case or in the case of ulcer the best you can do is give liquid antacid if you have some or milk and wait it out.
iv. If vomiting develops especially bloody vomiting then the ante went up and you should head for shore. A few flecks of
blood in yellow fluid is not bloody vomiting. Bloody is bloody throughout and usually happens more than one time. This is
a dangerous situation without medical care. The person can sip water. It is better to be hydrated than not and if their
stomach is bleeding it isn’t going to make it worse. Alcohol will definitely make it worse.
b. Mid center: Meaning around the umbilicus.
i. This is usually related to the small bowel and is crampy but
likely to go away.
ii. In a rare case it will get worse and worse to the point where
the abdomen is tender through out. If that happens it is bad
and medical care is imperative. Possible obstruction.
c. Lower center: This means between the umbilicus and the pubis
i. This is most likely related to colon or large bowel. Similar to umbilical pain it is usually not tender and usually crampy.
ii. Again tenderness is the key.
d. Positions lateral: Upper Right: Gall bladder.... Lower Right: Appendix.
Upper left: usually non-specific Lower Left: sometimes diverticulitis. However these positions are often wrong and
Appendix can be in the middle or left. You can’t go on position much and at sea and you don’t need to diagnose but just
decide if you need to turn back or alter course. Some one who is getting worse over 3 to 6 hours or is developing
tenderness needs to get your attention.
e. Note that it is better to examine someone no more often than every half hour. If you check too often you will be less
likely to notice changes.
8. Seizures
a. A seizure is an uncontrolled discharge of electrical activity in the brain. It can cause anything from an absent stare to
convulsions of the whole body. Generally, they are chronic and the person should know about them, have told you as
captain that they have them, and they should stay on their medications. It is surprising how often people don’t count their
pills and run out! What to do about that I have no idea.
b. A seizure can also follow head trauma and means you should head for port or call the helo.
c. During a seizure all you need to do is point their mouth in some direction so that if they vomit they won’t inhale the
fluid.
d. Most seizures last less than a minute. A seizure that last 3 to 5 minutes is a long one. One that lasts longer can often get
smaller or even seem to stop but the person doesn’t wake up. This is because the body and brain get tired but it is still bad
and they need medical help ASAP.
e. After a seizure is like re-booting a computer. It takes a while 20 min but usually less than an hour for things to
normalize. If they are not back to normal in one hour consider getting to help quickly.
f. A person who has known seizures. Is on their medications but still has them occasionally is Ok to observe if they have
one on the boat and they return to normal quickly. Some people have to live with this. It would be a danger if they were on
deck or if they fall but that is essentially the risk they live with. So coming aboard is their choice in my opinion.
9. Diarrhea: Diarrhea that is not bloody can be treated with replacing fluids. If the person will drink they will be Ok for
days.
a. If the diarrhea is maroon colored or black and sticky it is blood (smells terrible)a. Turn around or alter course. This
person is in trouble. Alcohol will make it worse.
10. Urinary retention: This can be a problem if you don’t have a Foley tube on board. This is a special tube for inserting
into the bladder. An untrained person is not likely to take this on.
a. A person who hasn’t peed in 8 to 12 hours and who has pain, tenderness and fullness in the area of the bladder needs
attention. If you have a tub and can fill it with warm water than might get things started. Retention can be caused by a lot
of medications like antihistamines. It is not immediately life threatening but can get to be very painful and once the
bladder is very over full it becomes even harder to pee the usual way.
b. This is an unusual problem for someone to have that hasn’t had it before but if it starts I would personally alter plans to
get that person taken care of. Oddly, if I didn’t have any other options, alcohol might get this situation to relax enough to
relieve.
11. Swollen leg:
a. Most swollen legs are not blood clots.
b. Most blood clots in the lower leg don’t do any damage but a leg that is swollen to well above the knee is a threat. This is
where a blood clot forms in the veins where it is not supposed to be and can subsequently break loose and lodge in the
lung causing shortness of breath and other problems.
c. These legs are not usually bruised looking just swollen and tender.
d. This is a medically treatable emergency and would warrant a change
of sailing plan. If the person suddenly becomes short of breath now you have to hurry more. If oxygen is available for
some reason it would be good to use.
e. The only thing you can do aboard is elevating the leg. Keeping it down won’t keep the clot from moving.
f. Blood clots are made out of fibrin so aspirin plays little role but you should have it and it might help somewhat so most
people say give it. One aspirin a day is enough when you are dealing with clotting. Think of a teeter-totter you want to
push just enough not too much.
12. Last comments on doing nothing, doing harm, and just not helping because you are scared.
a. Of course there is no dividing line between what a layman should be able to do and what is too much or too dangerous.
Fortunately, we have experience judging this type of thing since it is very similar to deciding if the seas are too rough or if
you and your boat are ready for any given crossing.
b. I mean: use your judgment.
c. Doing nothing can be as bad as doing something but doing nothing
because you are afraid of causing pain is like not raising your sail in a
10 knot beam wind.
d. How to gain the confidence to raise sail is up to each of us
Originally posted by Dale Phillips
· February 24, 2020 ·
A huge gift from Donna and Patrick from Jersey Girl
Shipboard Emergency!
1. Introduction:
a. Who am I
i. Retired Emergency Physician. License un-renewed 2018
ii. 35 years in rural ER’s
iii. Wilderness survivalist and instructor
iv. Wilderness awareness and tracking instructor
v. As a physician I was not at the top of my class nor did I seek extra letters to place behind my name. In general I was a
rogue who looked for the simple way and who distrusted anyone who was being paid as a sales person, which, toward the
end, was pretty much everyone.
b. Considerations for sourcing medical information
i. Despite quite a few years of scientific investigation there is
very little that is known for a certainty, much less than you would imagine. Certainty means multiple well-designed
scientific studies done by persons and institutions that do not have a financial connection to the process or product being
studied and agree on the same outcome. This is class A information.
ii. Class B information is when multiple but poorly designed studies that may have been done by interested parties that
don’t study exactly the same subject in the same way but never-the-less seem to generally agree at least according to
some people who often are ‘experts and leaders with a lot of letters behind their names but are also likely to be paid to
say what they say even while they vehemently deny it.
iii. Class C information, the most common, is what a bunch of white haired doctors have always thought was true.
