Medical Procedures - The Officer's Shipboard Guide
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[MUSIC PLAYING]
[MUSIC PLAYING]
Life aboard ship can be
strenuous, dangerous,
and even hazardous, no
matter how attentive we
are to safety and prevention.
Injury and illness at
sea are inevitable.
People get sick,
and people get hurt.
This program explains
and illustrates
the basics of maritime medicine,
from everyday to emergency.
You need to be able to hang
this somehow above the patient's
heart level so that
the fluid will flow in,
and so that it will
not just be backing up.
If you can't start an IV,
there's a very good chance
that person will die before
you can get help to them.
So having HIV capability
is very important.
You'll see and hear hands-on
demonstrations and commentary
by doctors and other health
professionals who specialize
in maritime medicine.
You can use this tape for
instruction, for training,
and for later reference.
And the bone that he's
fractured, as we saw in x-ray,
is between this knuckle
and the wrist bones.
I think seeing something
is always very valuable.
And in medical school,
they told us basically
see one, do one, teach one.
So here's the opportunity
to get partway down the pike
and to see one.
And hopefully, it's something
that can be quickly reviewed
before you start
an IV or suture,
if it's not been done recently.
Or if it's something that
the medical officer is not
comfortable doing, they
can refresh their memory
very quickly.
Part 1 of the program is
preparation-- the equipment
and information you need.
These segments are coded
green for later reference.
Part 2 of the program
is assessment,
from routine exams to
checking key vital signs.
These segments are coded yellow.
Part 3 of the program is
treatment-- techniques
from suturing wounds
to setting up IV lines.
These segments are coded blue.
We'll begin with code
green-- preparation.
[MUSIC PLAYING]
When it comes to the health
and safety of your crew,
expect the best, but
prepare for the worst.
Here are five key steps
that will prepare you
for most injuries,
illnesses and emergencies.
First, know the basics.
Ideally, all crew members must
know basic first aid, CPR,
and other emergency procedures.
These and more are covered in
the International Medical Guide
for Ships published by the
World Health Organization.
Since 1967, the International
Medical Guide for Ships
has been a standard reference
for medical care onboard ships.
The Maritime Labor
Convention or MLC
requires that all ships carry
a medical guide on board,
showing how to diagnose,
treat and prevent
health problems of seafarers.
Responding to an emergency
is everyone's responsibility,
not just the medical officer's.
Crew members must be able
to render emergency CPR,
or cardiopulmonary
resuscitation.
[RADIO]
Second, communicate.
Know who's in charge
and how to reach
them, your procedures
for a medical emergency,
and who to call for
consultation or advice.
Ultimately, the
master the vessel
is responsible for the care
that's provided on the vessel.
The master is free to
delegate that responsibility
down the hierarchy of
officers, as they see fit.
And then it's up to
that individual, based
on their experience
and their training,
and their level of comfort.
At the point wherever that
they feel that they're
out of their comfort zone, or
the response they're providing
doesn't seem to be getting
the anticipated results,
then I would recommend that
they ask for assistance.
Know your procedures and lines
of communication, both onboard
and with shoreside
medical assistance.
Third, maintain medicines.
Keep an adequate supply of
medications and necessary
medical equipment.
The International Radio
Medical Center, CIRM for short,
provides free radio
medical assistance
to seafarers around
the world, 24/7,
and is an essential
resource to use.
CIRM should be contacted in the
event of a medical emergency
onboard, for other
medical advice,
or to coordinate the emergency
evacuation of a patient
from a ship.
When contacting CIRM,
provide the name, location,
and coordinates of your
ship, its ports of departure
and arrival, and as much
information about the patient
and their conditions
as possible, including
their symptoms, medical
history, age, and the treatment
already provided.
Make sure you can cover
both routine illnesses
and medical emergencies.
Your medical supplies should
be appropriate to your ship's
size, its particular mission,
and the potential hazards
or illnesses you may be facing.
Every ship has
different circumstances.
They have different crew size.
They have a different mission.
They have different
ports of call.
And we recommend
that people utilize
the services of a
consulting physician who
has experience outfitting
ships for whatever
their particular mission is.
Whether you have a full-fledged
onboard hospital and dispensary
or simple medicine chest,
drugs and equipment
must be kept current,
and the equipment
functional and sterile.
Controlled medications
must be secure and safe.
You want to have a full
complement of gauze sponges,
and suture material,
tape, in order
to stabilize these things.
ACE wraps are very useful.
Splinting material is
also extremely beneficial.
Medicines range from
ointments and cold pills which
you might buy at
the local pharmacy,
to sophisticated drugs
for medical emergencies
like cardiac arrest.
When in doubt about proper
medication, communicate.
We do recommend
that people call us
before starting any of the
prescription medications,
of which antibiotics are one.
The typical medicine
chest will include
antiseptics to clean wounds.
MLC regulations now require
vessels to keep a medicine
chest on board.
You may find that
some flag states have
additional requirements for
the medicines and equipment
to be kept in a medicine chest.
Those that don't
rely on a basic list
included at the back of the
International Medical Guide
for Ships.
