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MARITIME LIFE SUPPORT - Danish Maritime Authority

1. Blow to the head Dress the wound and place the patient in a recovery position ve M c NN 921A19S YLCOH 9uinnije y Jo 193u82 92 pU ii Strangulation and Hanging General information We use the term strangulation when something is tightened around the neck so oxygen and blood do not reach the brain The cause may in the worst case scenario be hanging in connection with a suicide attempt Symptoms Bluish lips ears or wing of the nose due to lack of oxygen Unconsciousness Protruding bloodshot eyes and extravasations on the neck Action in case of strangulation hanging Cut the person free and remove the tight object from the neck Perform ABC and CPR in case of lifelessness Contact Radio Medical and follow the prescription Center of Maritime Health Service 93 Loosen and perform ABC and possibly CPR 991A19S Uu3JP9H OWIVIAeW Jo 1913u923 94 95 pU cM NN Bone Fracture s General information Strokes twists or severe bending of a bone may cause a bone fracture The ends of the fracture may be twisted and cause a deformity An open fracture occurs if the point of a bone pierces the skin or the skin 1s scraped on the outside Symptoms Pain on the area of the fracture e Swelling Possibly small wounds around the fracture arteries veins and nerves may have been cut Possibly abnormal shape of the bone Possibly sensation disorder and no puls
2. CIMI EB p1eoq UO 91e4D PXIPSW JO 61eyI u UOSI9_d 9Y 10 Ply S414 First Aid for the Person in charge of Medical Care on board Ships MARITIME LIFE SUPPORT On every occasion Compiled by Nurse Gitte Pihlman Richter and nurse Torben Leth for the Center of Maritime Health Service The Danish Maritime Authority 3 Edition Version 3 October 2012 ISBN 87 7454 283 4 1 Table of Contents Preface Introduction Responsibility and Competence MLS Maritime Life Support ABCDE and Secondary Problems Cardiopulmonary Resuscitation Heart Starter on board Danish Ships Basic Information Breathing and Shortness of Breath Heart Trouble and Circulatory disturbance Consciousness and Unconsciousness Procedures Maritime Life Support accident Maritime Life Support illnes Cardiopulmonary Resuscitation Children and Adults Maritime Life Support Examples of MLS in practice Examples of MLS 2 Example of MLS 3 Example of MLS Radio Medical Denmark RMD Medicine chests Hygiene Malaria prevention Maritime Life Support First aid procudures First Aid after Insect Stings and Reptile Bites Index of first aid procedures 921A19S Uu13 JP9H 9uinnije y Jo 193u82 Center of Maritime Health Service Preface This first aid booklet is specifically targeted the person in charge of medical care at sea and forming a supplement for the authorized Danish medical manual The booklet is based on modern international principles of treatmen
3. Capillary response pulse and quality of these Skin colour and temperature Are bleedings and wounds under control Does the venous needle work and is the drip running Eventually phone contact with Radio Medical 921A19S YLCOH 9Uuinnije y Jo 193u82 Center of Maritime Health Service Level of consciousness Pupil reaction 32 Disability Examine and assess the patient s level of consciousness from the following Is the patient 1 Awake alert and well informed 2 Is the patient s consciousness affected even though he reacts to speech 3 Unconscious but reacts to pain 4 Unconscious with no reaction to pain Examine the patient s pupils with light Direct the light source towards one eye and observe the re sponse on both sides Repeat on the opposite eye Observe the following The pupils shape and size round or oval dilated or the size of a pin head do they react to light one eye or both are the pupils the same size Transfer to sickbay Reassess ABCD Contact Radio Medical Continue Observation and Treatment Contact Radio Medical 33 Expose Sickbay on the site of the accident Examine in accordance with the patient s information Avoid transfer if treatment on the scene is possible without causing inconvenience for the patient and medical exam iner If the patient is transferred on a stretcher lift or log roll onto a back board assess which
4. NU Nr NN 921A19S YLCOH 9uinnije y Jo 193u82 MN NU ccn MEME ON Center of Maritime Health Service 62 When should you wash hands It is therefore essential to remove microorganisms from your hands before being passed on to other people or surfaces The refore you must always perform hand hygiene when you work in a clean area and when you just have worked in an unclean area e g Before and after all patient contact Before you get equipment in the medicine chest and before handling clean equipment Before and after you inspect clean sew or dress a wound Before and after catheterisation Before and after placing of vein canula and other injections e After handling soiled utensils After using gloves Before and after handling medicaments Before and after handling food What is hand hygiene To wash hands and wrists with water and soap To disinfect the hands and wrists with 11 1 chlorhexidine ethanol 0 5 96 85 e To use gloves when there is a risk of contact with the pa tient s body fluids vomit urine faeces blood wound secretion saliva etc The gloves are in the medicine chest they are clean but not sterile They are used to protect the person in charge of medical care and helpers against possible infection for the patient How should you wash your hands Make your hands wet under the tap Apply soap Distribute the soap on the palm between the fingers on each finger
5. Psychological first aid Contact Radio Medical and follow the prescription Center of Maritime Health Service 991AJ9S YLJCOH WIZIJEWN jo 1913u825 Center of Maritime Health Service 104 Neck and Back Injury General information Problems with neck and back are not always caused by a stroke or fall but may arise after a wrong twist or lift These problems are associated with pain but are not life threatening Consult Radio Medical in the acute phase for a prescription for pain relieving drugs In case of neck and back injuries and possible damage of the central nerves the following symptoms can be seen Symptoms Pain and sorerness in neck and back Weakness in arms and or legs Numbness or tingling sensation in arms and legs Complete or partial paralysis breathing difficulty or breathing stop Action Position the patient on the back e Support the patient s head and avoid nerves the following symptoms can be seen movement of the body Ask the patient to describe his symptoms Psychological first aid Contact Radio Medical and follow the prescription 105 991A19S Uu13JP9H OWIVAeW Jo 1913u923 106 107 p CU cM NE Chest Injury Severe injury Action Location of the injury via ABC General information If needed apply a valve dressing see below Minor chest injuries such as muscle sprains broken or bent ribs Apply a dressing ease the patient s breathing caused by e
6. le Action in case of severe burns Perform life saving first aid ABC Rinse with water immediately on the burnt area Hereafter perform the above mentioned procedure Rinse immediately Limited burn IM Severe burn 921A19S YLCOH 9Uuinnije y Jo 193u82 82 eT Frostbite General information If unprotected parts of the face nose ears hands and feet are exposed to immense cold it causes a local drop in temperature because the small blood vessels retract to minimize the heat loss Depending on which temperature the person is in and the duration of his stay in the cold weather frostbite may spread to large parts of the body Symptoms rritation of the skin Redness around the frostbitten area e Skin is cold e Skin turns waxy pale and cold e Small blister which may burst e Severely reduced sense of touch around the area e Numbness Black fingers or toes Gangrene dead tissue Action Bring the person in cover to avoid additional frostbite Avoid rubbing the frostbitten area f the frostbite 1s superficial which means that the skin can be moved over the joints the thawing out may begin slowly f the frostbitten area 1s white hard and unmovable the thawing out may begin with water no warmer than 37 degrees Center of Maritime Health Service 83 lume Sn Celsius This is a very painful process which must take place in consultation with Radio Medical
7. Action Avoid unnecessary movement to minimize the risk of poison spreading in the body To relieve the pain ice cubes can be placed on the bite wound In case of allergic reaction chock e Perform ABC e Give Adrenalin Contact Radio Medical and follow the prescription 921A19S YLCOH OWIVIIeW Jo 193u82 126 127 i NN Snake Bites Scorpion Stings General information General information snakes usually live in areas with high grass in woods and stony Scorpions are nocturnal animals and appear at dusk They hide ground and luckily there is only a minimal risk of snake en in cracks and vegetation and indoors in cupboards duvets beds counters at sea In the odd chance that there 1s a snake on board and the like Most scorpion species are harmless to humans even and it bites symptoms and subsequent action are as follows though the sting can be very painful Symptoms Symptoms On and around the bite wound there 1s pain swelling and The classic symptoms of moderate to serious poisoning are discolouration but these symptoms do not necessarily occur ndisposition immediately after the bite Perspiration Within the first 10 minutes and few hours after the bite Palpitation and raised blood pressure symptoms such as indisposition nausea vomit headache e Dizziness dizziness perspiration shortness of breath bleeding muscle Nausea and vomiting convulsions confusion cramps and paralysation chock
8. Contact Radio Medical and follow the prescription Skin is cold pale and waxy Severely reduced sense of touch small blister are formed which may later burst Black fingers due to gangrene dead tissue 921A19S YLCOH OWIVIAeW Jo 19 U 9 84 85 p UP oM NN Poisoning Follow the guidelines of MFAG in consultation with Radio Medical General information This general information on poisoning may be used in case of Contact Radio Medical and follow the prescription any poisoning The primary goal is to neutralize the harmful substance the person has been subjected to Symptoms rritation of the nervous system Changes in the level of consciousness confusion dizziness hallucinations delusions or unconsciousness Co ordination difficulty changes in the muscle tension possibly cramps or headache may be symp toms of poisoning Changes in breathing frequency or depth Irritation of the airways which may cause swelling of the mucous membrane and contraction of the bronchi s Inflammatory conditions in the bronchi s and lung tissue may cause water in the lungs Affected circulatory Upset stomach such as nausea vomit and diarrhoea Treatment RINSE RINSE RINSE Rinse remove air to neutralize the toxic substance If possible use a razor knife to scrape toxic substances from the skin The person in charge of medical care must monitor the patient constantly until Radio Medical takes over the treat
9. Before providing first aid make sure that the patient and tha medical examiner are safe from The climate e g cold weather or heat with a subsequent danger of heatstroke High sea and subsequent danger of MOB Fire that spreads Danger of inhaling toxic smoke chemicals Danger of a crash If the patient and medical examiner are in danger an emergency evacuation must take place immediately before further treatment Methods are for example Forearm hold ndividual hold Two person The medical examiner puts on gloves before being in contact with the patient He shouts at the patient to see if he is conscious and alert Where does it hurt Center of Maritime Health Service Sickbay Reassess ABC Keep a record and monitor the patient objec tively and first consultation with Radio Medical Continue observation and secondary treatment Follow Radio Medical s prescription 921A19S Uu13 JP9H WIZIJEWN Jo 193u82 Center of Maritime Health Service Inline stabilization Secure free airways Cervical collar Oxygen mask 20 Airway First of all the head is held manually The body is placed in a strait line on the back Examine mouth and throat Jaw lift gt Place both hands around the jaw bone and press this forward This grip is ideal if a patient is unconscious and his tongue hinders free airways Place a tongue depressor if the patient is uncon scious e Use mec