1. Which has been proven wrong often unfortunately.
iv. Class TV is where most lay people get their actual information.
1. Despite the fact that it could be good information delivered by a powerful medium it isn’t and the creators of it feel it is
their first amendment right to mislead you for laughs.
c. So, when you are trying to understand something medical it is important to at least give some thought to where the
information is coming from.
d. What is the point of a little bit of knowledge?
i. My purpose in making information available in this form is to
help you find the confidence to know when to act and what to do. My father, a physician of profound wisdom said. “Most
of what a doctor does is to try to stay out of the way while the body heals.”
ii. That said, as an emergency physician I did come across a few situations where it was better to do something. It helped if
that something was the correct thing to do and was confidently done.
iii. Even if you have the knowledge, if you do not have the confidence to help someone then you are not really able to help.
iv. At times helping means causing some initial pain. This will be especially problematic if you are out of sight of land and
there are no other options.
2. Eric Weiss MD has written “A Comprehensive Guide to Wilderness and Marine Medicine” He is very experienced in
supporting groups in the wild and has done a good job. This outline is not meant to be quite as comprehensive. He does
speak in terms of ‘worry’ ‘what to worry about’ Personally, I have never found worrying to be of much use. It is like telling
someone to ‘be careful’. If you need to say that the jig is probably already up. I prefer to focus on what to do next.
a. Except when specifically stated the following assumes a normal person before the injury happened or symptoms began.
3. Trauma
a. General stuff regardless of the type of trauma
i. Assessing for stability and sensation
1. In any traumatic injury this is an essential step
2. It means seeing if the nerves, tendons and muscles work
a. So basically see if it works
b. For stability move it around and make sure it
doesn’t move in ways it isn’t supposed to.
i. This is whether it is stable not does it hurt
to move it. It is going to hurt to move it.
a. If a wound or injury is not mechanically stable and awake to sensation
then this means it is going to have to go to the doctor. Ice and Elevation
a. Every body writes it that way ... it should be Elevation and more elevation and elevate it higher for longer and then, oh
yeah, you could put some ice on it too. Elevation means above the heart. Think of a plumbing pipe and you want the
circulation to passively drain back to the heart.
b. Ice constricts the blood vessels, which slows down swelling which is desired but also the general circulation, which is
not desired. Ice is also harder to come by at sea.
b. Splints
a. All the trauma kits seem to hold a large variety of these. Your
kitchen does too and they have at least two purposes, eating and splinting.
i. A serving spoon for the wrist
ii. A small spoon for the finger.
b. Ankles, knees and elbows are best splinted with rolled up towels held with duct tape. The tighter you roll it the stiffer it
is. You don’t need board ridged and you don’t want pressure points that can damage skin.
c. A splint should hold the joint in the middle of its range of motion.
d. If a splint is hurting it has to be removed and looked at. If the skin is getting red from pressure you have to fix that.
e. A skin infection over an injury is bad and avoidable.
4. Cuts: If it is bleeding what do I do? Answer: Push on it.
i. Bleeding is when the red stuff leaks out. Everybody gets
excited when that happens but a little bit of bleeding can be a good thing. It is the only way to wash out an injury from the
inside. That said some bleeding is going to happen with a cut anyway and you don’t have to encourage it. Still, you don’t
have to jump up and down as if there is a timer on a bomb (or as if you are filming a sit-com). Covering it with a handy
(dirty) rag might save your rug but it doesn’t do anything good for the cut.
ii. So the answer for bleeding is always the same. Push directly down on where blood is coming out. If you can find the
spot where, when you push the least hard, it stops the bleeding then that is great but there is nothing wrong with pushing
over a larger area. Push just hard enough so that the blood stops coming out. If it won’t stop push over a larger area and
harder.
iii. Since you are doing this to stop blood from leaking out it is best to push with something that doesn’t act as a sponge.
Despite TV and what is often done in real ED’s this is not a series of sterile cotton squares. You are better off with your
bare thumb or hand. It doesn’t look so cool and gets you covered in blood but it is quick and efficient.
b. What is actually happening?
i. Bleeding happens when blood vessels are damaged. Either cut
or crushed. Partially damaged vessels bleed more than completely cut ones. Either way you are pushing until the body’s
natural process plugs the hole. This is done first by the sticky part of the blood called the platelets. They very quickly
begin to stick to the edges of the cut and if you are slowing down the current (the rate of bleeding) they can stick better. In
a normal healthy person a platelet clot takes at least 10 minutes of constant pressure. If you let up too soon to see if it is
“still bleeding” then the blood pressure blows off the partially formed platelet clot and the body has to start over. Over the
next few hours 4 to 8 hours or so a fibrin clot will form. This is the stronger clot.
c. When do I wash it and how?
i. If it is a small-ish cut and isn’t bleeding too fast and you are in a
place where you can just wash it out immediately just do it before you stop the bleeding. There is a lot of disagreement
between folks selling product as to how to wash and ‘disinfect’ a cut. The following is my view, which does happen to be
backed up by non- profit research. First let me say that any bacteria in a cut come from what ever made the cut in the first
place and how much dirt it has been exposed to since it happened. The salient fact is that when considering washing
methods the number of bacteria in a cut is inversely proportional to the amount of clean-ish fluid you run through it.