These include-- drugs for the
eyes, ears, nose and throat
respiratory prescriptions,
and antibiotics,
a variety of
emergency medicines,
like atropine and nitroglycerin,
and basic medical equipment.
Here we have a suture kit.
And the suture kit, you can see,
comes with some nylon suture.
The size is 4-0, and it gives
a needle size on here as well.
In these kits, you
can see the needle.
The kit includes
some sterile drapes--
which you can see down below
there-- some gauze pads, a pair
of needle holders,
a pair of scissors,
and a pair of forceps for moving
the skin around and bringing
skin together.
The rule of thumb with
medicines is better
to be overstocked, then
understocked, especially
when the unexpected happens.
The fourth key to preparation
is to keep good records.
Access to crew medical
histories is very important.
Keep records of any previous
illnesses and injuries.
Record any treatments given
and all communications
relative to those treatments.
The better you
know the personnel,
the better you'll be
able to treat them.
It's especially
important that you
know any allergies or
sensitivities to various drugs.
Keeping a good medical record
is very, very important
for the crew member that
you're assisting, for yourself
as a medical
officer-- when you may
need to provide an
explanation as to why
you did or didn't do something.
And for the vessel owner,
it becomes a very, very
important to document.
So I encourage very
compulsive record keeping.
A final key to preparation--
when appropriate, use
sterile, disposable
equipment, always.
Check the integrity
of all packaging
and know the proper use
of all sterile materials.
Take special care to
ensure proper disposal.
Every time you're dealing with
body fluids, blood, urine,
or stool, or anything
like that, one
should be using the latex gloves
that are included in most kits.
There's a technique for opening
and putting on latex gloves
that avoids spreading
your germs too.
And this is setup where
the plastic peels back
and the contents are sterile.
So we open this up and drop
it onto our sterile field.
This is folded up in a little
bit of a complicated manner.
What you can do is open the
edges and spread it open.
Grab this, and then open
here and fold under.
You can see that.
That will prevent it
from folding back up.
Now what we want to do is get
the hands inside the gloves,
without touching the surface
that'll touch the patient
or crew member.
So we grab here.
Put our hand in and
wiggle our way in.
Put our thumb
underneath and pull up.
And now use this sterile surface
to grab the second glove,
under the cuff.
Take our hand, put it in.
Wiggle our fingers around.
And now we have
two sterile gloves.
Make final adjustments.
And we'd be ready to
do a medical procedure.
As important as the
proper use of sterile
gloves and other
medical equipment
is their proper disposal.
Anything that has
touched bodily fluids
or has been
contaminated in any way
must be disposed of in a
proper biohazard container.
These are called
universal precautions,
and prevent the
spread of Hepatitis B
or C and the HIV virus,
as well as the danger
of infection and contamination.
[MUSIC PLAYING]
Before we can treat
any illness or injury,
we need to know what's
wrong-- assessment.
In the case of a severe injury,
it's especially critical.
The first step in
assessment-- check
the ABCs-- the airway, the
breathing, and the circulation.
When you encounter what
looks like a severe injury
call for help immediately.
Make sure the area isn't
hazardous to rescuers,
then begin the assessment
process, called the ABCs.
Stands for airway,
breathing, and circulation.
The airways-- you make sure
that he's got a clear airway,
and this can be determined
by putting one's ear
down towards the nose.
And you can feel the
respirations on your ear
and you can hear them.
Then the next thing
is breathing--
does he have spontaneous
respirations?
And you can also
tell that by-- when
you listen for
respirations-- you
can feel breathing coming
out of the nose or the mouth.
And then the third
thing is circulation--
and you can feel the
carotid arteries here,
right across the larynx.
You can place your fingers
here and feel a pulse there.
And at the same
time, you can listen
for breathing in the chest.
And a crew member
will put his ear
on the chest to listen
for breath sounds
and to listen for the heart.
Because you can often hear
the heart through the chest
wall with the unaided ear.
If there is no breathing,
start CPR immediately.
CPR is as easy as CAB.
This stands for compression,
airway, and breathing.
Begin with chest
compressions immediately
by placing the
heel of your hands
in the center of
the victim's chest
and pressing down repeatedly.
After 30 compressions,
tilt the victim's head back
and lift the chin
to open the airway.
Then, pinch close
the victim's nose
and give two one-second breaths
into the victim's mouth.
If you're unassisted,
alternate one breath with 15
compressions.
If you're assisted, alternate
one breath with five
compressions.
If the crew member has a
clear airway, breathing,
and circulation, but is
unconscious, be cautious.
You must be alert
to possible injury
to the head or the spinal cord.
Before the injured
man is moved, someone
must be assigned to
stabilize the head and neck
during the entire process.
He has to stay in position and
hold that man's head until they
get a backboard under him
and get him log-rolled up
on his side, so they can
slide a backboard under him,
put him on the
backboard, strap him in,
and then they can secure
him to the backboard.
And often they'll use
things like duct tape,
or some kind of tape, to
strap his head in position,
at the head of the backboard.