10. M NNNM Center of Maritime Health Service 90 Head Trauma General information Concussion of the brain A concussion is a minor injury compared to other brain dam ages There are no changes in the brain tissue and the patient usually recovers without permanent ill effects Symptoms Dizziness nausea bump swelling memory loss of the injury headache possibly brief unconsciousness a few minutes Action If the patient 1s conscious he can be positioned as he wishes In case the patient is unconscious and the person in charge of medical care has to leave the patient place him in a recovery position Place his head high if possible Monitor pulse blood pressure and level of consciousness every 2 hour Contact Radio Medical and follow the prescription Fracture of the skull A severe blow on the head may cause a fracture of the skull Gen erally the symptoms are the same as the above mentioned symp toms of a concussion but often more severe Symptoms Wound and bump on the head bruises and swelling behind the ear around one or both eyes fluid or blood from ear or nose bloodshot eyes the white in the eyes turns red crookedness or asymmetry of the head and shape of the face reduced level of consciousness 91 Action If the patient is conscious find a position he feels comfortable with In case of unconsciousness place the patient in a recovery posi tion Open fracture of the skull
11. breathing and circulation Knife in the back must not be removed Action Stop the bleeding and dress the wound Foreign bodies that have entered the head chest or abdominal cavity must not be removed Contact R M after per forming MLS Under C a compress 1s placed around the foreign body This 1s fixated with gauze or elastic dressing Contact Radio Medical and follow the prescription Foreign bodies such as metal fragments and glass may be removed In the acute faze only what is strictly necessary is cleansed with Chloride Hexidine Bleeding is stopped by following the principles arterial venous bleeding Remove glass from the wrist and stop the bleeding Contact Radio Medical and follow the prescription Center of Maritime Health Service 9291AJ9S u13J89H OWIVACW jo 1913u825 110 111 pU i Support Bandaging General information Elbow Bandaging The purpose of a support bandage is to prevent additional swell Keep the arm slightly bent in a 45 ing and support the joints Fundamental rules of bandaging degree angle Lead the bandage twice around the elbow joint covering the tip Each time the bandage is led around it must cover 2 3 of the of the elbow previous round except the 2 fist and last rounds The elastic bandage must always be applied in one direc By turn lead the bandage over and tion from within and outwards under the joint to create a herringbone The ban
12. cold weather or heat with a subsequent danger of heatstroke High sea and subsequent danger of MOB fire that spreads danger of inhaling toxic smoke chemicals danger of a crash If the patient and medical examiner are in danger an emergency evacuation must take place immediately before further treatment Methods are for example forearm hold individual hold e two person Australian lift the Throne the Crab method 921A19S Uu13 P9H WIZIJEWN Jo 193ue82 Center of Maritime Health Service Placement Secure free airways Breathing quality Secure free airways 30 Airway Consider which position 1s most suitable for the patient alleviating dorsal position on the side in foetal position sitting or according to the patient s wish Capillary re sponse Examine mouth and throat n case of unconsciousness Jaw lift Place both hands around the jaw bone and press this forward This grip is ideal if the patient 1s unconscious and his tongue hinders free airways Place a tongue depressor if the patient is uncoscious Use mechanical suction in case of vomit phlegm and blood Skin colour in mouth and throat Give oxygen immediately hereafter Slightly affected respiration e 1 6 l min form a nasal cannula Placement of venous needle Severely affected breathing e 9 min with mask e 15 l min flow with ventilation back Breathing In case of unconsciousness Exp
13. the next day place a new bandage ELEVATION Keep the injured body part as high as possible and preferably above heart height as long as there is swelling Rest Compression elevation 921A19S U13 8P9H 9Uuinije y Jo 193u82 Center of Maritime Health Service 88 Heart Diseases General information Adults may experience heart diseases suddenly and unexpected during rest or activity Often the patient is aware of a high blood pressure and or other heart problems Symptoms in case of a dislocation A feeling of pressure or a weight on the chest A choking sensation around the neck or changed breathing Pain radiation to the arms jaw teeth ear stomach or between the shoulder blades Weight sensation numbness or sleeping sensation in the arm shoulder elbow or hand on both sides Gray pale face cold and clammy skin Action Perform life saving first aid A B C for illness f the patient has his own nitroglycerine administer this Place the patient in a semi sitting heart position or in a position the patient finds comfortable Loosen clothing and belt Psychological first aid try to calm the patient Contact Radio Medical and follow the prescription NB Be prepared to perform Cardiopulmonary resuscitation see page 35 89 Patient with chest pains Loosen belt and clothing Patient is placed in a semi sitting position 921A19S YPIE H OWIVIAeW Jo 193u82
14. A chapter IX B Ex amination treatment and ship medicine 921A19S YLLCOH 9Uuinije y Jo 193ue82 Mu nu RN N Center of Maritime Health Service 58 Placing the medicine chest There are no requirements for the location of the medicine chest If there is a demand for a hospital on board it would be natu ral to place the medicine and medical equipment in the hospital treatment room If there is no demand for a hospital on board it would be natu ral to place the medicine chest in the immediate vicinity of where you intend to carry out the treatment The medicine chest must according to the National Board of Health s Medicine cabin announcement be looked up This rule does also apply at sea Some countries have rules stating that some of the medicine must be kept in the safe The medicine there in these countries must be kept in the safe are typically found on a list with Con trolled Drugs In such cases the responsible of the ship must take contact to the local agent and ask for the provision of this list Acute mobile resuscitation equipment The Danish Maritime Authority has established rules for oxygen and the mobile resuscitation equipment in the existing notice A chapter IX B appendix 1 Beside this you can pack first aid equipment and medicines for first aid together with the mo bile resuscitation equipment There is drafted proposals for the packaging of the mobile resuscitation equipm
15. Serum Institut SSI urge the merchant fleet to follow the given regulation on malaria prevention and treatment but underline additional preventative measures which can reduce malaria incidents in the Danish merchant fleet What can be done differently 1 Risk assessment Ship destination 2 Crew information Before during and after 3 Mechanical and medical prevention 4 Procedures in case of illness 5 General and individual advice Trough the next pages the procedures will be unfolded as a guide On board considerations when entering malaria areas can be of tremendous importance and crucial to crewmembers 1 Risk assessment Ship destination Before every voyage to malaria areas the responsible officers should consider the following 5 risk parameters Destination and trade area Risk evaluation No risk risk or high risk of malaria According to the Danish Statens Serum institut SSI see homepage adress on page 70 921A19S YLLCOH OWIVIAeW Jo 19 U 9 Center of Maritime Health Service 66 67 Duration Number of days time of the year Where is the ship placed roadstead in the harbor along Crow on shore morning midday or Crew on shore morning midday or evenings Season October Advice from SSI Radio Medical if in doubt of medical pre vention Crew risk information mechanical On shore morning midday and prevention evenings Towards the above mentioned considerations an example on the
16. e Increased saliva unconsciousness heart failure and death may occur Diarrhoea Action If an allergic reaction occurs after a scorpion sting the symp Avoid unnecessary movement to minimize the risk of poison toms are spreading in the body If possible gently wash the bite wound immediately with Affected consciousness clean water and soap Unconsciousness Cramps Contact Radio Medical and follow the prescription Blood pressure drop Chock and with that a critical state Action Place ice cubes on the sting wound to relieve the pain Perform life saving first aid ABC Contact Radio Medical and follow the prescription Center of Maritime Health Service 9291AJ9S YLJCOH OWIVACW jo 1913u825 128 M ME Center of Maritime Health Service Index of first aid procedures The index below contains a series of procedures for the follow up on ABC the work in sickbay and the finishing treatments in consultation with Radio Medical Abdominal lesion open closed Abdominal pain illness Arterial bleeding Bone fracture Burns Chest injury Convulsion Diabetes Dislocation sprain Drowning Ear nose bleed First aid after insect stings and reptile bites Fluid loss Foreign body in the airways Frostbite Head trauma Heart disease Heatstroke sunstroke Hypothermia Mouth tooth injuries Neck back injury Patient positioning Poisoning Psychological first aid Shock Strangulation and hangi
17. g a stroke may be more severe than they appear at Position the patient according to the injury e g recovery first glance In accidents involving acute severe chest lesions position on the injured side such as penetration fall and or an injury where one 1s stuck Calming the patient psychological first aid between something extremely heavy the subsequent treatment primarily deals with the life saving functions Contact Radio Medical and follow the prescription Symptoms These will mainly relate to the concrete injury but general symptoms are Breathing difficulty pain when moving the chest and redness and swelling around the injury Direct and indirect soreness Possible hole in the chest with air whistling Minor injury Action Locate the injury via ABC f needed apply a dressing and position the patient depending on the size of the injury Calm the patient Contact Radio Medical and follow the prescription P Red blue bruise on the chest Valve dressing Center of Maritime Health Service 9291AJ9S YLCOH OWIVACW jo 1913u825 108 109 M et CENE Wounds infected with foreign bodies General information After accidents caused by e g an explosion stab or a fall for eign bodies such as metal fragments and glass may remain in skin and muscle tissue It may bleed from the wounds and there is a great risk of infection of the area Symptoms Bleeding from the wound Possibly affected consciousness
18. its shoulders and head are supported by your forearm Hold the head horizontally to secure free airways Observe feel and listen for breathing and vital signs for no more than 10 seconds No breathing vital signs Begin CPR Give 30 compressions with two fingers on the sternum on the line between the nipples Pressure depth 4 cm or 1 3 of chest height Compression frecuency 100 til max 120 per minute Blow twice light blows into the mouth and nose for no more than 5 seconds Continue CPR in series of 30 2 until obvious vital signs appear If breathing begins Bring the child to sickbay and contact Radio Medical Cough and movement Continue to blow into the mouth and nose until breathing begins The most common causes for heart failure in children from 0 1 y o a are foreign objects in the throat 37 Obstructed breathing 30 compressions with 2 tap on the back fingers on the line between the nipples pressure depth 4cm Blow into mouth and nose to Position the child in a and make the chest rise and fall dorsal position to secure to secure free airways f a foreign body has entered the throat give 5 thumps on the back and 5 compressions on the sternum until the foreign body shows 991A19S Uu13JP9H OWIVAeW Jo 1913u923 Center of Maritime Health Service 38 CPR for children aged 1 8 years Check consciousness Speak shake not too rough If unconscious Call for help