Water is the most commonly available fluid even on a boat. Fresh water is way better than salt water but if there is only a
little fresh and the wound is very dirty for some reason, like you fell on some sandy coral, rinse it with salt water then
follow with as much fresh water as you have. Remember that most salt water has bacteria in it and some of those bacteria
are nasty and poorly understood. There is a risk in using salt water, however, if the cut occurred in salt water this risk is
already taken. Personally, if I have fresh water I’m going to use it (probably not if I only have a little and I’m thirsty). It is
also important to gently agitate the wound to get the water to flush out all the little pockets and spaces. This might sting.
Well, this will sting but it really should be done.
ii. If the wound is contaminated with motor oil use soap and be generous. Oil doesn’t contain bacteria necessarily but the
body can’t heal through it so the body will wall it out and heal from the bottom up which, isn’t bad but does leave more
scar and takes longer.
d. Personally, I do not believe in ‘disinfecting’ a wound. The reason is that a fresh cut is not actually infected yet by
definition, it might be contaminated but it is not infected as yet. When you use Iodine, Betadine, peroxide or the like they
do kill the contaminating bacteria but they also kill the first layer of normal cells. These dead cells then become vulnerable
to other bacteria that inevitably get in there and feast on the dead cells creating an actual infection.
e. How to dress the wound?
i. The best initial dressing is one that continues to put a bit of
pressure on the wound during the next few hours while the fibrin clot is forming. A straightforward band-aide won’t do
this. This is the place for your medical duct tape = Coban. Wrap this on with a few layers. If it is a finger and it is still
bleeding wrap it a little tight. It will throb but you can loosen it an hour or so after the bleeding stops. Don’t leave it tight
enough to be throbbing all night. When it bleeds through the dressing just put a bit more on top without taking the
original off. If you do the platelet clot will be blown off and you start over.
ii. Change the dressing every two days. Soak it off. Don’t pull it off. If you dip it in motor oil you have to remove it. Wash it.
And redress. Keep it covered at least 5 days, longer if you want
f. Does it matter where the cut is?
i. Not for the basic stuff above. Soft places are harder to push on
effectively. To deal with that push over a larger area.
g. What if blood is continuing to squirt out even after I have pushed for a
long time like an hour?
i. That could happen if it is in the area of a major blood vessel. Make sure you are pushing in the right place, sometimes
you have to move toward the heart a little but just keep pushing and seek help unless you are prepared to find and tie off
that vessel in which case you don’t need this book. Ultimately, it doesn’t matter even the largest vessel vein or artery will
stop bleeding if you push long enough and don’t take breaks. So, if it is still bleeding (if you know this you must have let up
to take a look) just push on it more consistently and longer.
ii. What about tourniquets? This is basically applying pressure closer to the heart than where the bleeding happening.
This is good but the problem is it only works on an arm or a leg where you can get around it and it also cuts off the blood
supply that is likely flowing through other blood vessels that are not cut. So, basically tourniquets are ok when you don’t
have extra hands to push or if you have to move the person or if it is you that is injured and you can’t stop to push. But,
you have to release the tourniquet after some period of time that is vague, an hour, some say 30 min, and you might blow
off the clot when you do. Direct pressure is preferred to tourniqueting if at all possible.
iii. Or it could be that there are drugs involved that are slowing down the platelets; aspirin Ibuprophen some others that
basically contain aspirin or ibu. Interestingly, the “blood thinners” that older people with stroke risk are taking don’t
affect the platelets but do affect the fibrin formation. However, many of them are also taking some aspirin. So the answer
is keep pushing till it stops. It doesn’t matter what the reason is.
h. What about nerves and other stuff?
i. Depending on where the cut is and how deep it is this can be
important but it only really comes into play if you are considering never seeking help. If you are going to see a medical
professional as soon as practical then this consideration can wait. If you are thinking of going on your own judgment then
it is pretty simple. Everything has to work. And, you have to test it all to make sure. You have to test it enough to be really
confidently sure regardless of how much that hurts.
ii. Watching a wound over time where you are trying to avoid going to the doctor.
1. My opinion is that changing dressings every two days is the most you need. Clean it well and then let it heal. I’ve
personally left a wound 4 or 5 days when I know for sure it is clean. The only real reason for taking down a dressing is to
see if it is getting infected. The first sign of infection is increasing pain so in-fact you don’t really
need to look at it but you do have to have good information. When the cut is on someone else I have learned that you can’t
trust what they are saying and looking every two days is the best you can do.
2. All that said, if the wound is getting splashed with salt water just assume it is getting infected and wash it at least every
day.
i. If a wound is becoming fire engine red with shinny skin around it or becoming increasingly painful and or tender,
swollen or draining, not clear yellow fluid but cloudy thick fluid, or any one or two of these, it is infected and you need
help. Antibiotics are likely required. If you have some start taking them (Cephalexin if the cause is suspected to be dirt,
Doxycycline or both if seawater is involved, pretty much any antibiotic is going to be better than none). Until you can get
help soak the wound in warm to hot water three times a day with 50% peroxide if you have it, for at least 30 minutes and
elevate the wound above the heart when not soaking to increase circulation. This may slow things down and buy time but
probably won’t fix it. Plan to see a doctor asap.
5. Whacks and bumps: Straight forward impact without skin injury.
a. A whack against soft tissue that is hard enough generally breaks the
blood vessels beneath the skin causing bleeding and the classic discoloration of bruise. If the bleeding is fast you get more
of a bump as in a bump on the head. In the first hour or four it will flatten out as that blood spreads out. Hitting a nerve
hurts but isn’t treated differently. Hitting a bony prominence like the skull or an elbow hurts because the nerves by the
bone are sensitive and without padding but if you don’t break anything it is not special. Put elevate it and ice on it.
b. Important bumps or whacks by location:
i. Head, The head is the scariest bump of course but it is also one
of the simplest. Much is made on TV and news about head injury in the modern world but if you are not near a large city
and trauma center it is not so complicated. This is because there is only one treatment for head injury besides rest and
that is surgery. If you personally are able to refuse surgery, even if you are in a city, you probably should. It is one of the
oldest forms of surgery because if you need it you are still alive but you are unconscious so people around you can do
whatever they want, hence all the holes drilled in skulls of antiquity. What I’m saying is; surgery is generally a last resort
for the very badly injured and everyone else should just use ice and rest there is no middle ground.
ii. All other things besides severe obvious brain injury don’t really matter.
