MEDICAL EMERGENCIES AT SEA Beyond First Aid

MEDICAL EMERGENCIES AT SEA Beyond First Aid
MEDICAL EMERGENCIES
AT SEA
Beyond First Aid
“I have known the sea too long to believe
in its respect for decency”
Joseph Conrad
Capt Sam Lyness, M.D., F.A.C.S.
Subjects
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•
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•
•
•
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Medical Planning and Prevention
Communications
Resources
Triage
Medical Kits
Sea Sickness
Lacerations and Major Hemorrhage
Subjects
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•
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Burns
Hypothermia
Fractures
Carbon Monoxide Poisoning
Eye Problems
Anaphylactic Shock
Head Injury
Disclosures?
None
Disclaimer
(doctors differ)
SCENE:
Half-way between coastal USA and Bermuda
(300nm from nearest landfall)
Between Los Angeles and Hawaii (1,000+nm
from nearest landfall)
Half-way between Cape Charles and
Newport, RI (1-125nm from nearest landfall)
Planning and Prevention
RESOURCES
Weiss and Jacobs
2012
IMMUNIZATIONS
•
•
•
•
•
•
•
Tetanus-every 10 years
Polio-not needed if received once in adult years
Hep A and B –advised if going to tropics
Japanese B –Asia, India, Western Pacific
Typhoid – areas of poor sanitation
Yellow Fever- Africa and parts of Latin Am
Measles- if born after 1956 and not had a
second one on or after first birthday
Pre Voyage Briefing
• Safety +++++ Captain should have access
to health issues and medication list for all
crew members
• HIPAA regulations may interfere
• Ask crew members to have more than
enough of their personal medication,
perhaps twice as much
COMMUNICATIONS
• VHF radio w/ or w/o DSC no good >25 off
shore:
Suggest:
Satellite Phone
COMMUNICATIONS
• Iridium Satellite Phone:
• Rental plans:
$25 - $60/wk
some are waterproof w/ built in GPS
$1. 75/min
TELEMEDICINE ASSISTANCE
Remote Medical International (RMI) :
George Washington Med Ctr, Wash, DC
MD on call 24/7, sign-up in advance, fee
based
202-715-4219
206-734-3427
In 2010 Bermuda Ocean Racers covered for
about $95 per boat.
TELEMEDICINE ASSISTANCE
• Divers Alert Network (DAN): started as
diving emergencies only
24 hr hotline, Duke University, Durham, NC
800-446-2671
DANBOATER Safe Passage Program
$60/yr –(family $100) membership, 24/7 hotline
$150,000 global rescue , land and sea
$25,000 medical repatriation
$25,000 search and rescue
Sign up web site: DANBOATER.ORG
U.S.C.G District 5 Command
Hampton Rhoads
Rescue Coordination Center
Cape Hatteras to Delaware Bay
(for Annapolis-Bermuda Race)
beyond VHF range
757-398-6232
U.S.C.G. Atlantic City
Sector
Rescue Coordination center
Off New Jersey shore
beyond VHF range (25nm)
609-344-6594
U.S.C.G. Montauk Sector
Rescue Coordination Center
Montauk Point area-Block Island
Sound
631-668-2773
U.S.C.G. Castle Hill Sector
Rescue Coordination Center
Rhode Island Sound
401-846-3675
RESCUE
• Coast guard MH-60 helicopter~
range: 700 nm, 180 kn
Unlimited range in tandem with Coast
Guard C-130 --- refuels in the air
• Coast Guard Cutters -16-35kn
• Coast Guard reconnaissance: HC 144A
• turboprop (2000 nm range, 240 mph)
Bounty
Oct 29, 2012, Hurricane Sandy
16 total crew
14/ 16 rescued in about 1 ½ Hrs
1 dead - found later that day
1 missing
LIABILITY
Who’s to blame?
Jones Act (1920):
owner at fault
Was vessel seaworthy?
Civil Tort:
Captain or Master at fault
Mental state of Capt/Master?
Did he/she act reasonably?
----the knowledge and ability to act
reasonably under stress and make
tough decisions with respect to
human life.
Costa Concordia
Capt Francesco Schettino
32 dead
64 injuried
16 total crew
1 dead
1 missing
2 injuries
Capt Robin Walbridge, 63
Bounty
Oct 29, 2012, Hurricane Sandy
What is a doctor’s primary
obligation to the sick and injured?
• SAVE LIFE?
• RELIEVE PAIN/SUFFERING?
Basically, to relieve pain and
suffering, but
Depends on
TRIAGE!
TRIAGE:
“The sorting out and
classification of casualties
of war or other disaster, to
determine priority of need
and proper place of
treatment.”