19. of cardiac arrest 921A19S YPIE H OWIVIAeW Jo 193u82 10 144 pu RN ccm NN Basic Information Shortness of breath has a significant impact on the body and the With the basic information about regular irregular breathing cells function and survival Especially brain cells are vulner circulatory and level of consciousness the person in charge able and react quickly to lack of oxygen of medical care is quickly able to determine if a crew member If there 1s no breathing the person in charge of medical care needs help As breathing circulatory and consciousness are vi must either blow into the mouth or ventilate with a ventilation tal bodily functions a short repetition of these 1s given below bag and mask If the breathing 1s either very slow or very fast the brain may not have enough oxygen This affects the patient s Breathing and Shortness of Breath consciousness and he must therefore have supplementary oxy The breathing ensures that the lungs are filled with air and gen bring oxygen to the blood stream and the red blood vessels via the bronchi s and alveoli s and at the same time dispose of CO Heart Trouble and Circulatory disturbance via expiration This 1s an automatic process controlled by the The circulation consists of the heart arteries and veins which breathing centre in the elongated spinal cord and mechanically provide oxygen and energy to the body s cells via the blood by means of the diaphragm and
20. the back of the hand and around the wrists 63 Wash for 15 seconds 1s any use nail brush Thoroughly rinse the soap of Dry the hands on paper towel and close the tap with the pa per Cleaning the instruments To prevent infection the instrument are cleaned properly before and after use A lot of the equipment in the medicine chest is disposable equipment and is used only once then disposed It is known to be packed in sterile packs A 3 oxygen masks and F 5 tongue depressor is not sterile packed but must also be disposed after use The instruments used for sewing wounds are reusable instru ments and they are not packaged sterile They shoul be cleaned before and after use Immediately before use The instruments are located in D 5 metal box with a lid Pour the instruments with med 11 1 chlorhexidine ethanol 0 5 96 85 so they are covered with fluid Put on gloves Take the instrument from the metal box and place them on a C 7 sterile cover e Wait 30 seconds before use After end treatment Rinse the instruments and metal box under running cool water Wash the instruments and metal box thoroughly in water and 921A19S YCOH WIZIJEWN Jo 193u82 MU c NN ee Center of Maritime Health Service 64 detergent with a brush remove all visible dirt Rinse the instruments and metal box thoroughly for soap residue Place the instruments in the metal box and pour them with 11 1
21. there is something wrong Fever disease where the temperature is gt 39 C at a temper ature of 39 C or more the condition can develop into a life threatening situation Fever disease where the disease persists beyond 2 3 days fever with duration over several days must be dealt with by a doctor Any condition with pain in the chest or abdomen this may be a sign of severe conditions that requires evacuation Furthermore RMD is always contacted Before administering the medication check the guidance and record over content in the ships medicine chest if there stands Seek consultation with Radio Medical there is a case of prescribed medication which only may be given after contact with a doctor Before the following procedure injection of medication and infusion of fluid stitching of wound treatment of fractures and large wounds and emptying of the urinary bladder all procedures that are potentially dangerous at the wrong ap proach If you have any doubts get help where expertise is ask RMD Radio Medical records When contacting RMD the Radio Medical records RMO is filled out all Danish vessels must have it on board RMO is ex pected soon to be available in an electronic version in addition to the printed The records contain both guidance and schemas which can be 921A19S YULLOH OWIVIAeW Jo 193u82 54 55 ur nM RN n use for reporting on the patient s condition over a period
22. to malaria suspicion the following procedures will take place Early examination of the person s blood Use the ready set available on board and you will detect the deadly malaria within 15 minutes Prepare a thick blood specimen for consignment to the SSI The blood should dry out and be placed in the fridge Examination of the urine gt for blood General examination of the person The temperature will independently go up and down according to the malaria spe cies 69 Depending on the previous medical history and ongoing re sults Radio Medical will give the proper advice towards the right treatment Can the ill person continue the journey or must he be evacu ated as soon as possible Radio Medical will take responsi bility Read the exact recommendations in the Danish malaria strategy 5 General and individual advice According to registrations on malaria in Denmark nearly all cases come from Africa Recommendations towards medical prevention when sailing other regions than Africa seek individual advice and informa tion from the SSI The risk of getting malaria depends on the parasites resistance to medicine and also 1 Which countries and harbours the ship enters 2 How far the ship goes up rivers 3 How long the stay in the area lasts 4 Is it wet or dry season Remember to perform the risk assessment Individual advice The purpose of individual advice is to secure ships sailing in malaria risk
23. Bites Bee and Wasp Stings General information Bees and wasps inject a small amount of poison under a person s skin when they sting This 1s often associated with pain and red ness on the sting wound but in the worst case scenario it may cause an acute allergic reaction with redness and swelling of the throat and with a subsequent danger of respiratory failure This reaction can happen very quickly Action In case of a non allergic reaction Remove the bee sting with tweezers Place an insect remover over the sting wound to suck the poison out Wash the wound with clean water and soap In case of an allergic reaction e Perform ABC Give adrenaline Contact Radio Medical and follow the prescription 125 Spider Bites General information Generally spiders prefer moist places with some shade and therefore like to hunt indoors during the day Symptoms On the bite wound a tingly slight stinging burning or severe pain may be felt n some cases pain does not occur immediately Vesiculation swelling of the skin due to bleeding in the sub cutis and cramps of the muscles may occur n some cases tissue death may occur at a later stage The general symptoms are anxiety a state of weakness head ache indisposition perspiration and dizziness swelling around the eyes nausea in the worst case shortness of breath drib ble vomit and cramps of the airways In the worst case allergic chock
24. Cardiopulmonary resuscitation is an important factor in surviv al after heart failure It is hard work and it is therefore recom mended that the person who performs cardiopulmonary resusci tation 1s replaced every 2 minutes Studies also shows that the quality of cardiopulmonary resuscitation decreases after 1 5 3 minutes of compression The change must be planned and hap pen without interruptions and it 1s the very quality of cardio pulmonary resuscitation and use of a heart starter that increases the chances of survival after heart failure Heart Starter on board Danish Ships Heart starters gain more and more access in Danish society This 1s also the case in maritime affairs even though the Danish Maritime Authority does not require heart starters by law at the present time As heart starters are recommended for passenger ships and several shipping businesses acquire these information nd user instructions must be given It is emphasized that a heart starter in combination with car diopulmonary resuscitation offers a better possibility for resus citation but the distance to the nearest hospital and the ship s navigational area are of significant importance in connection with survival The most important thing is to evacuate the ill or injured patient as soon as possible Most heart starters come with user instructions and mainte nance directions If the heart starter is carried on board it must be used along with CPR in case
25. Initiated medical prevention in Tbl Malarone 1 2 days before next page shows how to perform a Risk assessment coop with during and after according to the A documented Risk form should initiate both mechanical and SSI RMD malaria guideline medicine chest medical prevention which is recommended on board Danish ships 2 Information to the crew If doubts occur information and help is a joined matter be Before arrival 1 2 days before arrival in malaria areas the tween company and ship management crew must be informed of which precautions to take Any clari fication concerning mechanical medical prevention and how to do the practical things will be handled by the person in charge of medical care on board A security meeting is recommended Risk assessment During the stay in the period the ship stays in the area with Destination area season any level of risks there is a risk of infection It is very impor Africa Nigeria High risk 12 davs oct tant that medical prevention is administered at the same time every day Keep focus on the mechanical prevention day and J night Be aware of each other and do only take the medicine Prevention which is handed out Medical Mechanical Leaving the area in the period after the ship has left the malaria area the administration of medical prevention is just as 1 tbl Malarone a day Mosquito repellent important as during the stay Follow the recommendation of the person
26. Medical as painkillers may interfere with uncovering the patient s symptoms 115 Hypothermia General information The core temperature drops when the body s heat production is not able to cover the body s heat loss Naturally time wind and water temperature decide which symptoms occur The body temparature is registered based on symptomps e 35 34 Shivering e 34 30 weak trembling muscles e lt 30 Unconscious Symptoms e Shivers muscle trembling when the temperature drops Pale and bluish skin colour Confusion muddle headedness and fatigue which may lead to unconsciousness A body temperature below 28 30 degrees Celsius may lead to cardiac arrest Action Bring the patient in cover or inside Remove wet clothes and wrap the patient in non heated blankets and possibly an isolating plastic wrap aluminium foil blanket see illustration page 98 Avoid unnecessary movement of the patient Give warm sugary beverages Do not rub or massage as it leads to additional loss of body heat In case of unconsciousness e Give 9 min oxygen on mask ntensified observation of breathing 921A19S YLCOH WIZIJEWN Jo 193ue02 116 117 p UP ae Monitor vital signs Mouth and Tooth Injuries Begin CPR if there is no breathing or vital signs General information When a person is suffering from severe hypothermia it can be Bleeding from the mouth can be caused by a bite or cut in th
27. Medicine chest Legislation content and organizing Center of Maritime Health Service 991AJ9S YLJCOH OWIVACW jo 1913u825 16 17 p RN cmo NN Stop the Accident Maritime Life Support Accident What happened Center of Maritime Health Service 921AJ9S u1J8e9H OWIVAeW JO 19130925 18 MLS Accident Stop the Accident What happened Quick survey Is the site of the accident safe for the medical officer and the injured person s the injured person conscious and alert Emergency evacuation Airways Inline stabilization the position of the head is secured Secure free airways if needed use tongue depressor Place a cervical collar Give oxygen Breathing Assess breathing quality Circulation Examine capillary response Do you feel a pulse and with which quality Skin colour and temperature Check for haemorrhage Place a venous needle and drip Reassess ABC in case of complications Disability Examine and assess level of consciousness Examine pupil reaction to light Assess if treatment can continue at the site of the accident Expose Top to Toe examination Fixation in the stretcher Transfer to sickbay What happened Secure the site of the accident Emergency evacuation 19 Stop the Accident When the medical examiner arrives at the site of the accident the following is assessed What happened Where did it happen How many are injured