1. Like, did you break your skull? No treatment. We don’t care.
2. Or do you have a concussion? No specific treatment, just rest and if your head hurts rest some more. If you get tired
early just rest. Just rest and don’t drink alcohol because if you pass out someone might come by and operate on your head.
iii. And then from TV there is “you have to stay awake,” which is the opposite of rest and is only good for sit-com plots.
Yes, it is good to have someone check to see if you are asleep or unconscious every once in a while so they can cut on your
head if they want. Or more likely arrange for someone else to do that.
iv. So Ice and rest. Elevation too of course but generally your head is already elevated. That is pretty much it outside of a
trauma center.
v. If it is bleeding we already covered that.
1. And yes, it is a BAD idea to take aspirin Ibuprofen ie
Motrin and the like. You can take Tylenol
(acetaminophen) If you take prescription blood thinners skip a dose or two at least.
a. A note: One of the latest feeding frenzies in US medicine is the person who is on a blood thinner and hits his head. More
and more people are on them and the definition of ‘hit your head’ is getting pretty silly. The frenzy is about Mandatory CT
scans! Observation not good enough. Lots of little bleeds are found stimulating lots of transfers and lots of
hospitalizations. There are some but not so many surgeries. Lots of liability issues. Lots of money changing hands.
vi. Questions:
1. “But it he might need surgery shouldn’t we get him to a
hospital where they can (and here the euphemism) “make sure.” I never really understood “make sure.” It means turn the
responsibility over to someone else who supposedly knows something. But since there is no magic it means do a scan for
lots of $$. It is helpful to remember that the decision to operate is clinical, meaning it depends on what is happening to the
patient. It is not scanned based. So the scan helps you to decide how to observe the patient not what else to do. So if you
have a CT scanner on your boat using it would be cool but otherwise it is just ice elevation and rest.
a. If you hit your head and don’t get knocked out, your likelihood of needing surgery is very, very low, as long as you are
normal and stay that way. I’m not going to quote numbers. For some people any number above 0 is too much. These
people don’t understand numbers. For others a 50/50 chance is fine. These people don’t understand consequences. I can’t
help.
b. If you hit your head and do get knocked out or are otherwise not normal for a short while but now you are awake and
normal the likely hood of needing surgery is very, very low. Pretty close to if you didn’t get knocked out at all as long as
you stay normal.
c. If you hit your head and you are not normal, even if you were normal for a while then there is probably big trouble. But
still, there is nothing new to do except arrange to go see if they want to operate on your head. Usually, if you get worse it
is in the first 24 hours (~90%).
d. Not normal can mean anything like drunk walking, slurring speech numbness and weakness, real confusion getting
worse, (not ‘he is acting funny’). A little bit of nausea or vomiting only once is unlikely to require surgery. These situations
where the person is not normal are significant head injuries where it would be good for you to move toward medical care
while resting and hoping for the best. In this setting in a US hospital we do lots of images and watch for progression of
injury but it is the person who continues to get worse who really benefits from surgery.
vii. Top of the head
1. A hard blow to the top of the head is worrisome if it has
significant force like falling down the gangway. All of the above applies plus the possibility of having broken the first
cervical vertebrae, which is a good road to paralysis. You might even feel Ok for a while, well not OK but not paralyzed
because there is quite a bit of room in there for swelling before the spinal cord gets crushed.
a. Luckily there has been some very good research into this. The Nexus trial produced the “Nexus decision rule”.
Specifically this is the question: Do I need an image? These days that means CT or MRI but in small hospitals a regular x
ray. So if there is any risk of a break we need an image. The rule has five parts.
i. Patient is not drunk.
ii. Patient doesn’t have some other painful
injury that is distracting from examining
the neck.
iii. There is no alteration of consciousness
from head injury.
iv. There is no neurologic problem present,
no numbness, weakness, visual problem,
or ANY other problem.
v. There is no tenderness when you touch in
the exact middle of the back of the neck. This is the important one.
1. The person should be on their back on a flat surface.
2. Touch and press in the groove in the center of the back of the neck
3. There should be no pain with pressure. There can be tenderness in the muscles to the side but not in the center groove.
b. If there is tenderness then you have to stabilize the neck as best you can. A rolled up towel and duct tape can work well.
It has to be snug so you need a beach towel size. Think of a big collar that keeps the person from moving the head. The
swelling comes, (24 to 48 hours) the swelling goes, (can be a long time) hopefully without causing so much pressure that
it blocks the blood inflow. Surgery early is for the relief of pressure. Usually 24 hours, if not immediate due to bleeding
and this usually doesn’t turn out so well. Surgery late is for stabilizing the bone but usually we will do some kind of
external stabilization and let it heal. Either way if the neck is tender in the midline they need professional help a.s.a.p.
viii. Side and back impacts.
1. Hitting the side of the head is not special. Just usual
head bonk info. Same with the back.
c. Neck
i. Pretty much covered this in the last section on a blow to the
top of the head. Striking the neck directly is unusual and is generally just a muscular impact. So Ice and contusion stuff.