Key to Assessment
TRIAGE
1. Will survive and recover whether treated
or not. Pain control is 1st priority
2. Will die whether treated or not
Pain control is 1st priority
3. Treatment will make a difference
between saving and losing life/limb
Saving life/limb is 1st priorty
PAIN CONTROL
• VICODIN or LORTAB
- HYDROCODONE 5 mg with
TYLENOL 325
1-2 tabs every 4-6 hours as needed
Must get prescription from a doctor
ANXIETY/PANIC CONTROL
• Ativan (Lorazepam) 1.0 mg tabs
1 tab twice or three times/day
Prescription from doctor
Saving Life
ABCs
• A
• B
• C
Airway
Breathing
Circulation
You learn these in CPR
What’s new in CPR?
(Hands only CPR)
1.
2.
3.
4.
No more mouth to mouth breathing,
rather 100/min chest compressions
except in the following:
Children < 12
Known or suspected drug overdose
Drowning
CO poisoning
then 30/2 (compressions/breaths)
MEDICAL KITS
Medical Kits
$15
$80
$45
$125
$760
R.M.I.
$7,295
Medical Kits
A La Carte =
more for less
Make your own
What I carry
HeartSine A.E.D.
Sea Sickness
Mal de Mer
Dr Graybiel
Astronaut Program
Sea Sickness
Dr Graybiel
A. Mental Phase
1. Malaise 1 = tiredness, sleepiness
2. Malaise 2 = apathy
B. Physical Phase
3. Vomiting
4. Prostration
C. Adaptation and Recovery-about 72 hours
Risk: Dehydration and Prostration
Sea Sickness
Dr Graybiel
Requires two medications:
One for physical symptoms = Phenergan 25 mg
orally or rectally
One for mental symptoms and drowsiness
caused by the Phenergan
25 mg orally
= Ephedrine SO4 mg
Prescription items
Non-Prescription
• Dramamine
(dimenhydrinate 50mg)
• Caffaine(NODOZ)
200mg tabs
Non-Prescription
• Dramamine (less drowsy)
Meclizine 25mg (Bonine)
Sea Sickness
Scopolamine Transdermal
visual side effects
Prescription
STUGERON
(Not made nor sold in USA)
“PREVENTS OR CURES sea sickness w/o side effects”
• CINNARIZINE - 40 different preparations
• Mfg 1955 Janssen Pharm - Anti-histamine/ Calcium
Channel blocker, 15mg, 25mg and 75mg (forte)
• Not FDA approved due to many reports of adverse
reactions including coma and death
• Banned for use by pilots in US because it impairs
judgment.
• Available from other countries (Canada) via internet
$35 for 100 15 mg tablets
• CAUTION ADVISED
Sea Sickness Remedies
•
•
•
•
Ginger Tablets
Ginger Ale
Ginger Snaps
Acupressure (sea bands) on P6
acupuncture site - wrist
• Electrical stimulation at same site
• Aroma therapy
Assign victim to lookout duty
or helmsman duty
Cuts and Lacerations
No wound has to be sutured
Just keep it clean
Irrigating solutions
1. Bottled water
or
2.
Betadine 2 teas per
pint of water
(disinfected soln.)
How to stop major bleeding
from lacerations of large arteries
and veins
Chitin derivative (Chitosan):
crab, lobster and
shrimp
shells
.
Chitosan Hemostatic Agents
1. Celox
2. HemCon
both come as powder, gauze or pad
gauze is the most useful version, also
good for 3rd degree burns (later)
(short video)
HELPS TAPE STICK TO SKIN
Tourniquet
Still has some usefulness if employed
temporarily:
• Apply to save life
• Limb is lost if tourniquet is on for more
than 3-4 hours
BURNS
• 1st degree – painful, touch pain, no blister
• 2nd degree- painful, touch pain, blisters
• 3rd degree - burn area usually black, is
numb and insensitive to touch
BURNS
Rule of nines
1st and 2nd Degree Burns
Burn area is painful to touch
Rx:Pain Control, Keep it clean
3rd Degree Burns
Dressing AlternativeCelox or
HemCon Gauze.
Cooling and antibacterial
When to worry
1. >20% 2nd Degree
2. >10% 3rd Degree
Leads to dehydration and shock. Must
push fluids.