28. WIZIJEWN Jo 193u82 14 15 pn eee Procedures Hygiene Infection spreading circle hand hygiene and general In the following section MLS CPR and a number of topics are principles on hygiene described and defined for use as a reference book e g in sickbay Malaria Addendum to the Danish malaria strategy and as general background information in case of accidents and illness on board Also 3 examples of MLS in practice are given First aid Selected parts of first aid as a supplement and help for the person in charge of medical care We have divided MLS in two sections accidents and illness since these two naturally require different actions when han dling the ill or the injured patient The procedures are basically similar as the principles of AB CDE wich first and foremost deal with life saving issues there after minor injuries and in collaboration with Radio Medical the final treatment MLS accident The cover gives an overview of the upcoming actions which will be specified on the follow ing pages The cover can be used as a to do list laminated and carried in the mobile equipment MLS illness The cover gives an overview of the upcoming actions which will be specified on the following pages CPR Revised outlined cardiopulmonary resuscitation for children and adults MLS in practice 3 examples of MLS in practice Radio Medical Definition and cooperation with the person in charge of medical care
29. according to the Cause of the Injury General information Blisters Damaged tissue due to high temperatures Action Rinse until the pain stops Do not puncture the blisters When the fluid runs out and the protection bubble bursts it hurts more than before Dress blisters in the burn area so that they do not burst so easily f the blisters burst cut off the loose skin Contact Radio Medical and follow the prescription Sunburns Heavy sun exposure may result in painful superficial burns Cold running water will relieve the pain if the extent of the injury is not so big Give water to drink to maintain the fluid balance In severe cases intravenous NaCl may be necessary Action Contact Radio Medical and follow the prescription Burns in mouth and throat By consuming hot beverages or inhaling steam and smoke the mouth throat and lungs may suffer a burn This may lead to swelling of the mouth and throat which could close off the upper airways 921A19S U13 JP9H 9Uuinnije y Jo 193ue82 120 121 p eU MEME NE Action Electrical burn Give cold beverages to relieve the pain of a mouth and When an electrical current courses through a body it throat burn damages all tissue on its path There may bea contact burn Bring an injured person who has inhaled smoke out into where the current enters and exits the body fresh air and supplement with an oxygen mask If the current runs through th
30. ad the bandage 3 times around the metacarpus Begin by the knuckles and lead the bandage diagonally up over the back of the hand Lead the bandage 12 times around the wrist and secure with tape Continue diagonally down the back of the hand an around the wrist The bandage must create a herringbone pattern ina straight line on the back of the hand Fin ish with 3 times around the wrist and secure with tape Center of Maritime Health Service 921AJ9S u1Je9oH OWIVAeW JO 190 2uUaD M CU i Center of Maritime Health Service 114 Abdominal Pain and Illness General information Abdominal pain and illness are for most person in charge of medical cares a non specific and difficult condition to address This change in the common condition must be taken serious and examinations and treatment must not be postponed Symptoms Abdominal pain is the most common symptom of an abdomi nal illness The symptoms vary depending on which organs are involved see the medical book The pain can be described in many different ways and can occur on varying times and inter vals The change in the common condition will determine how serious the situation is Action Position the patient comfortably Fill out the Radio Medical record if the patient 1s not acutely ill Psychological first aid Consult Radio Medical and follow the prescription NB As a general rule do not give any painkillers before consulting Radio
31. and an emergency bag Secure free airways Bend the head back and lift up the chin Observe feel and listen for breathing and vital signs for no more than 10 seconds No breathing vital signs Begin CPR Give 30 compressions with 1 hand on the middle of the chest Pressure depth 5 cm or 1 3 of chest height Compression frecuency 100 til max 120 per minute Blow twice into the mouth and nose Continue CPR in series of 30 2 until obvious vital signs appear Bring the child to sickbay and consult Radio Medical Continue to blow until breathing begins If breathing begins Bring the child to sickbay and contact Radio Medical Cough and movement Continue to blow until breathing begins 39 Bend the head a little observe listen and feel Give 30 compressions on the middle of the chest press with one hand Pressure depth 5 cm Blow twice effectively through mouth so chest rise and falls 921A19S YPIE H WIZIJEWN Jo 193u82 Center of Maritime Health Service 40 CPR for patients older than 8 years adults Check consciousness Speak shake If unconscious Call for help and an emergency bag Secure free airways Bend the head back and lift up the chin Observe feel and listen for breathing and vital signs for no more than 10 seconds Begin cardiac massage and blow in case there is no breathing and vital signs Expose the chest Give 30 compressions and blo
32. areas Both to give the right preventative medical advice and to balance a sound suggestion between 1 The risk of getting life threatening malaria 2 The risk of resistance towards the medicine 3 The risk of getting ill of side effects 921A19S YLCOH OWIVIAeW Jo 190 2uU9a9 70 71 Mur nu NN mM ts The ship management or the person in charge of medical care on board can always seek individual advice on the following ad dress Statens Serum Institut Parasitologisk Afdeling Artillerivej 5 DK 2300 K benhavn S Phone 3268326895 Maritime Life Support E mail hvn gssi dk or lav ssi dk Back up gt pea ssi dk First aid procudures World map on malaria Rejser og smitsomme sygdomme on the Statens Serum Institute homepage only in Danish www ssi dk Vaccination Center of Disease Control and Prevention CDC gt alternatively to the Danish SSI http www cdc gov malaria malaria worldwide 1mpact html Center of Maritime Health Service 9291AJ9S u13J89H OWIVACW jo 1913u825 72 73 Mur nM CR nn EHMNMNMEEEN Mn NN Arterial Bleeding General information In case of an arterial bleeding blood is pumped out in tact with the heartbeats The severe blood loss may be life threatening Venous bleedings may seem less dramatic but may be serious Venous bleedings are stopped the same way arterial bleedings are controlled see below Symptoms Bleeding from the wound in question Possibly affecte
33. chlorhexidine ethanol 0 5 85 in 10 minutes Wipe the instruments and metal box with a clean and lint free cloth The instruments are stored in a metal box in the medicine chest Hygiene in sick bay ship hospital Did you know that microorganisms can lice in a speck of dust for up to a year and still be infectious That 1s why we clean up Therefore there also must be cleaned in sick bay ship s hospital and in the medicine chest at regular intervals when there is vis ible contaminated and or dust Cleaning sick bay ship s hospital and in the medicine chest med icine cabinet is done with water and soap In areas that are contaminated with blood vomit faeces urine and other body fluids the cleaning is performed with water and soap disinfection with 1 1 chlorhexidine ethanol 0 5 9o 85 9o In infectious diseases such as meningitis tuberculoses or severe diarrhea seek individual advice from Radio Medical Denmark Did you know that if you drop something ont the floor it 1s considered unclean and must be discarded or cleaned Sterile packed disposable equipment cannot be cleaned Source www ssi dk 65 Malaria Prevention in the Danish Merchant Fleet Addendum to the Danish malaria strategy Facts To this day Malaria is a serious illness Every year millions are infected and die from the disease Through this addendum to the Malaria guide line on board the Danish Maritime Author ity and Statens
34. consciousness may be af fected Action e Check the bandage again e Place the patient on his back with the knees slightly bent e Loosen tight clothing and belt e Psychological first aid in case the patient is conscious e Follow Radio Medical s prescription e Be prepared for Cardiopulmonary resuscitation in case of unconsciousness see page 42 Stroke in the abdomen Symptoms In case of closed lesions pain is the primary symptom What and which organs are injured are uncertain If there is bleeding in the abdomen the abdominal muscles may be hard and blue and red bruises may indicate where the injury is Breathing circulatory and consciousness are affected Action e Place the patient on his back with the knees slightly bent Place the patient in an or in a position the patient finds comfortable On the side with E R eCen nee Center of Maritime Health Service 9291AJ9S YIL H WIZIJEWN jo 19 U 9 E LESE Center of Maritime Health Service 2 76 Drowning General information The causes of drowning are many An obvious cause is hypo thermia If a person is drowning it is important to rescue him from the water immediately and provide first aid Symptoms Unconsciousness No breathing Pale cold and lifeless No perceptible pulse No vital signs Action When the person in charge of medical care has rescues the person from the water A Secure free airways B Observe l
35. d consciousness breathing and circulation Hold the pressure area Action Lay the patient down and lift the bleeding wound as high as possible Press your fingers directly into or under the wound Bleeding control in case of severe bleedings Put pressure in the armpit or groin with your fist Perform life saving first aid ABC under C Hold a compress dressing to the bleeding area and fixate with sterile gauze bandage Bind the corners of the bandage in front of the wound f blood seeps through the bandage place a new one f the bleeding still has not stopped apply a pressure bandage This is done by applying a firm object on top of the compress and fixate with gauze bandage Contact Radio Medical and follow the prescription Center of Maritime Health Service 9291AJ9S u13J89H OWIVACW jo 1913u825 s 34 75 pr M CR nnn NN Abdominal Lesions open closed the legs up and under the body may ease the pain Loosen tight clothing and belt General information Psychological first aid Injuries brought on by a violent external force may cause open or closed abdominal lesions There is a danger that this leads to Contact Radio Medical and follow the prescription organ system failure and bleeding can be life threatening in the acute phase Symptoms In case of open lesions pain and blood loss are the primary symptoms As the patient looses blood the breathing frequency increases the skin 1s pale and the
36. dage must not be so tight that the patient has a pattern on both sides of the elbow tingling sensation in e g fingers or toes joint Foot Joint Bandaging 1 Lead the bandage 3 times around the metatarsus Begin by the knuckles and lead the bandage diagonally up over the back of the foot Lead the bandage 3 times around the arm and secure with tape 2 Continue diagonally down over the back of the foot until the bandage reaches the ankle joint The bandage must create a herringbone pattern in a straight line on the back of the hand Lead the bandage 3 times around and secure with tape Center of Maritime Health Service 921AJ9S u1J8e9H OWIVAeW JO 10 2uU9aD 112 113 p UP cM NN Knee Bandaging Mitella Arm Sling Keep the knee slightly bent in a Used for support and relief of arm or shoulder 45 degree angle Lead the ban dage twice around the knee joint covering the knee cap By turn lead the bandage over and under the joint to create a herringbone pattern on both sides of the knee joint i ae r Lo kl Er f ip k E J ie P a Thumb Bandaging Lead the bandage 3 times around the wrist diagonally up around the thumb and around the tip of the thump Lead the bandage 3 times around just below the knee and secure with tape Lead the bandage diagonally down over the thumb and around the wrist Continue until the bandage reaches the root of the thumb Wrist Bandaging Le