The exam and the decision rule is the same as before and revolves around tenderness in the midline.
d. Clavicle impact
i. The clavicle or collarbone is a common place to hit when you
fall shoulder first. Broken collarbones are painful and hurt with direct pressure over the injury. They heal well and don’t
require any special treatment. Bone doctors argue about use of slings or braces to hold your shoulders back etc. There
should be no numbness in the arm or hand. If there is and it doesn’t go away in a day or so off to the nearest doctor you
should go.
e. Ribs
i. You can’t tell a broken rib from a bruised rib by anything other
than an x-ray. And even in an ED the x-ray is just for curiosity and billing purposes. If you have trouble breathing not just
pain that is a problem. Perhaps there is a lung injury. Injured ribs just hurt. They hurt a lot so sometimes it is hard to
separate difficulty breathing from it just really hurts a lot.
f. Finger nail bash with blood under nail
i. This is when you smash your fingernail and there is blood under it and it is throbbing to beat the band. Letting that
blood out will help with the pain but is otherwise optional. A non oily wood drill that is nearly new and about 1/16 or less
in size can be spun BY HAND right over the blood spot until you get a drop of blood out.
ii. Purists wouldn’t do this without an x-ray to make sure there is no broken bone under the nail because by drilling a hole
you would introduce the possibility that said broken bone might get infected. Personally I have never seen this happen
but, of course, it could and you could get sued for it.
6. Joint injuries
a. These come in two categories.
i. It looks Ok in the beginning... but then a question arises.
ii. It looks funny right off, that is crooked, out of shape or doesn’t
work right.
1. Easy ones
a. Fingers and toes
i. Broken or dislocated it doesn’t matter the
answer is pull on it longitudinally that is, along the direction the end part is pointing to. Once you get it pulled then move
it to its normal position. Often it will snap into alignment. Then splint it.
ii. There are times when it won’t come straight. In this case you have to actually re create the injury by bending it
backwards a bit while pulling.
iii. This is difficult to put into words perhaps but all you have to do is think of a green stick that you have broken. The
break is not straight across but rather jagged and having splinters that are still holding it partly together but also keeping
it bent. To get this to go straight you have to bend it more to the opposite direction (that broke it in the first place) then
pull and try to get the broken pieces to slide back together. Doing this with a wooden stick is actually good practice.
b. Knee cap
i. The knee cap can break by direct impact
and there is nothing to do but splint the knee fairly straight and then verify it with
an x-ray. It generally heals but often requires a wire. So seeing a doctor is a good idea but a few days won’t matter. I won’t
say that some Ortho guy won’t disagree with me so make the call a.s.a.p.
ii. Or the knee cap can be dislocated or slid to the side, usually it goes to the out side of the knee. This hurts a lot and is
easy to fix. You simply straighten the leg. It hurts like blazes for a second and then becomes almost normal. No splinting is
required.
2. Medium hard: Deciding what to do with these depends entirely on where the boat is. Even two days from help it might
be Ok to splint in place and head for help but if it is longer, if there is numbness or if the extremity becomes pale and cool,
in other words it isn’t getting enough blood then your hand is forced whether you like it or not.
a. Shoulder dislocation and break
i. The way to tell if it is dislocated or broken
is to slide your fingers along the top of the shoulder from the neck town the trapezius to the curve of the deltoid. So down
the top of the shoulder. If there is an abrupt drop or step off, where the shoulder should be rounded it is very likely
dislocated. The person will also be holding the arm against their body and having pain with any movement.
ii. If the shoulder is broken the symptoms depend on whether it is broken in the upper arm bone or on the clavicle or
body side.
1. The body side often doesn’t hurt as much as you might think but it pinches with movement and just doesn’t feel right.
Sometimes after the swelling occurs in a couple hours the swelling presses on nerves and causes tingling or aching in the
lower arm or hand.
2. If the upper arm bone or humerus is broken it will hurt with any movement like a dislocation but there will be no step
off and there will be grinding that you can feel
b. What i.
ii.
with your hand at the elbow when there is any movement. It will hurt when you push up on the elbow while holding the
shoulder that is, compressing the humerus bone.
3. Dislocations also produce fullness in front of the shoulder relative to the un injured side.
4. Of course it can be both dislocated and broken. Not an easy situation to be sure about without an x ray.
to do.
The safest thing especially when you can’t tell if it is broken or dislocated is to lay the person down on a table or high
bunk where their injured arm can hang off the side. You then tie a 5 to 10 lb. weight to their wrist, not more, and wait.
Alcohol as a relaxant can actually help here but you wouldn’t want them to get nauseous. Often, after a while which can be
an hour or so, a dislocation will simply slide into place. A Humerus break will straighten as much as it is going to and
sometimes these remain rather crooked but ultimately heal well regardless. A proximal or body side break to the
olecranon or styloid, which are parts of the wing bone, won’t really be affected by this procedure.
Next see if the person can bend the elbow 90 degrees and bring it elbow over in front of their body. If so the dislocation
has been relocated and splinting in this position is best. Check to see that the step off is gone.
If it is still dislocated they really won’t be able to get into this position and will resist moving their elbow over in front of
their belly.
There are a lot of other methods to relocate a shoulder but all require some hands on teaching or at least u-tube-ing If it is
a humerus break in front of the body with the elbow bent is still the best place to splint.
iii.
iv.
v. vi.
vii. In both cases a sling around the wrist and a band around the body keeping it next to the body is best. A dislocation can
reoccur if the arm goes out 90 degrees or over head even in sleep
c. Shin bone
i. This bone is large and strong which
doesn’t mean you can’ t break it. If it is broken you can’t bear weight. But just because you can’t bear weight doesn’t mean
it is broken. Some of this has to do with your pain tolerance. Being too macho isn’t good. Elevate it and put ice on it and
see what happens. A bruised Tibia will feel better in a while a broken bone won’t. If it isn’t getting better splint it and stay
off of it till you can see a doctor. Obviously elevate it and use ice if you want.
