Medical Procedures - The Officer's Shipboard Guide

[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]