37. e heart it may lead to cardiac ar rest Contact Radio Medical and follow the prescription Action As soon as the power is switched off the patient must be given a cooling treatment If the patient has suffered cardiac arrest perform CPR Blisters whole burst Contact Radio Medical and follow the prescription Chemical burn Various chemical substances that damage the skin at contact Action If the chemicals are in a powder or crystalline form brush off all loose particles with a cloth Rinse with water until it does not sting anymore Contact Radio Medical and follow the prescription Sunburn ix Center of Maritime Health Service 921AJ9S u1J8e9H OWIVAeW JO 19130925 122 123 a NN Heatstroke Sunstroke Fluid Loss General information The body can be exposed to a rise in temperature after a long General information stay in a very warm climate The situation may worsen after hard Different scenarios may lead to fluid loss but regardless of labor or if the recommended amount of fluid is not consumed whether it is a fever burn vomit diarrhoea or dehydration from working in high temperatures fluid loss can develop into a life Heatstroke threatening condition occurs when the body is not capable of cooling itself down When the air and the skin are warm no temperature regulation takes Symptoms place and this leads to a rise in body temperature Thirst A state of weakness fatigue Symptoms e Di
38. e tongue lip difficult to see 1f there 1s breathing and vital signs in general or the inside of the cheek The cause can be insignificant as well as severe The patient therefore demands an extra 10 seconds intensified observation to monitor the breathing before possible CPR is Symptoms of bleeding in the mouth performed Bleeding from the mouth s mucous membrane or the lip Breath ing difficulties due to blood in the throat and subsequent danger Contact Radio Medical and follow the prescription of airway blockade this 1s rarely seen in the waking state Action Let the patient sit with his head leaning forward and to the side of the bleeding Let the blood run out of the mouth Use suction if possible Ask the patient to hold gauze to the wound for at least 10 minutes Contact Radio Medical if the bleeding does not stop spontaneously General information Below the focus on knocked out teeth is on bleedings See other guidelines in the medical book Symptoms in case a tooth has been knocked out Bleeding from the mouth where the tooth has been knocked out Wrap the person suffering from hypothermia in blankets Action Rinse the mouth Replace the tooth with a light pressure and hold the tooth down e g with a piece of gauze f it is not possible to replace the tooth keep the tooth in Sodium Chloride the patient must see a dentist within 1 2 hours if possible Consult a dentist and Radio Medical Cente
39. e under the fracture The patient has heard a crack Open fracture with no circulation Action A closed fracture is supported in the position in which it was found During transport position the arm leg in the nor mal position and later in an inflatable splint An open fracture is supported in the position in which it was found and a sterile bandage 1s applied over the fracture During transport position the arm leg in the normal position and later in an inflatable splint Contact Radio Medical and follow the prescription Attention The inflatable splint is only to be used for trans portation Max inflated time 45 min g Er ua ni Closed fracture in an inflatable splint Center of Maritime Health Service 921AJ9S u1J8e9H OWIVAeW JO 19130925 96 97 pe NE Patient Positioning General information on recovery position Use in case you have to leave the patient if the patient has un stable breathing and risk of airways blockage due to blood and mucus and in case of unconsciousness General information on alleviating dorsal position Use in case e Breathing is hindered by cough phlegm and the like and when the patient is not able to sit up e n case of chest pains and if the patient is not able to sit up Closed or open abdominal lesion e Stomach and abdominal pain Recovery position Alleviating dorsal position General information on dorsal position Use in case the patient 1s con
40. ent on www dma dk under the tab Maritime Health and then under the tab Pu plications 59 Exemption for other medicaments In cases where it is not possible to meet the requirement for the content of medicine and medical equipment in the medicine chest can you apply for exemption The exemption application may for example be required upon delivery of medicaments that do not contain the correct medica ment or correct strength It may also be necessary to apply for exemption to have other medicines on board An example could be vaccine against outbreaks of diseases The procedure for Exemption for other medicine 1s available at www dma dk under the tab Maritime Health 921A19S Uu13JP9H WIZIJEWN Jo 193ue82 Center of Maritime Health Service 60 Hygiene Good hygiene is to prevent the disease from spreading To help preventing the spread of disease on board you can use the Infection circle It describes the factors that affect transfer of pathogenic microorganisms from one person to another Each arrow in the chain of infection can be broken by perform ing hand hygiene Infection Circle Source of infection Infection recipients Route of infection Infection gate b The source of infection may be bacteria viruses fungi mi croorganisms from sick people urine and faeces blood body fluids and wounds Route of infection may be our hands handles taps and the equipment we
41. es on board that will help the patient Often several people on board have the qualifications to provide first aid and medical treatment and this should be welcomed ABCDE and Secondary Problems ABCDE are the new first aid procedures for use in case of ac cidents and illness They lay down a standardized procedure for control of breathing circulation consciousness et cetera 921A19S YLLCOH OWIVIAeW Jo 10 2uU9a9 Center of Maritime Health Service This method where Airways Breathing Circulation Disability Expose ABCDE are assessed helps the person in charge of medical care by using familiar procedures but in a more system atic and prioritized way ABCDE can be used in connection with any first aid as the actions ABCDE give the person in charge of medical care a quick survey of the patient s condition Furthermore it is of great help in the communication with Radio Medical Radio Medical is very interested in early contact in case of injury or ilIness and in acute situations the satellite telephone 1s ideal Here information concluded on the basis of ABCDE is report ed where after a plan for further treatment 1s specified Treatment in Sickbay Not all ships have a sickbay hospital on board where patients can receive medical treatment but the most important thing in this connection is that equipment and medication are within reach We know that the bridge or tables in the mess are used in medical treatment
42. evel of consciousness has been 4 but the person in charge of medical care still checks if there is any pain response The assistant shows no response to pain The stretcher team arrives and it 1s decided that the assistant must be transferred to sickbay from where Radio Medical is contacted E In sickbay a reassessment of ABCD is made before Radio Medical is contacted by telephone The first mate who is also a trained person in charge of medical care begins monitoring the 921A19S YLCOH WIZIJEWN Jo 193ue82 a ee Center of Maritime Health Service 48 assistant s concrete data which means breathing frequency per minute pulse per minute and blood pressure The Radio Medical record is followed categorically The oxygen cylinder from the mobile resuscitation equipment is replaced by a 10 liter cylinder in sickbay Later this information will be sent to Radio Medical by fax but is reported at the present time by telephone As the assistant remains unconscious after 2 hour and the per son in charge of medical care estimates his condition as critical the doctor orders an evacuation after consultation with Radio Medical The coastguard will be arriving in an hour and the as sistant 1s prepped for transport It is checked if the oxygen flow and oxygen cylinder are working if the drip 1s running slowly as prescribed and if there are any changes in the assistant s condition Continuously consciousness breathing pulse blood press
43. gulation A chapter IX B Examination Treatment and ship medicine regulation 3 Technical Regulation A chapter IX B Examination Treatment and ship medicine regulation 4 2 B s The medicine chests A B C and supplement type P and CR are published as separate publications The supplement types M G and F are annexed in notice A chapter IX B Underlying basis for the Danish medicine chests content and structure is the European Directive 92 29 EEC Minimum record for safety and health requirements for improved medical treatment on board ships Organizing the medicine chest The organization of the medicine chest in cupboards drawers and bags are no requirements Regardless of where the medicine chest is placed it 1s recom mended that the person in charge of medical care organize after group number as in the Record control document and user instruction The medicine must be provided with a label that informs the group number corresponding to the number system in Record control document and user manual Medical equipment must be stored dry and dark and it should not be stored near chlorine The explanation of the system in the medicine chest is described in the guidance for Record control document and user instruc tion for respectively medicine chest A B C and the supple ment chests CR and P Statutory basis for storage of medicine and medical equipment can be found in Technical record notice
44. hanical suction in case of vomit phlegm and blood in mouth and throat A cervical collar is placed In case of suspicion or uncertainty about the accident fall injury where one is stuck between something extremely heavy and other accidents where a severe force or external influence cause the accident Give oxygen immediately hereafter 9 liters min with mask Ventilation bag with a mask 15 l min flow Breathing Breathing Expose the chest lift the shirt or cut it off quality Observe if the chest rises and falls Listen if the patient has shortness of breath or if his breathing is normal listen to the patient s voice Feel on the cheek to check if the patient exhales Assess breathing frequency and depth fast shallow slow and deep normal n case of B problems examine the chest for injuries and note these for use in later treatment This examination must not take more than 10 seconds Capillary response Skin colour Observe if there are haemorrhages Placement of venous needle Reassess ABC 24 Circulation Put brief pressure on the patient s nail it turns white under the nail and observe how long it takes before it turns pink again If it takes more than 2 seconds it is a sign of circula tory disturbances Observe the quality of the pulse Feel the neck groin or wrist to check for a pulse Is it slow fast strong weak irregular regular do not count for more than minute at this
45. he evacuation The authority whom is responsible for the evacua tion contacts subsequent the ship and arrange the details After contact with med Radio Medical The patient is being observed at the intervals agreed with RMD and changes are communicated to RMD Any prescriptions are carried out If there is any doubt about observations prescrip tions of medication or procedure contact RMD again Center of Maritime Health Service 9291AJ9S u13J89H OWIVACW jo 1913u825 ur nc CR n Center of Maritime Health Service 56 Medicine chests For the person in charge of medical care and Radio Medical it has great safety importance that there is a good overview of the medicine and medical equipment regarding of cooperation on the treatment of the sick At the same time there are legal requirements for storage of medicine in Danish land based legislation and hereby also in the laws at sea The medicine chest Almost all Danish vessels have required medicine chest De pending on the area of operation the chest must have the size A B or C Area of operation is described in notice A chapter IX B Depending on the function of the ship there is complement medicine chest A B and C The supplement types CR P M G and F refers to the following Rro RM Rescue fleets Passenger MOB boat War gas Coastrescue and boats ships vessels The supplement types are describe in the notice A chapter IX B l Technical Re