And then they can move him
up to an indoor compartment--
or a room in the
hospital per se-- where
they can check vital signs,
do their secondary survey,
see if they can find out
where his other injuries are.
To sum it up, when you come
upon an emergency, call for help
and check the ABCs.
Then, if CPR is necessary,
proceed with CBA.
[MUSIC PLAYING]
The next step in assessment
is to look for symptoms.
Conduct a visual exam
and note what you see.
Talk to eyewitnesses, if
it's an accident someone saw.
Question the crewman
if he's conscious.
Never underestimate the
importance of communication.
When you're assessing
an illness or injury,
the best source of information
are the patients themselves.
If they're groggy, begin
with their general awareness
and orientation.
We talk about being oriented
to person, place, and time.
Now, albeit, that
could be very confusing
when you're on a ship
in a circumnavigation,
and are working shifts and
variable hours during the day.
But I think asking a crew
member or another officer that's
injured or ill if
they know who you are
or who the captain is, if
they know approximately where
they are, ocean-wise is fine.
But then also getting an idea
of what the name of the vessel
there on and they're sailing
with-- something that they
should know or that
before the injury,
or before they became
ill, you knew they
were aware-- person,
place, and time.
One of the most crucial
steps in assessment
is to take the vital signs.
The pulse, breathing,
temperature, and blood
pressure.
They're called vital
signs for a reason,
because they tell us--
not specifically, what's
going on-- but they give
us a lot of information
about the condition
of the patient.
To check vital signs, you need
a thermometer, a clock or watch,
and a sphygmomanometer.
That's the fancy name for
the familiar cuff and dial
we use to check blood pressure.
I need to check
your vital signs.
That's your temperature, your
blood pressure, your pulse,
and respiration.
OK?
We like to get a
beginning set of those.
This goes under your tongue.
The pulse is checked-- radial
pulse rate-- either arm,
right here.
These two fingers.
Do not use your thumb.
Your thumb has its own pulse.
You have an artery in
your thumb and you'll
be counting your own pulse.
So use these two fingers.
I'm going to be counting for 15
seconds and multiplying by 4.
If you're not
comfortable doing that,
you can certainly count
for a full minute.
But the vital signs are
predicated-- especially
the pulse and respiration and
temperature-- on a minute.
After noting the pulse,
or heartbeat rate,
check the rate of respiration
by simple observation
and counting.
Then you want to just look
and watch their chest rise
and fall, and count how many
times they breathe in that 15
seconds and multiply it by 4.
The general range that's normal
is anywhere from 12 to 20.
Most people breathe
around 16 times a minute.
And the pulse rate should
be between 60 and 100.
That's considered a
normal pulse rate.
After you've noted
pulse and respiration,
it should be time to
check temperature.
It's been about a minute,
so we'll check this.
This is what we call a TempaDOT.
And his temperature
is about 98.4.
He lit up those little
dots up to 98.4.
You need to read this
within the first minute,
because it starts to fade.
In taking the blood pressure,
have the crew member
seated comfortably.
Support the arm, but no higher
than the level of the heart.
There is a technique
to putting a cuff on.
This little mark says artery.
On the arm, the artery
is the brachial artery
and it runs to the inside.
So if you're going to
be accurate about this,
you want to position
this artery marker
to the inside of the arm.
If you have a
stethoscope, place it
on the inside crook of the
elbow to hear the blood flow.
Or simply use your two fingers.
The screw near the bulb
controls the release of air
from the cuff.
Now, I tightend down
this screw, and then I
pump up to around 160, 180.
Release it gradually so that
the needle is kicking back
every two millimeters.
Note where you hear
the first sound.
And the last sound I
heard is at 134 over 90.
And you can remove that.
With blood pressure, you
may need a bit of practice.
But once you've got the hang
of it, taking vital signs
is relatively easy, and it's a
crucial step in your assessment
and treatment.
Somebody that has a cold with
vital signs of normal blood
pressure, normal pulse
under 100, or under 80.
Say they have a
pulse of 60 or 70
and a normal blood pressure and
a temperature of 98 or even 99.
That's a vastly different
scenario from someone
who has a temperature of 101.
Their heart rate is 120.
Their blood pressure
might be 100 over 60,
or even 150 over 100.
Immediately, I know that
the first person is not
terribly ill.
They may just have a cold.
The other one is
ill-- could have
something as bad as pneumonia
or perhaps bronchitis.
So the vital signs really
give us a very good indicator
of what's going on.
[MUSIC PLAYING]
Another crucial
diagnostic skill is
care for the eyes, which can
include removing foreign matter
and treating injury
or infection.
We're looking at the eyes
here for any evidence
of bruising or swelling
or injury around the eye.
And here, there is none.
We're also looking at
the white of the eye,
called the conjunctiva,
to see if there's
any bleeding underneath or
redness or for a foreign body.
And we're looking at the
symmetry of the pupils--
that they're approximately
the same size--
and that they
dilate and constrict
when exposed to light.
So one of the tests--
Look for proper
dilation of the pupils,
and that both pupils
dilate the same amount,
even if you're shining
the light in only one eye.