d. Ankle breaks and dislocations
i. An ankle that can bear weight now and
right after the injury occurred even if it hurts to do so and that does not have any tenderness on the tip of the outer ankle
bone is unlikely to be broken
ii. The only ankle fracture or break (they are the same thing) that doesn’t produce a floppy ankle is a break of the outer
fibula bone. This is the bone that forms the outside anklebone. A break of this bone hurts but generally heals well and
splinting is just as needed to reduce pain. A fibular break feels pretty much the same as a bad sprain and can be treated
very much the same. If you absolutely have to you can bear weight on this as tolerated but it will swell more and you will
pay.
iii. Ankles generally don’t dislocate without breaking. Such an ankle is floppy.
iv. A floppy ankle is just that; it’s loose. It can be loose and crooked. If it is crooked it is important to pull on it directly
down or away from the knee, by cupping the heel and holding the fore foot pulling directly away from the knee. No
twisting is
required. Once you have it straight have someone place a rolled towel under the arch and up the sides of the ankle and
wrap it with duct tape. Sometimes it is helpful to lay it in a second towel folded around the calf down to the foot to create
even more bulk is helpful. Don’t wrap anything round and round except the tape holding the towel, which shouldn’t be too
tight.
v. A round and round ace bandage is not for a floppy ankle but rather a sprain where there is pain on the outside but no
deformity or instability.
vi. An ankle, like any other injury that is getting worse and worse needs more rest and more professional doctoring.
e. Wrist
i. Broken wrists hurt quite a bit and can be
deformed by rapid swelling due to bleeding or the actual bones being crooked. It is pretty hard to get these straight
without anesthesia. You have up to a week or so before anything absolutely has to be done.
ii. A dislocated wrist is rare but in line pulling or laying over the edge of a bunk with weight tied to the fingers may help.
Mostly, you won’t be able to be sure with out an x ray. A situation of a funny looking wrist that hurts really bad often with
increasing numbness in fingers where splinting and elevation isn’t helping much needs a doctor but you have time, days
not weeks. Head to port and your nearest x ray.
iii. Splinting with a large kitchen-serving spoon wrapped with a small towel and duct tape seems to work better than
something flat. Splinting in the position that the person is holding it is usually Ok.
iv. If it is really crooked some in line traction or weight hanging is in order and getting to the doctor faster.
v. If there is numbness or tingling in the fingers swelling may be pushing on the
nerves traversing the wrist. Elevation is
the answer.
vi. Any crooked wrist should see a doctor
eventually.
3. Hard ones where it would be asking a lot for a nonmedically
trained person to have a clue what to do or how to do it much less have the confidence to actually make it
happen. They all require significant relaxation or anesthesia. All these should see a doctor a.s.a.p. That said:
a. Elbow: Dislocation is where the forearm bone is forced rearward from the upper arm bone. The elbow is fixed at 90
degrees usually. The move is to pull hard away from the shoulder and gradually straighten the arm.
b. Knee (Not knee cap). This is where the lower leg usually goes forward relative to the knee but it can be the other way
around. The danger is stretching of the blood vessels and nerves. Pulling hard and a long time in line with the leg is the
move but to pull hard enough the person’s upper body would have to be tied in place and you would have to be able to
use your body weight not arm strength. It is a slow constant increasing pull. It is possible to do it wrong and cause damage
so if you are anywhere near help working on getting that help is probably better. If the foot is white and cold meaning
getting no blood your hand is forced and you have to try.
c. Hip. Here the ball of the hip usually winds up behind the socket. It happens most often in people with artificial hips and
some of these folks have learned what to do. The person is usually holding the leg up at 90 degrees. The move is to weight
down the pelvis and pull up on the leg with the knee bent. It takes a lot of force even with anesthesia but there is less
likelihood of causing more problems than with the knee. So it is not unreasonable to try since the person will be
immobilized and in pain until it gets fixed. Tying the legs together in the flexed position is as good as you can usually do
for stabilization while you head for help.
d. Fore Foot. This is usually a fracture dislocation from getting the foot caught and then falling one way or another. The
foot will be floppy below the
ankle and it will swell al lot. The best you can do is stabilizing it with towels and duct tape, elevate it constantly and use
ice while heading for help. This can be a debilitating injury even with help and time does matter.
7. Eyes
a. Tangent lighting,
i. Spot on the cornea
1. Having a something lodged on or in the cornea is
painful. It is very hard to get this out without anesthesia and a very confident stable hand. Washing with lots of water is
second best. The cornea can scar from a foreign body that stays too long. However, while you are heading in the thing
often will pop loose and the eye may heal in 24 hours. If the eye doesn’t hurt sees well and looks normal with tangent
lighting it is probably normal but if you are worried and have access having a professional look is a good idea.
ii. Blood layering out over the iris
1. This is bad go to the doctor.
8. Swallowed a fish bone
a. The problem with this is that if you really do have a fishbone stuck in
your throat it can cause infections and hurt basically till it comes out but most of the time when you think you have one
you really have a scratch caused by a fish bone. There is no practical way to look down there without special equipment
and knowledge much less pull anything out. So, the best you can do is sip on soothing fluids like milk not whiskey and see
what happens. If it is a scratch it will be better tomorrow and gone in two days. If it is a persistently caught bone it will get
worse and worse. Both can be pretty uncomfortable in the first hour or so and making your self cough or gag doesn’t help
and may make it worse.
Medical issues
1. Headache: While painful most headaches are do not cause lasting injury. The exception is the Headache due to bleeding
in the head.
a. While quite rare the most reliable characteristic of this headache is that it comes on suddenly and is maximally painful
in the first minute. It is diagnosed with a CT or MRI scan of course and making way to the nearest medical facility that may
have one is worthwhile though there is no easy treatment. In a modern center with up to date neuro- surgery a procedure
to stop the bleeding by going through the vessels and planting a coil is done but it needs to be accomplished quickly. It is
not likely that you can get a crewmember to an advanced center quickly enough without helicopter transport.
b. Baring advanced treatment rest is the best you can do. Maintain fluid intake and lying down with no exertion is best. I
think if I was alone and I could I might just drift for a while. This headache is pretty incapacitating. Any lessor degree of
headache is unlikely to be due to a bleed. Bleeds are quite rare.