3. Burns, flash or flame, on face.
Leads to airway obstruction. Must be
prepared to perform cricothyrotomy
CALL FOR RESCUE
Flash burns of face and
neck
Rusch QuickTrach
YouTube video available on line
Heat Exhaustion vs Heat Stroke
Heat Exhaustion:
• Profuse perspiration
• Normal temp +/• Mentally clear
Problem: dehydration
Rx: Hydrate promptly
Rapid recovery
Heat Stroke:
• Little or no perspiration
• Temp =104+ degrees F
• Delirium
Problem: failure of brain
temp. regulation
center, 4+ dehydration
Rx: rapid cooling, hydrate
30% mortality
Call for rescue
Fluid Formulas
Hydration fluids orally
1. ½ teasp salt and 3 Tbls of sugar per quart
of water, or
2. Gatorade dilute to 1/3rd with water, or
3. Kool-Aid with ½ teasp salt per quart.
Immersion Hypothermia
Web Site:
COLD WATER BOOT CAMP USA
Dr Giesbrecht
click on the video or YouTube links
FOUR PHASES OF IMMERSION
HYPOTHERMIA
1. Cold water shock- Respiratory crisismay drown from gasp reflex (older
people ventricular fibrillation)
2. Cold water incapacitation – 5-15 min
not be able to stay afloat, can’t self-rescue
3. Core body hypothermia - 1-2 hours
ventricular fibrillation
4. Rescue collapse – death during rescue.
Cause?
COLD WATER RESCUE
Life Jacket
• HORIZONTAL AND GENTLE = GOOD!
• VERTICAL AND ROUGH = BAD
FRACTURES AND
DISLOCATIONS
FRACTURES
An educated guess unless:
• Deformity
• Crepitus(grating sensation)
Persisting point tenderness, rapid
swelling, back and blue
FRACTURE TREATMENT
BASICS FOR ALL FRACTURES:
• Place the part at rest by splinting and
immobilizing as best can be accomplished
Pain Control
Fractures
If no deformity, ask the victim to move the
extremity. If the range of motion is full
there is probably no fracture and definitely
no dislocation.
Eastern Mountain Sports
or On-Line
Splinting a thigh fracture
If circulation is impaired, the hand
or foot will last about 3-4 hours
before permanent damage sets
in leading to amputation.
Fractures with deformity and
impaired circulation
If the bone is protruding through
the skin:
• Saturate the tissue and bone with
Hydrogen Peroxide
• Then with antibacterial solution
• Cover with sterile dressing
• Then reduce and splint
Call for Rescue
All Fractures of Extremities
RICE
•
•
•
•
REST
ICE
COMPRESSION
ELEVATION
In the absence of a fracture the
victim will automatically begin to
use the extremity after a short
period of time, perhaps several
hours. No harm will be done
even if a fracture does exist.
CARBON MONOXIDE
POISONING
Most Common Cause of Death
Due to Poisoning in the United
States.
CO Poisoning
Symptoms
(do not arouse from sleep)
•
•
•
•
•
•
•
•
Not unlike seasickness or flu
Headache
Nausea
Dizzy feeling
Vomiting
Drowsiness
Cherry red color to skin (not always)
Coma
Carbon Monoxide
• Colorless, Odorless, Tasteless
• Slightly lighter than air, diffuses rapidly into
entire space
• Combines with blood rendering it useless
in carrying oxygen
• Harm related to dose and duration
CO Sensors
Kidde
(battery operated)
First Alert
(battery operated)
Fireboy
12 v only
Fireboy- XINTEX
• Marine store or online
• $85-$110
• Claims to be for marine
environment
• 12v only
• Biomimetric sensor
• Remote units all alarm at once
• Auto shutdown of genset
• Lasts 5 years
CO poisoning
Treatment
• Fresh air
• Oxygen if available
• CPR (30/2) if no pulse and no breathing
Half-life of COHb is about 5 hours
False and Nuisance Alarms
EYE emergencies
UVB damage to eye
UV blindness
• Photokerititis
• Prevented by glasses or sunglasses
SALT WATER CONJUNCTIVITIS
Vibrio Vulnificus
EYE TREATMENT KIT
Prescription item
Penetrating Eye Injuries
• Leave object in eye and cover with a
cardboard or styrofoam cup tapped to the
face as best you can
Antibiotic Eye Drops
Spontaneous
conjunctivitis
Traumatic
conjunctivitis
Anaphylactic Shock
Allergy/Anaphylactic Shock
• Bee stings, Hazardous marine life stings,
Food allergies, Unknown allergens
• Most people with allergic histories have a
routine for avoidance and have
appropriate medications
Severe Allergic Reaction
Anaphylactic Shock
swollen lips and tongue, wheezing, severe
asthma, obstructed breathing, choking
loss of blood pressure (shock)
Anaphylactic Shock
• First treat the shock- have victim lie on
back an raise feet and legs up at least 12
inches.
• Give epinephrine (adrenalin) injection
ASAP
• Benedryl 50 mg
• May need 2nd inj.