Another key test for
the eyes is tracking--
that they track together while
following your movements up,
over, across, and down.
Be especially aware if one eye
moves and the other doesn't.
If that were to occur, as
might happen after an injury,
it would suggest what we
call blowout fracture, which
can be a medical emergency.
One of the most common
shipboard afflictions
is foreign matter
in the eyes-- debris
from sanding or grinding, fish
scales, rust particles, grain
or dust.
In these cases, you need
to look under eyelids
for foreign material.
So we'll want to look
at the white of the eye
by averting the lids.
The lower lid is the easier,
where you just pull down
and then you can look into
the sac for a foreign object.
Ask the patient to look
up and you get a nice view
of the white of the eye there.
No foreign body.
The upper lid presents a
little more of a challenge.
What we do is roll the lid
over a cotton applicator.
First, look down for me please.
Use this as a little
bit of a fulcrum.
Grab onto the eyelids, pushing
down on the cotton applicator,
and flipping the lid over,
trying to keep the fingers away
from the eyelid, which is tender
and, just on the eyelashes.
And then we can
look at the eyelid.
And again, seeing
no foreign body.
A more advanced exam involves
putting a small amount
of fluorescent dye in the
eye to detect injuries
to the cornea, which requires
a well-equipped dispensary
or hospital equipped
with ultraviolet light.
If there were an abrasion,
the flourescein dye
would pool in the defect.
As you can see, it's a
little bit darker green down
in a sac of the lower
portion of the eye.
Your medicine kit should
include antibiotic eye drops
and other medicines
designed to treat eye
infections and mild injuries.
[MUSIC PLAYING]
A final procedure that
can be very useful
onboard is to check the urine.
This can be done
with a convenient kit
and may be requested
by a consulting doctor.
The first thing we
need to learn are
all of the details
surrounding the nature
of the injury or the illness.
One of those key details
is revealed in the urine.
And the test is relatively easy.
This is the urine dipstick test.
This is something that
can be done on the vessel
and interpreted by you.
You need to have a urine sample
from your client on the vessel.
So they can go in a cup.
It should be clean.
They can go into a specific
type of urine container
if you stock those
on your vessel.
The test kit is a bottle of
plastic test strips called
Multistix-- 10
separate tests in one,
which detect abnormalities
in the urine.
The key to using
the kit is reading
the scale of reactions on the
bottle and timing each test.
Some require 30 seconds of
exposure, some 60 seconds,
some two minutes.
Simply dip the test strip in
the urine and begin timing.
The test strip is individualized
and it goes this way
down the bottle.
The last test is glucose--
this blue strip here.
So it's going to change colors
when you dip it in the urine
and you want to note the color
change at the specific time
when you're doing a
test on the urine.
1, 2, 3, 4, 5, 6 tests down.
1, 2, 3, 4, 5, 6 tests down that
there is blood in this urine.
This is the sixth test.
It's turning green.
And you want to read across
there-- small, moderate,
or large at 60 seconds.
You can also see
that on the glucose
it didn't change colors, so
there is no sugar in the urine.
It's important to record
all information from any
of your diagnostic
tests for your own use,
to create a record, and
to provide key information
to a consulting
physician or nurse.
[MUSIC PLAYING]
First, preparation.
Then, assessment.
Finally, treatment.
In this segment, we'll look
at 10 of the most commonly
used treatments.
Remember-- stay in
your comfort zone.
If you have questions or doubts,
consult a maritime physician.
The first of the treatments
we'll demonstrate
is giving injections.
We'll look at filling the
syringe, preparing the skin,
and finally, giving the shot.
Begin by pulling the
plastic protective cover
off the syringe.
This particular syringe
has a safety guard on it.
Yours may look
slightly different.
The technique is
that you pull back
the equal amount
of air that you're
going to displace in
the bottle with fluid.
So to 2cc.
Push that in, and it
will help the medication
to come out more easily
into your syringe.
So we've got 2cc of
medication in here.
You want to have a
little air bubble that's
going to go in at the
end of the injection,
behind the medication.
So like 0.1 to 0.2
of an air bubble,
you want to pull down also.
Because when I get
the shot, I want
this to go in behind the fluid.
It will help to keep any
from leaking back out.
The second step--
preparing the skin--
requires finding the right
place on the arm or buttocks,
and then swabbing the
area with alcohol.
You want to find the pelvis
here, mark your spot,
right in here.
Any of this area in here.
The reason is
you're staying away
from the sciatic nerve that way.
Just like a dart.
You pull back a little bit
to make sure you're not
in a blood vessel.
Go ahead and inject slowly.
You don't want to
take forever, but you
don't want to go too fast
because that's more painful.
What we've just seen is an
intramuscular injection.
A subcutaneous injection uses
a finer needle placed just
beneath the skin.
Some medications are given
through an intravenous line.
The following section deals
with dispensing medicines--
knowing what to give, verifying
your treatment if you're
unsure or need backup,
and determining the dosage
and duration.