46. in a Evacuation from Danish passenger ships in Danish wa manageable form ters Rescue crew who picks up the patient need to know exactly what Cooperation between the person in charge of medical treatment is given so far and what instructions RMD has given care and Radio Medical Denmark Information on treatment and observations can with advantage As soon as RMD is contacted RMD takes over the legal respon be written down on Handling over to Emergency Personnel sibility for the patient s treatment form which can be downloaded from the Danish Maritime Au The person in charge of medical care and RMD agree together thority s website www dma dk MaritimeHealth Sider Publica on how the patient should be observed and treated tions aspx It is RMD who is responsible for the medical officer under stands what is expected of him including what treatment medi cine is to be given and what observations is to be made if nec essary with referrers to the procedures in the medical manual or guidance in the control document Medication will always be accompanied by appropriate number of medication in the control document Ship RMD and SOK RMD is responsible for the medical treatment while the captain is responsible for the ship and the crew Together they agree on how a possible disembarkation will take place If an evacuation is current RMD contacts Admiral Danish Fleet SOK which contacts other foreign authorities whom are responsible for t
47. in charge of medical care on board Because of the incu bation period it is even more important to keep an eye on each In doubt contact other and not to accept fever and headache It might be malaria Statens Serum Institut Radio medical DK 921A19S Uu13 JeP9H 9Uuinije y Jo 193ue82 M c n Center of Maritime Health Service 68 3 Mechanical og medical prevention The person in charge of medical care on board is familiar with malaria prevention both mechanical and medical The medicine chest is not according to the law equipped with mosquito repel lents but it has to be underlined that mechanical prevention will create a significant impact on the fight against malaria Special ists state that mechanical prevention can reduce the risk of get ting the infection by 50 It is recommended that the ship management train the crew in mechanical prevention and inform about the expectation con cerning mosquito repellents on board Secondly posters can be very helpful when arriving to the area Medical prevention should be decided upon from the result of the risk assessment and possible advice from Radio Medical or SSI By experience seafarers seems to be reluctant in taking unnecessary medical prevention but with the risk or high risk of getting malaria SSI and the DMA will always recommend medical prevention 4 Procedures in case of illness Should a crewmember get ill and the corporation with Radio Medical leads
48. isten and feel If there are no obvious vital signs begin Heart Lung Res cue see page 42 Contact Radio Medical and follow the prescription a 77 Rescue the person and perform cardiopulmonary resuscitation ashore 991A19S U3JP9H OWIVIAeW Jo 1913u923 Mr MM CN n Center of Maritime Health Service 78 Foreign Body in the Airways and Strangulation General information Strangulation can occur if a foreign body has obstructed the airways or the nose and mouth are blocked e g in connection with an accident or if the patient has been subjected to violence towards the neck Symptoms Bluish lips ears and wing of the nose due to lack of oxygen Unconsciousness n the worst case scenario respiratory failure When removing the foreign body from adults and children from the age of 1 take these actions f possible bend the patient forward e g over a table or chair Give 1 thump on the back between the shoulder blades with a flat slightly hollow hand f this does not work repeat the thump up to 5 times Heimlich method If the 5 thumps have no effect use the Heimlich method e Stand behind the patient Place your hand just below the sternum Clench the hand farthest in and press hard inwards and upwards at the same time Continue until the foreign body comes out or the patient falls unconscious 79 NB The patient must be attended by a doctor afterwards In case
49. l record and if possible Radio Medical is contacted by phone The ship receives the fol lowing prescription Observe the assistant for signs of a possible concussion If his condition deteriorates contact Radio Medical Describe the chest injury precisely bent or broken ribs and observe the breathing quality Continue oxygen 3 l per minute Shave cleanse apply a local anesthetic with lidocaine gel and sew the wound in the scalp Use the medical book Contact Radio Medical again after 4 hours or if the assistant s condition changes The medical prescription 1s sent to the ship via fax e mail 921A19S Uu13 JP9H 9uinnije y Jo 193ue82 ee ee ee Center of Maritime Health Service 46 2 Example of MLS Background MLS illness During a paint job on deck a 56 year old ship assistant suffers an indisposition and passes out A colleague sees the event and rushes to help He tries in vain to contact the assistant and calls for help but no one hears him After determining that the ship assistant is breathing he positions him in a recovery position where after he gets help When the person in charge of medical care reaches the ship assistant he finds him lying on his stomach on deck He looks pale and has shortness of breath The sea 1s calm and the out door temperature is approximately 25 degrees Celsius The person in charge of medical cares actions The person in charge of medical care has brought the fi
50. laced B The breathing is faster and slightly more shallow than nor mal The chest is exposed to see if there are any visible injuries but none are apparent C Pulse measurement capillary response skin temperature The pulse is fast but quite powerful Good capillary response and normal skin temperature the face is still a bit pale though A quick examination of the patient s body does not reveal any other bleedings A venous needle is not placed D Good pupil contraction on both eyes During the entire ex amination the level of consciousness has been lon the scale and therefore no further checks of consciousness are made 45 E Examination from Top to Toe Follow the guidelines the head is examined and despite the cervical collar the wound on the back of the head is easy to describe cm deep 4 cm long and it only bleeds a little The wound is cleansed with chloride hexidine and a clean dressing 1s applied The overall is gently removed to expose the body The back of the chest 1s tender to the touch corresponding to the bottom rib on the right side The examination is completed with a roll onto the side to check the back on the lower part of the loin above the buttock are red marks If there are no changes in the patient s breathing circulatory and level of consciousness the examination will be concluded by monitoring breathing frequency per minute pulse and blood pressure All data is entered in the Radio Medica
51. llows the arranged records writes down and provided that he in contact with RMD ac cording to an established set of rules Arranged records As a minimum the person in charge of medical care must write down the following e Who is treated position age gender e When is the request treatment happened date time Problem reason for the request Treatment what has been done decision on no treatment is also treatment Medicine does the patient take any kind of medicine what medicine Allergy is the patient allergic to something especially medicine If given antipyretic medicine 3 1 paracetamol there should be a temperature measurement prior to administration Contact to RMD The person in charge of medical care decides whether the first contact should be made by telephone or by e mail it depends on how urgent the request is There are established guidelines for cases in which the person in charge of medical care ought to contacted RMD RMD ought to be contacted in any case where there is a need for a medical assessment of the condition Contact RMD if the following is observed in the patient Any abnormal state of mind the patient behaves strange inexplicable different Any abnormal condition that affects the consciousness breathing pulse or blood pressure which need to be dealt 53 with if the patient isn t fully awake or lucid not breath ing normally and does not have a normal circulation
52. ment What how much and how long the influence of the toxic substance is coordinated with Radio Medical M z kF Person has toxic substance removed from arm Center of Maritime Health Service 921AJ9S u1J8e9H OWIVAeW JO 1913u925 M i n Center of Maritime Health Service 86 Dislocation and Sprain General information A severe blow or twist of a joint may lead to a dislocation A joint is dislocated when it is out of the normal position A sprain means that the ligaments are sprained and minor blood vessels may be burst Symptoms in case of a dislocation Deformity of the Joint e Swelling and possibly bluish discolouration Severe pain Action in case of a dislocation Keep calm and possible fixation in the position in which it was found Contact Radio Medical and follow the prescription Symptoms in case of a sprain e Swelling and possibly bluish discoloration Pain Action in case of a sprain RICE REST rest the injured body part and avoid unnecessary activ ity ICE Place ice on the injury as quickly as possible There must not be direct contact between the ice and the skin place a towel or the like in between The next 3 hours treat the injury with ice for 20 minutes followed by a 20 min break 87 COMPRESSION when the swelling and pain subsides place if possible a compressing bandage The bandage must not be too tight and must be removed at night If the injury 1s swollen
53. move is most suitable for your patient If the patient has been transferred to sickbay reassess ABCD to begin with and register and relieve possible changes in the patient s condition Contact Radio Medical by telephone or fax when you have additional concrete data on the patient s condition when a record has been made and the objective observations and examinations are completed Describe in record What happened history Which actions have been performed until now Objective observations Count breathing frequency longer than 1 minute Normal adult breathing frequency 12 16 min Blood pressure measurement Count pulse beats more than 1 min Normal adult resting pulse 60 80 beats minute Examine capillary response Reassess ABCD frequently and perform basic first aid Patient positioning place the patient in a comfortable position and make sure he is not too cold or too hot Psychological first aid Inform the patient and speak in a calm voice Wait for further prescriptions from Radio Medical and prepare if necessary for an evacuation 921A19S Uu13JP9H WIZIJEWN Jo 193u82 35 Cardiopulmonary Resuscitation Children and Adults 921A19S Uu1 8P9H WIZIJEWN Jo 193u82 Center of Maritime Health Service 36 CPR for children age O 1 y o a Check consciousness Speak shake not too rough If unconscious Call for help and an emergency bag Place the child so that
54. ng Support bandaging Wounds infected with foreign bodies UCUCUCO OC UC OC UC DOCU UO UCD UU CU UD Uo UC OU UP UU UU 74 114 P 94 80 119 106 101 118 86 76 98 124 123 78 82 90 88 122 115 117 104 96 84 100 103 92 110 108 Special thanks to Head of clinic Marie Hamming and Consultant Lars Erik Larsen Sydvestjysk Hospital in Esbjerg for professional sparring and proofreading and also much regard to other proofreaders and models used in this pamphlet Publisher Center of the Maritime Health Service Vestervejen 1 6720 Nordby Fano Tel 76 66 04 24 Email cms dma dk www soefartsstyrelsen dk Layout and DTP Casa Grafika Fang Printing house BHM tryk a s This pamphlet falls under the law and copyright cf Executive order no 194 of 11 March 1997 with amendments of Act no 407 of 2 June 1998 First Aid for the Person in charge of Medical Care on board Ships
55. ng does not stop spontaneously within hour or if the bleeding is severe s Psychological first aid Nose bleed Let the person with the nosebleed hold the bridge of his nose until the bleeding stops Ear Bleeding from the ear rarely happens spontaneously It may be caused by an inflammation of the middle ear blasts and stroke to the ear A blast may split the eardrum and cause subsequent bleeding from the ear Symptoms Bleeding from the auditory canal km Bleeding from the auditory canal Place gauze at the ear and let the blood run out of the canal Center of Maritime Health Service 921AJ9S u13Je9H OWIVAeW jo 1913092 Mur nM CEN n Center of Maritime Health Service 100 Psychological First Aid General information Psychological first aid 1s a continuous process which begins with the first contact In sickbay or after the life saving ac tions there is often better time and energy to grasp the previous scenario People have different reactions and therefore demand individual care Symptoms Common reactions Scared anxiety restlessness apathy weep ing hyper activity At first sight it may seem as if the person has control over the situation where after he or she collapses Action Always let the person know what 1s happening Listen and be honest Try to remain calm no matter how confusing the situation may be Use the time to gather information that will be useful in further treatme