Prescription item :
2 pack
HEAD INJURY
Head Injury
Frequently associated with a
neck injury
C-spine Immobilization
Rest and Pain
Control
Head Injury Treatment
• No treatment for brain- it will recover or not
depending on the magnitude of injury
• Skull fracture – not serious in itself since not a
vital structure and requires no treatment unless
depressed which usually can wait.
• Concentrate on ABCs and neck immobilization if
victim is unconscious, rest for 24 hours.
• Most, 90%, recover and are fully active in 24
hours and can return to crew duties
Head Injury
when to worry
• Prolonged unconsciousness or prolonged
periods of bewilderment or poor
performance. Others have to make this call
• Open skull fracture with brain tissue
exposed. Cover with a dressing and wrap
head
Call for rescue
HEAD INJURY
Victims that talk than die
After being alert,
deteriorates with
headache, vomiting
coma and brain death within
12-24 hours
EPIDURAL HEMATOMA
Prescription
Natasha Richardson, age
45
March 2009
Fell while skiing on a beginners slope.
Thereafter alert, joking. Several hours
later back at the hotel complained of
severe headache. Lethargy, coma
followed. Brain dead the next morning.
What could have saved her life?
PRURITIS ANI
Itchy anus
Wash clean, dry
and apply, “Ah”
Off-Shore Medical Kit
Dry Supplies:
•
Bandaids- assorted
•
4x4 gauze dressings
•
Gauze roll
•
Eye patches- gauze
•
Adhesive tape
•
Latex or plastic gloves- one box
•
Rusch QuickTrach
•
Celox or HemCom gauze
•
Ace elastic bandages- 4” and 6”
Off-Shore Medical Kit
Dry Supplies (continued)
• SAM splint
• Thermometer that reads below 90 degrees
• C-A-T Tourniquet
• Triangular bandage-for sling
• Sail ties – for fixing splints to leg and body
• Telescoping Paddle or Oar- for long leg splint
• Wooden applicator sticks w/ cotton tip – to turn eye lid
and remove foreign bodies
• Tongue blade - for finger splints
Off-Shore Medical Kit
Wet Supplies
• Soft Soap-antibacterial
• Solarcaine or Burnjel Plus
• Betadine (10% Povidone-iodine) soln
• Hydrogen Peroxide
• Tincture of Benzoine
• Alcohol swabs
• Eye kit with sterile saline wash and eye cup
Off-Shore Medical Kit
Medications: non-prescription:
• ASA 325 mg
• Headache remedy: Tylenol, Advil
• Antiinflammatory: Advil, Aleve
• Dramamine 50 mg (Dimenhydinate)
• Dramamine 25 mg “ less drowsy” ( meclizine) also known as
Bonine
• Ginger Tablets – for sea sickness prevention and treatment
• Caffaine 200 mg – to counteract drowsiness from sea sickness
and Dramamine
• Benadryl 25 mg, Zyrtec 10 mg for allergies
• Imodium (loparamide) 2 mg -for diarrhea
• Nupercainal Ointment – for pruritis ani
• Antacid w/ Pepcid (Famotidine 10 mg) for acid reflux heartburn.
Off-Shore Medical Kit
Medications: Prescription
• Vicodan or Lortab 5/325 x 30 generic brand- for strong
pain
• Ativan 1 mg x 30
generic brand – for anxiety/convulsive seizures
• Phenergan 12.5 mg for sea sickness
• Albuterol Inhaler – for asthma attacks
• Compazine 10 mg injectable for severe sea sickness, last resort
• EpiPen ( epinephrine 0.3 mg injectable) x2 for
anaphylactic shock
• Eye drops: Tobradex (Tobramycin/ steroid) for inflammation/
Sulfacetamide (non-steroid ) post-traumatic inflammation
• Ear drops: Neomycin/Polymyxin/Hydrocortisone for
external ear infections
• Silvadene 1% - for 3rd degree burns
• Z-Pack ( azithromax 250 mg )- antibiotic for respiratory infections
• Cipro 750 mg x 20 for infections other than respiratory
Off-Shore Medical Kit
Other Supplies borrowed from galley and tool box:
•
Vinegar- white, for ear drop solution.
•
Ginger Snaps for sea sickness prevention
•
Ginger Ale for sea sickness prevention
•
Duct tape for stronger dressings
•
Drill and large drill bit – for cranial trephine
Off-Shore Medical Kit
• Resource: MARINE MEDICINE:
Comprehensive Pocket Guide
by Eric Weiss, MD and Michael
Jacob, MD 2nd edition, 2012
• Communication: While not part of the first
kit, some dependable form of
communication is important in the
overall medical management plan
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