As we've seen, injection
is one important method
of giving medicine to
an ill crew member.
Another essential
technique is setting up
an intravenous, or IV, line
to get the medicines or fluids
to those under your care.
We'll look at that procedure
in our next section.
We're going to
focus now on what it
is that comes out of the
medicine kit-- dispensing
drugs.
Your first task is
knowing what to give.
Making this call
depends upon your level
of training, your common sense,
your available references,
and the severity of
the illness or injury.
A localized skin rash
may require little more
than reading a label and
dispensing the medicine.
We do provide a lot of
reassurance along the way.
And sometimes just speaking
to a medical officer
and saying everything
you've done
is exactly right on
target, and nothing more
to add-- let's hear from
you tomorrow and see
how your crew member is
doing-- provides a great value.
Never be afraid to call
for help and get advice
from a medical professional.
If you have any questions when
you're dispensing medicine,
review your treatment plan
with the maritime physician.
We like to be called early
in the course of an illness
or soon after the injury occurs.
But medical care should
never be postponed in order
to call us-- meaning that if
someone is on the deck, not
breathing, not with a pulse,
the first responsibility is
to stabilize that person,
and then to call us.
The third thing you
pay attention to
is actually two
things-- the dosage
and duration of that dosage.
Many medicines must be continued
for a certain number of days.
Be aware that some medicines
are measured and delivered
differently.
There are many different ways to
take medications-- among them,
topical medicines, ointments
and creams for external use,
oral medicines--
pills and capsules
that are swallowed--
inhalers containing
powders or sprays absorbed
through the lungs,
and suppositories-- medicine
absorbed through the rectum.
Keep a record of every
medicine you dispense,
its dosage, and the
duration of your treatment.
Determine and record
any known drug allergies
or previous adverse reactions.
[MUSIC PLAYING]
Among the most critical
medical procedures
is setting up an IV line.
In this segment, we'll
discuss the equipment
you need, connecting
the fluids and tubing,
inserting the needle, and
moderating the flow and dosage.
If you've determine that
you have a crew member that
needs to have an
intravenous line started,
I believe these are
the basic things
that you need to get started
to put an IV in that patient.
You need your fluid bag.
You need your tubing
to hook into the bottom
of the fluid bag that's
going to go into the patient.
You need a gauze pad.
You need something to
clean the skin with.
We use alcohol.
You can use alcohol
out of a bottle
and pour it onto something
clean like a gauze pad
to clean the skin.
You can use tap water
and soap, if you need to.
But something to clean the
area where you're going
to be doing the venipuncture.
You need tape to tape
down the tubing and the IV
once you get it in.
You need a tourniquet to
tourniquet the vein so
that you can get the line in.
And you need an IV catheter
of some kind, whichever
you carry on your vessel.
And always-- because you're
going to be contacting blood--
you need to be wearing gloves
when you do this procedure.
IVs are often used
to provide liquids
to people who are
badly dehydrated
and can't hold fluids
down any other way.
They can be life
savers, literally.
Once you've organized
your equipment,
check the bag for
leaks or contamination.
You need to be able to hang
this somehow above the patient's
heart level, so that the
fluid will flow in and so
that it will not
just be backing up.
Let gravity be your friend,
hanging the bag on a hook
or from the ceiling.
Then, hook the
tubing to the bag.
Now, this has some
sterile areas on it
that you don't want to touch.
This is the pin that
goes into the bag.
It's sterile and it's
got a cover on it.
You're going to take that
off and puncture your bag.
Both ends of the tubing
are sterile and capped.
When you're ready, remove the
cap and the plug from the bag,
and insert the pin,
turning and pushing.
You will get fluid
into your chamber.
This is called the drip chamber.
It has a little line on it.
You want to at least
fill it up to there.
What you're going
to be watching for
is how fast the fluid is
dripping into this chamber
once you get it hooked up.
Again, using gravity, fill
the tubing below the bag
all the way down the line.
Remember to keep both ends
of the tubing sterile.
Now I've got the cap off, but
I'm not letting that tip touch
anything.
When you fill the
IV line, you're
ready to prepare the crew
member for the other major part
of the procedure--
puncturing the vein
and inserting the catheter.
I'm just going to put
a tourniquet on the arm
here and see what
kind of veins we have.
Go for something nice
and straight and obvious
for starters.
Again, use gravity.
Lowering the arm will
help blood accumulate
below the tourniquet.
Arteries pulsate.
Veins do not.
And they are slightly softer
than the surrounding tissue.
Once you've determined
a likely vein,
clean the skin with alcohol and
a disinfectant of some kind.
Iodine is the familiar
reddish brown liquid you often
see used for this purpose.
Now you're ready to insert
the needle, bevel side up.
The metal tip of the catheter
is shaved on an angle.
So you want the bevel
or the angle to be up.
In other words, you should
be able to see the opening
of the needle in the catheter.
The catheter is actually
over top of the needle.
Tighten the skin a bit, so that
the vein doesn't roll around.
Then insert the
needle into the vein.
You'll get a small backup
of blood into the needle,
indicating you're in the vein.