56. nt If for examplethe person has not been able to inform you of any allergies or medication now is the time to write this down Be present and make sure the basic needs are met Find a calm suitable place to talk A Radio Medical prescription for calming medication may be necessary Contact Radio Medical and follow the prescription 101 Convulsion General information Convulsion are often caused by damage to the head lack of oxygen and sugar for the brain diabetes poisoning also alco hol abstinence Convulsion are divided into 2 sections below during and after as Convulsion rarely come with a warning Symptoms During e Sudden unconsciousness stiffness of the body followed by intermittent rhythmical movement of arms and legs Breathing may stop lips turn blue Uncontrolled biting in tongue and lips may happen Uncontrolled urination defecation After Muscles are relaxed breathing returns to normal over the course of a several minutes the person slowly returns to normal The person may feel confused and does not remember anything from the episode After the seizure the person is often very tired and falls asleep 921A19S U13JP9H 9UuiniJe y Jo 193u82 102 103 pU ccn NN Action Shock e Support the person and try to cushion the fall Sit by the person s side support the head and try to hinder the General information person from hitting furniture and the like Physi
57. o see if there are any bleedings or fluid rolled blancket between the legs 2 Examine the back of the head and neck examine if there Arms fixed to the body with duct tape are any deformities or soreness Observe if there are any traces Head fixes at the end with either backboard s own equipment of blood on the gloves or duct tape 3 Examine the chest using both hands feel the right and left sides on the front and back of the chest use log roll to examine the back Press lightly on both sides of the chest to examine if there is direct or indirect pain and stability focus on pain wounds and soreness 4 Examine the abdomen feel if the abdomen is hard or soft with attention to internal injuries 5 Examine the pelvis place a hand on both sides of the pelvis Press lightly to examine if there is any direct or indirect pain 6 Examine the arms and legs feel and observe if there are any injuries wounds or soreness 7 Examine the back this examination can be performed in con nection with a roll on the side or when the patient is moved onto a stretcher Fixing a patient to a backboard should be done as follows Center of Maritime Health Service 991AJ9S YLCOH OWIVACW jo 1913u825 Center of Maritime Health Service Reassess ABC Contact Radio Medical 26 Sickbay The patient arrives at sickbay and 1s installed A BC 1s reassessed right away and possible changes in the patient s condition is registered and
58. of unconsciousness Perform life saving first aid ABC and possibly Cardiopulmo nary resuscitation Contact Radio Medical and follow the prescription Thump method Heimlich method 921A19S YLLOH OWIVIAeW Jo 193u82 80 NU NM Burns General information Burns cause a rise 1n skin cells metabolism and increase the cells need for oxygen Due to the reduced blood supply the cells perish In connection with a fire warm air in mouth throat and airways is a serious problem Symptoms In case of limited burns Limited burns are 2 degree burns that are limited to a smaller skin area On the skin there are blisters containing fluid Pain In case of severe burns e Severe burns are burns that cover a large part of the body Consciousness breathing and circulatory may be affected Pain Circular burns on arms legs Action in case of limited burns Rinse with water immediately on the burnt area Remove loose clothing while you rinse If clothing sticks to the skin leave it and only cut it free around the burnt area Blisters must not be punctured Remove all jewelry watches that may squeeze the skin if there is swelling Avoid rinsing with water where there are no burns to avoid hypothermia Continue rinsing with temperate 20 de grees warm water until the pain subsides this may take hours Contact Radio Medical and follow the prescription Center of Maritime Health Service 81
59. ological shock is an acute condition which at best is prevented e Secure free airways and monitor the breathing and relieved No matter which state of shock the person is suffering Try to loosen tight clothing around the neck there are preventive elements At first the body seeks to mend itself When the person regains consciousness offer him a piece of e g pulse and breathing are faster than normal if a person looses chocolate or other sugary foods blood These symptoms tell the person in charge of medical care and Keep the person under observation as a new seizure may oc Radio Medical to perform the life saving preventive treatment If the cur blood pressure drops severely it may be hard to rectify Contact Radio Medical and follow the prescription Symptoms Level of consciousness 1 4 NB Never try to remove anything from the mouth or insert any Possible increase in breathing frequency thing into the mouth before the cramps cease Pulse may rise e Skin may turn pale Bluish fingers toes ear lobes and lips Reddish in case of allergy Body temperature may feel cold and clammy Capillary response gt 2 seconds Blood pressure may drop quickly The patient is anxious scared Action ABC Observe if possible dressings are soaked with blood Generally ob serve if there are any changes in the patient s condition Wrap the patient in an aluminum blanket or the like Follow Radio Medical s prescription
60. ose the chest lift the shirt Observe if the chest rises and falls Listen if the patient has shortness of breath or if his breathing is normal listen to the patient s voice Feel on the cheek to check if the patient exhales Reassess ABC Assess breathing frequency same procedure as if the patient was conscious see below Is the patient awake Assess breathing frequency and depth fast shallow slow and deep normal listen to the patient s voice This examination must not take more than 10 seconds 31 Circulation Put brief pressure on the patient s nail it turns white under the nail and observe how long it takes before it turns pink again If it takes more than 2 seconds it is a sign of circulatory disturbances Observe the quality of the pulse Feel the neck groin or wrist to check for a pulse Is it slow fast strong weak irregular regular do not count for more than 1 minute at this stage Observe the skin colour and temperature Colour Pale blush reddish yellow Temperature Cold warm perspiring cold sweats Is the patient pale with bluish skin fast and shallow breath ing weak pulse and capillary response gt 2seconds Place a venous needle and start an infusion set Important in case of infusion e l NaCl slow drip 20 30 drops minute If the patient s general condition changes reassess the following Free airways Oxygen flow intact Respiration quality
61. r of Maritime Health Service 991AJ9S YLCOH OWIZACW jo 1913u825 eee oU Center of Maritime Health Service 118 Diabetes General information When the pancreas partly or completely stops the production of insulin it leads to diabetes See symptoms below First aid in case of diabetes is primarily needed if a diabetic crew member sudden ly experiences low blood sugar It is therefore important that the person in charge of medical care is familiar with this information Symptoms in case of low blood sugar Fatigue Muscle shivers Muddle headedness rritability e Sensation of hunger Perspiring cold and clammy skin Loss of consciousness Action Position the patient and depending on his level of conscious ness offer him sugary beverages a piece of chocolate orange small piece of sugar or the like If the patient has a quick response to the sugar offer him additional sugary beverages snacks e g whole grain bread Let the patient rest Symptoms in case of high blood sugar Heavy thirst frequent urination infection Expiration smells sweet like acetone Ata late stage the skin is warm and dry fast respiration and pulse the patient is in a dazed state leading to unconsciousness Action in case of unconsciousness Secure free airways contact Radio Medical and follow the prescription Contact Radio Medical and follow the prescription 119 Classification of Burns Scalding
62. rangement is free for Danish ships commercial vessels RMD has for many years been physical located at hospital 1n Es bjerg RMD is manned around the clock by a permanent staff of doctors who have knowledge of the training and qualifications of the person in charge of medical care on board The requests for RMD relates to all types of diseases injuries and accidents There are approx 1200 requests a year and most of them deals with injury infections skin problems and stom ach problems The request form has change over the years as the phone is used increasingly as first contact and many requests are supple mented with pictures The person in charge of medical care The prerequisite for becoming the person in charge of medi cal care on board a Danish flag ship 1s that you have a Danish STCW course as medical officer which must be updated with new knowledge every fifth year If you have a foreign STCW course or a Danish STCW course which is more that 10 years old you must have a Danish supple mentary course before you can work as a person in charge of medical care It is necessary to know the Danish concept medi cine chest books manuals etc When a crew member or a passenger address the person in charge of medical care becomes ill or injured he start treat Center of Maritime Health Service 9291AJ9S YLJLCOH OWIZACW jo 1913u825 mE Loa Center of Maritime Health Service 52 ing the person provided that he fo
63. relieved The secured patient remains secured until Radio Medi cal gives permission to do otherwise If possible phone contact Radio Medical in an acute situation and or e mail when you have concrete data about the patient s condition Keep a record and monitor the patient objectively De scribe What happened Background How did it happen When did it happen Which actions have been performed until now Objective monitoring Count breathing frequency longer than 1 minute Normal breathing frequency for adults 12 16 minute Blood pressure measurement Count pulse beats longer than 1 minute Normal resting pulse for adults 60 80 beats minute Examine capillary response Examine pupil reaction OF lt Maritime Life Support Illness 921A19S YPIE H WIZIJEWN Jo 193u82 Center of Maritime Health Service 28 Survey the Site Stop Deterioration What happened Secure the site Emergency evacuation 29 MLS Illness Stop deterioration The medical examiner puts on gloves before being in contact with the patient He shouts at the patient to see if he is conscious and alert Where does it hurt When the medical examiner arrives at the site of the accident the following is assessed What happened Where did it happen What caused the situation Before the medical examiner provides first aid are the patient and medical examiner safe from the climate e g
64. rge of medical care asks if the chef has cut himself anywhere else but he has not The blood loss is as sessed as minimal and a venous needle is not placed D During the entire examination the chef s consciousness has been 1 awake alert and well oriented Pupil reaction is not checked E The person in charge of medical care observes the wound and notes that it is deep and must be examined and assessed in consultation with Radio Medical In sick bay the wound is cleansed with chloride hexidine It turns out that it is approximately 5 cm long and 1 cm deep The person in charge of medical care applies a clean dressing to the wound and contacts Radio Medical Radio Medical gives the following prescription The wound must be sewn cleansed local anesthesia with 921A19S YLLCOH WIZIJEWN Jo 193ue82 50 51 M RN N lidocaine but no adrenaline and sewn see the procedure in the Radio Medical Denmark RMD medical book RMD is established with the purpose of assisting Danish ships Find out quickly when the chef had his last tetanus vaccine in the treatment of sick and injured persons on board The over e The following days the wound is observed to see if there all principal 1s that the person in charge of medical care whom is heat redness swelling or pain signs of infection acts as the doctor s eyes ears hands reports to RMD RMD diagnoses and prescribe the necessary treatment observation or medication The ar