2. Difficulty swallowing
a. Choking. Heimlich maneuver is fairly well known now. Even if you
have only seen photos you can probably do it. Failure is more likely if you don’t try. There might not be much time. This is
a good thing to look up on You Tube and at least know what it looks like.
b. The child who swallowed something.
i. Small children; those that can be held in one hand can be
turned upside down and a couple of sharp raps on the back. This is stuff you can learn in a emergency course but even
watching You Tubes can be better than nothing.
ii. Children who are too big to hold can be bent over a knee or any way to get their airway upside down. But another
school of thought is that if they are not infants they are just small adults and Heimlich is the best.
c. If this is a chronic problem that has gotten worse but fluids can still be swallowed waiting is best. I wouldn’t try to ‘force
it down’ with bread or whisky.
d. If this is a sudden problem and nothing, not even saliva, can be swallowed you will need to head for port. It is likely that
the obstruction will resolve on the way but that can’t be known. A bit of steak not chewed well is most likely to be the
problem and although it is uncomfortable it is not life threatening unless it goes on for a day or so. Most people with this
problem have had it before and know what to do. If it is the first time waiting it out will likely work. Afterward they still
need to see a GI specialist at their next opportunity and chew well until then.
3. Sore throat
a. These are common of course and most are viral, which as everyone knows do not respond to antibiotics. Of course lots
of people think they are different and only get better with antibiotics. How special.
4. Sore throat that gets worse and worse.
a. It is important to look in the throat. White spots really don’t mean
anything, viruses and bacterial throats have white spots. This is the
body fighting the infection.
b. A bad case of halitosis, green pus and large tender nodes under the
jaw... I would take the antibiotics. Most strep throats come on faster than viral throats and are bad in a short time. Where
the pain of a viral throat plateaus the strep throat keeps hurting more. Often fever is more prominent but viruses can
cause fever too.
c. The decision to take an antibiotic is thus not clear. If you know you tolerate the drug well, and you have some and you
are worse trying it is Ok with me. I might try in for 48 hours. If the results aren’t dramatic it is probably a virus and you
are wasting your pills. If the results are good take the drug for at least two days longer than you have any symptoms. No,
this is not what the AMA says.
d. One sided swelling with pus pushing the Uvula (thingy that hangs down in the middle) over to the side. This can be a
peri-tonsilar abscess and can grow to close the airway. You need help pretty quick. Take the antibiotics if you have them
but it probably won’t fix it. Head in.
5. Chest pain
a. Most chest pain is not from the heart. Most of it is sharp, well
localized, and doesn’t last too long (less than 5 min.) This type of chest pain is from the esophagus or the chest wall well
over 90% of the time. It can be recurrent and pretty severe but goes away with rest and calming down.
b. Cardiac pain, pain from the heart, is typically poorly localized, dull, and associated with at least one secondary symptom
such as nausea, shortness of breath, (not panting), radiating pain (though esophageal spasm can also radiate.
i. If you think it is cardiac put the person at rest, give an aspirin and drink water not alcohol. If you can head for port great
but when the pain goes away, even if it was a heart attack the person is going to look pretty normal afterwards which
doesn’t change the risk that it is going to happen again so once you decide to seek help stick with it.
c. Hyperventilation and panic
i. These problems are perhaps the most common medical
problems and quite difficult to deal with. Seasickness can be combined as well. The important thing to remember is
although the crewmember may be panicking it is very important that others do not. A calm demeanor in the presence of
the panic is essential to the boat and the patient.
ii. Alcohol does not help.
iii. Hyperventilation symptoms are a cascade of symptoms
depending on the severity of the problem. Symptoms range from; the sensation of shortness of breath or ‘can’t breathe’
even though in truth they are breathing too much, next tingling, then dizziness, next tetany or involuntary contractions of
first hands then face then the rest of the body and finally passing out. At that point breathing will normalize and the
person will wake up in a few minutes but may repeat the entire thing.
1. Breathing in a paper bag is hard to do because the bag has to be sealed to the nose and mouth for at least 10 minutes
without ever letting go. Every time you let go you start over.
2. I have had better luck with
a. Have the person count their respirations against
a clock for a full minute and then repeat to see if their rate is decreasing. Often the mere distraction of this helps.
b. If they are getting through the counting then have them try slow their breathing for the next two minutes counting each
respiration to see if they are speeding up or slowing down.
c. Breathing too deep can also cause hyperventilation even if it is only 8 per min.
d. Hyperventilation usually lasts less than a half hour so you can often just wait it out. Sitting with them and doing the
counting with them often helps.
e. This can be a problem in rough seas a problem that is best known before leaving the dock but that is not always
possible.
6. Shortness of breath (not related to hyperventilation, note that if there is tingling of the finger tips the likelihood of
hyperventilation is near 100%)
a. This is generally a problem that the person knows about and has medication for so it is nice to know that all your crew
has their meds and is taking them.
b. So Shortness of breath not related to hyperventilation is about the heart or about Allergy or Asthma. Asthma essentially
always has a history so the person knows. New Shortness of breath can be allergy or heart. If there is a suspected allergy
give 50mg oral Benadryl (diphenhydramine). If it is heart give Aspirin. Allergy should be better in an hour and you can
repeat the dose or half the dose in 30 min if needed. If you think it is heart then treat it like chest pain.