Now, slide the
catheter into the vein
as you withdraw the needle.
Cap the catheter and
tape it down on the arm
The catheter is your
line into the body.
It can be used to withdraw
blood, hooked into your IV line
to begin the drip process, or
to administer IV medication.
Checking the drip
chamber will allow
you to time the
frequency of the drops
and determine the
amount of fluid
the crew member is receiving.
Now, let's look at a common
shipboard injury-- laceration--
and how to treat it.
[MUSIC PLAYING]
The next three sections
deal with treating wounds.
First, inspecting the wound,
numbing the area of the wound,
and cleaning the one
before stitching it.
For our demonstration,
we're going
to look at two finger injuries--
one, relatively minor, one,
rather serious.
Both requiring stitches.
We are going to be
very interested in what
is the range of
motion of the finger.
Where is the laceration?
If they have a laceration
on the back of their finger,
that's different from a
laceration on the palm
of the hand, for instance.
The first step with any wound
is to inspect it carefully.
This includes looking
at the wound itself,
and how it might
be affecting normal
function of the
body part itself.
It's a different territory.
They have different tendons
and different functions.
We want to know whether the
finger can fully extend,
whether it can flex.
We want to know
what their strength.
We want to know
whether it's bleeding
and how much it's bled.
One way to assess both
wounds, and the dressing
we ultimately put on them, is
their effect on blood flow.
The capillary refill
check is simple.
Press on the end of
the finger or toe
and see if normal red
blood flow returns
within one to three seconds.
If the affected area stays
pale, either the wound
or the dressing is
affecting circulation.
We'd like to know if there
have been any previous injuries
to the finger.
We'd like to know if
there's any sensation,
distal to the injury.
If they injure their finger
in the area right close
to the hand, there
are nerves that
supply the outer
portion of the finger.
And if they have
sensitivity out here,
it's very important to
know if that nerve is
intact at the time of the
injury or shortly thereafter.
Inspection of the wound
will offer two options.
Option 1, you need
medical assistance
which may be beyond
what you're equipped
to do-- an amputated
finger, for instance.
In that case, a
consulting physician
would help you handle the
situation until he or she could
be seen in port.
Option 2 is numbing, cleaning,
and suturing the wound
yourself with the resources
available on board.
Typically, we numb it up
before we even clean it.
Often you like to clean wounds
with high pressure saline.
And that's not terribly painful,
but it is uncomfortable.
And if we numb the wound
up before we do it,
it makes the procedure
much more comfortable.
And it gives us the ability
to really clean and scrub
the wound and get all
of the dirt out of it.
And that makes for a much
better healing process.
Very few of those
will become infected.
Numbing the wound
requires an injection,
usually first at the
area of the wound
closest to the
heart-- in this case,
toward the base of the
affected finger or thumb, then,
in and around the wound itself.
Numbing the wound will give
the patient greater comfort,
and allow you to do
a thorough cleaning,
using a sterile saline solution
with plenty of moisture
applied.
With the wound inspected,
numbed, and cleaned,
you're ready for suturing.
[MUSIC PLAYING]
Suturing wounds is easier
than you might think.
You begin by disinfecting the
area where you'll be working.
Suturing technique improves
quickly with practice.
And you may wish to consider
the use of wound closing strips
for smaller cuts as an
alternative to suturing.
Before suturing, you
must disinfect the area
where you will be working.
In this instance, the doctor
is using povidone iodine
to liberally clean the area.
A typical suture kit has all
you need for stitching wounds--
suture material, a suture
needle, sterile drapes
and gauze to absorb
blood or other moisture,
a needle holder called
a needle driver,
scissors, and sometimes forceps.
Forceps are used to
manipulate the skin,
opening or closing
the cut as needed.
Before suturing inspect
inside the world
for any foreign material
or further damage.
The curved needle is inserted
on one side of the wound
and emerges on the other,
pulling the flaps of skin
together.
Remember-- the purpose of
suturing is to close the wounds
and hold them closed
to promote healing,
so the knots are important.
Tie a number of square knots,
then cut with your scissors
and proceed to the next stitch.
Judge the number
of sutures needed
by the width of the wound,
to create an even closure.
For more superficial wounds
that are not likely to reopen,
you may wish to consider using
simple wound closing adhesive
strips.
These are little tapes,
very strong pieces of tape
that are adherent, and you
can pull together wound edges
with these pieces of tape.
You would use a Steri-Strip
in an area that is not going
to separate spontaneously.
You would never use
Steri-Strips, for instance,
over a joint where the
skin has to slide and move.
But on the face,
lacerations on the face
often respond very
well to Steri-Strips.
Now, let's look at
removing sutures--
in the case of this patient,
a laceration to the eyebrow.
The nurse begins by
asking if the healing has
been progressing normally.
I'm just going to wash this
off with a little hydrogen
peroxide.
She's done a good job of
cleaning this because there's
not a large scab build-up.
And that's important
we want people to not
have a standard build up
because that widens the scar.
This looks pretty good.