7. Abdominal pain: In general abdominal pain without tenderness is less likely to be something bad than pain with
tenderness even if the tenderness isn’t so
severe pain wise. Tenderness means it hurts worse when you press on it. The less pressure it takes to make it hurt worse
the more likely it is to be something where you need to abort and head for help. Note that it is not the severity of the pain
that matters but whether it is tender or not. Often really bad pain is not tender and not associated with the need for
intervention while moderate to mild tenderness can be very important.
a. Upper center: This means pain in the very top of the abdomen between the junctions of the ribs.
i. First, this can be chest pain and especially if there are other symptoms as stated in sections 4 and 5 above it should be
considered cardiac until proven otherwise.
ii. However if it is pain with tenderness, that is it hurts more to push on it then it is less likely to be from the heart and
more likely to be stomach or pancreas. This is especially true if there was preceding alcohol involved.
iii. In either case or in the case of ulcer the best you can do is give liquid antacid if you have some or milk and wait it out.
iv. If vomiting develops especially bloody vomiting then the ante went up and you should head for shore. A few flecks of
blood in yellow fluid is not bloody vomiting. Bloody is bloody throughout and usually happens more than one time. This is
a dangerous situation without medical care. The person can sip water. It is better to be hydrated than not and if their
stomach is bleeding it isn’t going to make it worse. Alcohol will definitely make it worse.
b. Mid center: Meaning around the umbilicus.
i. This is usually related to the small bowel and is crampy but
likely to go away.
ii. In a rare case it will get worse and worse to the point where
the abdomen is tender through out. If that happens it is bad
and medical care is imperative. Possible obstruction.
c. Lower center: This means between the umbilicus and the pubis
i. This is most likely related to colon or large bowel. Similar to umbilical pain it is usually not tender and usually crampy.
ii. Again tenderness is the key.
d. Positions lateral: Upper Right: Gall bladder.... Lower Right: Appendix.
Upper left: usually non-specific Lower Left: sometimes diverticulitis. However these positions are often wrong and
Appendix can be in the middle or left. You can’t go on position much and at sea and you don’t need to diagnose but just
decide if you need to turn back or alter course. Some one who is getting worse over 3 to 6 hours or is developing
tenderness needs to get your attention.
e. Note that it is better to examine someone no more often than every half hour. If you check too often you will be less
likely to notice changes.
8. Seizures
a. A seizure is an uncontrolled discharge of electrical activity in the brain. It can cause anything from an absent stare to
convulsions of the whole body. Generally, they are chronic and the person should know about them, have told you as
captain that they have them, and they should stay on their medications. It is surprising how often people don’t count their
pills and run out! What to do about that I have no idea.
b. A seizure can also follow head trauma and means you should head for port or call the helo.
c. During a seizure all you need to do is point their mouth in some direction so that if they vomit they won’t inhale the
fluid.
d. Most seizures last less than a minute. A seizure that last 3 to 5 minutes is a long one. One that lasts longer can often get
smaller or even seem to stop but the person doesn’t wake up. This is because the body and brain get tired but it is still bad
and they need medical help ASAP.
e. After a seizure is like re-booting a computer. It takes a while 20 min but usually less than an hour for things to
normalize. If they are not back to normal in one hour consider getting to help quickly.
f. A person who has known seizures. Is on their medications but still has them occasionally is Ok to observe if they have
one on the boat and they return to normal quickly. Some people have to live with this. It would be a danger if they were on
deck or if they fall but that is essentially the risk they live with. So coming aboard is their choice in my opinion.
9. Diarrhea: Diarrhea that is not bloody can be treated with replacing fluids. If the person will drink they will be Ok for
days.
a. If the diarrhea is maroon colored or black and sticky it is blood (smells terrible)a. Turn around or alter course. This
person is in trouble. Alcohol will make it worse.
10. Urinary retention: This can be a problem if you don’t have a Foley tube on board. This is a special tube for inserting
into the bladder. An untrained person is not likely to take this on.
a. A person who hasn’t peed in 8 to 12 hours and who has pain, tenderness and fullness in the area of the bladder needs
attention. If you have a tub and can fill it with warm water than might get things started. Retention can be caused by a lot
of medications like antihistamines. It is not immediately life threatening but can get to be very painful and once the
bladder is very over full it becomes even harder to pee the usual way.
b. This is an unusual problem for someone to have that hasn’t had it before but if it starts I would personally alter plans to
get that person taken care of. Oddly, if I didn’t have any other options, alcohol might get this situation to relax enough to
relieve.
11. Swollen leg:
a. Most swollen legs are not blood clots.
b. Most blood clots in the lower leg don’t do any damage but a leg that is swollen to well above the knee is a threat. This is
where a blood clot forms in the veins where it is not supposed to be and can subsequently break loose and lodge in the
lung causing shortness of breath and other problems.
c. These legs are not usually bruised looking just swollen and tender.
d. This is a medically treatable emergency and would warrant a change
of sailing plan. If the person suddenly becomes short of breath now you have to hurry more. If oxygen is available for
some reason it would be good to use.
e. The only thing you can do aboard is elevating the leg. Keeping it down won’t keep the clot from moving.
f. Blood clots are made out of fibrin so aspirin plays little role but you should have it and it might help somewhat so most
people say give it. One aspirin a day is enough when you are dealing with clotting. Think of a teeter-totter you want to
push just enough not too much.
12. Last comments on doing nothing, doing harm, and just not helping because you are scared.
a. Of course there is no dividing line between what a layman should be able to do and what is too much or too dangerous.
Fortunately, we have experience judging this type of thing since it is very similar to deciding if the seas are too rough or if
you and your boat are ready for any given crossing.
b. I mean: use your judgment.
c. Doing nothing can be as bad as doing something but doing nothing
because you are afraid of causing pain is like not raising your sail in a
10 knot beam wind.
d. How to gain the confidence to raise sail is up to each of us