While the sutures were
healing, the patient
was asked to clean the
wound twice a day to keep
the scab from building up.
This just takes a pick up,
which is this forceps here,
and a little iris
scissor with a tiny point
so that I can get
under the stitches.
I want to cut close
to the edge so
that I'm not pulling
the suture all
the way back through the wound.
With the sutures
removed, the nurse
applies a topical ointment to
promote healing and minimize
scarring.
If you'll note
one thing, this is
a laceration
through the eyebrow,
but we have not
shaved her eyebrow.
And that's something
that you want to avoid.
If you are on a vessel and
somebody gets a cut like this,
you just need to suture
with the eyebrow intact.
Do not shave it.
Don't be intimidated
by suturing.
It's an important technique
for medical care at sea.
If you're unsure how to
proceed, call for advice.
Next, we'll look at
dressing the wound.
[MUSIC PLAYING]
Dressing wounds requires
cleaning the area carefully,
applying ointments or salves
to promote healing and minimize
infection, and the application
of gauze, bandages,
or other protection
for the wound.
Once a wound has
been treated, it
must be thoroughly
cleaned and dressed.
That means first
removing any blood
or residue from your procedure
and swabbing the area
carefully.
You're not going to
get this wet, OK,
for at least a couple days.
The dressing stays
on for a couple days.
Then take it off and wash it
gently with soap, just Ivory
soap, water, nothing fancy.
Often, some type of
ointment is applied
before dressing the wound to
promote healing, keep the wound
supple, and help minimize
the chance to the dressing
will adhere to the
wound when it's changed.
There are a variety of ways
to dress a healing wound.
Have plenty of gauze pads
and bandages available.
In the case of this
lacerated finger,
the nurse is
applying tube gauze.
The gauze is loaded
into a metal cylinder
to make application
easy and painless.
Applying the tube
gauze is simple.
Insert the metal
cylinder over the finger,
give a twist to hold it,
withdraw the cylinder, twist,
and begin again.
Once you've built up five
or six layers, cut the gauze
and bind it with adhesive tape.
Make sure you've not bound the
dressing so tightly that you'll
restrict blood flow or cause
numbness to the finger.
If for some reason,
this gets wet
even before the two days is
up, then change the dressing.
OK, you want it
always clean and dry.
All right.
So until the sutures
are out, you're
not going to go swimming,
hot-tubing, any of that, OK?
The final step in dressing
the wound is protecting it
and it's dressing.
This is both to promote
healing and prevent pain
from bumping or jostling.
There are numerous types of
splints that can be attached.
They're flexible and could
be form-fitted to accommodate
the particular
injury or body part.
Dressings should be
changed to regularly
to keep the wound clean
which may ooze and bleed
during the healing process.
Next, we'll look at one
of the potentially most
serious onboard injuries.
[MUSIC PLAYING]
Few procedures are as critical
as properly immobilizing
the neck to prevent further
injury and for safe transit.
A designated crew
member would do nothing
but stabilize the neck
during a traumatic situation.
Often a cervical
collar is attached
to help the immobilization.
As we've seen,
any serious injury
demands a serious assessment.
If he is unconscious it
sends you down one pathway.
If he is conscious,
you can determine
at least where
they injuries have
occurred-- where he has pain,
can he move or can he not move.
If a conscious
patient complaints
of neck, head or back
pain, or witnesses
say he has suffered
a blow to the head
or possible spinal
injury, take precautions.
And if he is unconscious,
assume the worst
and stabilize the head and neck.
They're stabilizing
his neck and you
notice since he's
unconscious, they
have no way of determining
where his injuries are.
And so you'll notice that at
the head of the crew member--
the injured crew member--
is a man who is designated
to stabilize the neck.
A cervical collar is used
to help immobilize the neck.
These often attach
with straps or Velcro,
and are common in
emergency kits.
We're having the neck stabilized
and held in a neutral midline
position by my assistant.
And then we'll use a
hard cervical collar,
which provides a rigid support
to the neck and the structures
of the neck.
And we apply this by sliding
the collar beneath the neck,
applying this under the
chin, and stabilizing it
on the sternum.
And wrapping the
Velcro device, now we
have a basically stabilized
neck ready for transport.
OK, and now log roll
him up on his side,
trying to keep
everything straight.
And you tell us when
to roll back, Art.
When you roll, or
move the crew member,
make sure the person stabilizing
the neck moves in concert
and directs the action.
Often, tape or some
other biting is
used to keep the
head and neck steady
once the crewman is
on the stretcher,
and especially while he or
she is being transported.
If necessary, the
individual designated
to stabilize the neck can
walk with the stretcher.
[MUSIC PLAYING]
Splinting an injury is
another protective measure.
You splint a limb
for immobilization--
so an injury isn't
worsened-- for stabilization
until further care can be
given, and for protection.
In the hospital, an x-ray
can reveal a broken bone.
Onboard most ships, when
assessing and treating a sprain
or break, you'll have
to use other methods.
Begin with a visual
inspection, and look
for signs of discomfort.
I'm not going to make our
friend here have discomfort,
but if I grabbed here
and here, and pushed
with a little pressure, you can
be sure that he'd have pain.
When you don't have
the luxury of an x-ray,
for instance, on a ship,
that's one of the ways
you can establish if there
might be a fraction in there.
One thing we could also
do a ship without an x-ray
is assess range of motion.
Can you bring your
fingers down a little bit?
How far can you move?
Starting to get painful?
That's as far as I can
go with the index finger.
OK, so another indication
there's a problem
here is the restriction
in the range of motion.
He's not able to have a
normal range of motion
with flexion of the fingers
without producing pain.
So in this instance, on
a ship, we would split.
And this is exactly what
we do in the hospital,
knowing there's a fracture.
But even without a fraction,
we'd splint for comfort.
There are many types of splints.
They can even be fashioned
from scratch, if necessary.
The purposes, again, are
to immobilize, stabilize,
and protect.
Now the idea with this is
we want it to be supportive,
but not too tight.
So if you notice that your
fingers are feeling swollen
or you're having trouble
moving them, or they're cold,
yeah, loosen it up.
Since the purpose is
immobility, the injured wrist--
when splinted-- is
then bound to the body
to further restrict motion.
This can be done with a sling
or an improvised bandage.
Next, we will look at a further
degree of immobilization--
splinting injury with plaster.
[MUSIC PLAYING]
Splinting an injury
with plaster is
an effective protective step.
We'll look at the
preparation, wetting
the plaster and its application,
and wrapping or slinging
the limb.
In this woman's ankle, you
can see that the swelling
it is over the lateral portion.
And this is actually the point
here of maximum tenderness.
Sometimes an injury
will be sufficiently
serious to require splinting,
for maximum immobility.
Both plaster and fiberglass
splinting materials
are available.
Ideally, we like to split the
foot in a 90 degree position.
But if someone's
having too much pain
when you flex the foot
into a 90 degree position,
then you splint it in the
position of maximum comfort.
Before plastering,
comes preparation.
A length of stockinette
is placed over the area
to be splinted to
protect the skin.
Then a material
called web roll is
wound around the leg to give
more padding and protection.
When you wrap web roll,
it's very important
that when you wrap whatever
portion of the body
that you're wrapping, that
you have at least three layers
of web roll covering the
entire area that you're
going to be applying plaster.
The web roll can
be torn and shaped
to give coverage to all areas.
Then, the plaster-- which has
already been cut to length--
is ready for its bath.
These are three sets of
five layers of plaster,
each 5 inch by 30 inches.
And when you have
your water ready,
you want to make sure that it
is relatively cool, not too hot,
because the plaster will
heat up when you wet it.
And what you do is put it into
the water and you squeeze.
And when you open it up,
you can run your fingers
down the layer of the plaster
to help spread the material.
There will be three
sets of strips applied.
The first is
applied immediately,
beginning on the inside of the
ankle and crossing the foot.
The plaster is smoothed
out to conform to the leg,
but not too tight.
A second set of strips is
then applied laterally,
from the outside of the
leg, over to the inside.
A final set of strips
is applied posteriorly,
from the back of the leg,
across the length of the foot.
This is a standard posterior
splint of the left ankle.
The splint is not meant
to be walked upon.
It's meant to be used in
conjunction with crutches.
Walking on it once it's
hardened will break it,
and it will lose
its effectiveness.
Once the plaster has been
applied and smoothed out,
fold the stockinette back
over the plaster at both ends.
Again, check for
capillary refill
to make sure there's good
circulation to the toes.
The final step is
two more layers,
more web roll to help
absorb some of the moisture,
and an ACE bandage
on top of that.
Make sure that when they
wrap the ACE wrap to not
wrap it too tight.
But to wrap it tight
enough so that it
helps the mold the split.
When you're done,
caution the crew member
that the plaster will grow
warm as it dries and hardens.
And make sure
they're comfortable.
[MUSIC PLAYING]
One of the most crucial steps
you can take in medical care
is monitoring progress.
Most illnesses or injuries
are not just one event.
You may need a course of
medicines, close observation,
and modification
of your treatment.
Although we've concentrated
on specific treatments
for specific injuries
and illnesses, in fact,
good medical care has
a time component too.
Monitoring an
injured or ill crew
member, until you can get
additional help or into port,
can be as critical as the
initial treatment itself.
The care of a crew
member should not
be thought of as a
single incident--
that it's really
one event that's
followed by a period
of observation
or further medical care,
antibiotics, pain medicine,
changing dressings.
And one of the things we have
a lot of in this environment
is time.
And we can use
time to our favor.
Monitoring is a time when you
use your powers of observation
and communication.
You continue to
check vital signs,
and you perform
maintenance activities--
changing dressings, checking
the healing process,
and perhaps giving drugs
or medications for pain
and to prevent infections.
This introduction
to maritime medicine
has given you a
few of the basics.
Remember-- there's no
substitute for good training,
good equipment, and
good communication.
If you're well
prepared, you can handle
most injuries and illnesses
with competence and confidence.
[MUSIC PLAYING]