65. rge of medical care must first and foremost survey the damage He must consider the safety in the area and the situation on the site of the accident The person in charge of medical care must ensure that he is not injured If the site of the accident remains unsafe everybody should stay clear of the site until e g the fire extinction 1s over To ensure that the injured person is not subjected to additional harm 1s of course of utmost importance Can ABCDE see page 10 take place on the site of the accident The person in charge of medical care must in any dangerous situation evacuate the patient to a safe area before commencing treatment 2 Situation The situation on the site of the accident may seem chaotic and it is not always easy to imagine the previous events The person in charge of medical care must survey the damage by observing the scene speaking to witnesses and also find ing out how many people where involved in the accident This information gives the person in charge of medical care a clue about the accident if e g the accident involved energy such as a fall from a ladder a blow an injury where one has been stuck between something extremely heavy or if the injured person col lapsed on the spot The extent of the accident determines the subsequent treatment on board the ship and the consultation with Radio Medical Den mark It is the person in charge of medical care s responsibil ity job to use the resourc
66. rib muscles Adults breathe ap During rest the heart beats approximately 60 80 times per min proximately 12 16 times per minute and children breathe twice ute and the arteries lead the oxidized blood to the capillaries as much The breathing may become irregular due to a number cells and liberate the oxygen The arteries pulsate in step with of different reasons but most often it stabilizes itself quickly the heart beats and therefore bleed severely in case of a leak age On the other hand blood runs calmly through the veins that transport CO and other waste products which under less and less pressure are brought back to the heart and returned to the lungs Center of Maritime Health Service 9291AJ9S YLJCOH OWIZVACW jo 1913u825 epi UTI aei UT Center of Maritime Health Service 12 Circulatory disturbance may be caused by different reasons but especially bleedings or lack of pressure in the circulatory may cause the body severe problems The cells play a vital part for the sustenance of life If the bleeding is not controlled or the pressure is not stabilized quickly the body will be affected The pulse will rise and the skin will turn pale when blood runs from the area Bluish skin indicates insufficient oxidation and possible cold and clammy skin indicate poor blood circulation Consciousness and Unconsciousness Consciousness is the brain s response when the 2 before mentioned systems are functioning normally Brain cell
67. rst mate from the bridge where skipper is now on duty The mobile resus citation equipment is quickly fetched on the deck office Stop deterioration emergency evacuation The person in charge of medical care surveys the scene There I no immediate explanation for the situation and there does not seem to be any danger in providing treatment here at the present time 47 ABCDE A As the assistant remains lifeless on deck he is quickly posi tioned on his back Free airways are secured via a jaw lift and a tongue depressor is placed Meanwhile the first mate has pre pared the oxygen Hudson mask with 9L min and he has also alerted a stretcher team B The assistant s breathing 1s still irregular and slightly shal low The overall is opened to expose the chest Here the first estimate of the assistant s condition is verified and there are no signs of strokes or anything else that may obstruct the breath ing C It is estimated that the assistant s pulse is fast but weak Slow capillary response gt 5sec His face is still pale and the skin on his body feels moist and warm On the basis of the gath ered information a venous needle is placed along with 11 NaCl with slow drip of 20 30 drops per min D The person in charge of medical care also checks the assis tant s pupil reaction Right eye shows a good contraction but the contraction on the left eye 1s weak During the entire examina tion the assistant s l
68. s are the body s most sensitive cells and if they are not oxidized and soaked with a sufficient amount of oxygen and blood the level of consciousness drops If the brain s functions shut down the body s functions will also shut down as the brain is the superior operating system Therefore it 1s once again stressed that the person in charge of medical care s primary task is to secure free airways The blood must circulate in the body if an ill or in jured patient is to survive The level of consciousness is an expression of the brain s con dition and an indicator for content of the injury The level of consciousness is examined standardized under ABCDE Dis ability where the brain s consciousness is categorized according to 4 levels of consciousness 1 Consciousness reacts normally aware of time place and personal data 2 Falls asleep responds to speech and touch 3 Seems unconscious but responds to pain 4 Unconscious no response to pain 13 Different situations such as accidents and illness may lead to unconsciousness The body is not necessarily in a critical state but if an uncon scious person is seen from a distance he appears lifeless Every muscle in his body is relaxed and there is a risk that the tongue will drop to the back of the mouth and block the airways If the patient 1s left without supervision he must be placed in a recov ery position Recovery position 921A19S Uu1 JP9H
69. scious and alert and has no Life threatening injuries e Signs of shock Discomfort or dizziness With bent or stretched legs General information on abdominal position Use in case the patient is unconscious and has lesions which hinder a recovery position Abdominal position Foetal position lateral position General information on foetal position lateral position Use in case the patient has open or closed abdominal lesions and is feeling nausea or discomfort Center of Maritime Health Service 991AJ9S YLJCOH OWIZACW jo 1913u825 98 99 p CU i Ear and Nose Bleed Action Let the patient sit or lie down with the head placed high General information Place a gauze meche at the ear to catch the blood There can be many reasons for a nose or ear bleed but they of Contact Radio Medical if the bleeding does not stop ten occur after severe strokes or falls and may be symptoms of a spontaneously within hour or if the bleeding 1s severe more severe injury see head trauma A spontaneous nosebleed may be caused by high blood pressure or if you blow your nose too intense Nose Symptoms Blood from one or both nostrils Possible sensation of blood running backwards down into the throat Action Let the patient sit with his head bent forward hold the nose bridge Cool inside and outside Offer crushed ice to make the veins in the mouth and nose cavity contract Contact Radio Medical if the bleedi
70. stage Observe the skin colour and temperature Colour Pale blush reddish yellow Temperature Cold warm perspiring cold sweats Observe if there are haemorrhages Blood pulses out of the artery Place a finger in the wound lift the bleeding area and dress the wound Blood runs from the vein same procedure as in Arte rial hemorrhages WHEN the patient is has pale bluish skin fast and shallow breathing weak pulse and capillary response gt 2seconds a venous needle is placed and infusion is set up Important in case of infusion 1l NaCl slow drip 20 30 drops minute If the patient s general condition level of conscious ness changes reassess the following Free airways Oxygen flow intact Capillary response pulse and quality of this e Skin colour and temperature Are bleedings and wounds under control Does the venous needle work and is the drip running Aventually phone contact with Radio Medical 921A19S YLLCOH OWIVIIeW Jo 193ue82 p LN nM NN Center of Maritime Health Service Level of consciousness Pupil reaction 22 Disability Examine and assess the patient s level of consciousness from the following Is the patient 1 Awake alert and well informed 2 Is the patient s consciousness affected even though he reacts to speech 3 Unconscious but reacts to pain 4 Unconscious with no reaction to pain Examine the patient s pupils with light Direct the ligh
71. t source towards one eye and observe the reaction on both sides Repeat on the opposite eye Observe the following The pupils shape and size Round or oval dilated or the size of a pin head Do the pupils respond to light one eye or both Are the pupils of the same size Top to Toe examination Transfer to sickbay 23 Do a top to toe examination before placing the patient in the stretcher Cut the clothes so the medical exam iner it better able to examine the patient see next page Transfer the patient with great care of neck and back There are different ways of doing this Pull in the longitudinal direction lift or log roll onto a back board Assess which move is right for your patient When fixating the patient to a back board or a stretcher secure the patient in the following order chest pelvis and head Keep legs apart e g with a folded blanket where after arms and legs are secured with gaffe tape Wrap the patient in a hypothermia blanket ordinary blanket Place oxygen and infusion set with the patient 921A19S Uu13 JP9H 9uinije y Jo 193ue82 24 25 p RN ccm NN Top to Toe examination Chest fixed with belts in cross position 1 Examine the head examine the skull and face to see if there Pelvis fixed with belts 1n cross position are any bumps blows or wounds Examine eyes ears nose and Legs fixed with duct tape at upper legs shins and feet Place a mouth t
72. t where the vital functions are controlled in order of priority We have called this Maritime Life Support MLS The MLS book is divided into a part about accidents and a part about diseases The book describes the treatment both at the site and in the ship s hospital as well as the cooperation with Radio Medical Denmark RMD Cardiopulmonary resuscitation CPR accordance with current international guidelines are describes and the use of defibrilla tor are involved Subjects of special interest for seafarers such as hygiene Radio Medi cal guidelines for medicine on board and malaria are also involved In addition are general first aid topics with MLS focus and a little basic knowledge of anatomy breathing circulation and level of consciousness added Introduction The term first aid has been defined in various ways through the times Contrary to the regular first aid provider ashore the the person in charge of medical care follows the doctor s prescription directly and has the qualifications to use the equipment on board the ship The combination of the person in charge of medical care at sea and the doctor ashore makes the system unique This will in the following be specified Responsibility and Competence The person in charge of medical care is obligated to follow a set of ethical rules such as loyalty and professionalism and he must also keep the pledge of secrecy in connection with the patient It is of the utmost impor
73. tance that the responsibility and quali fications in connection with the job as the person in charge of medical care are clearly defined also concerning the coopera tion with Radio Medical The doctor makes a prescription that the person in charge of medical care follows and as long this division of responsibility is observed the doctor 1s always responsible for the treatment 921A19S YLLCOH WIZIJEWN Jo 193ue82 Center of Maritime Health Service MLS Maritime Life Support First aid principles for the person in charge of medical care Maritime Life Support in short MLS is the title of the new first aid principles in this pamphlet MLS is a combination of first aid principles the existing equipment on board the competenc es of the person in charge of medical care and the consultation with RMD ashore MLS must be provided in every situation where the person in charge of medical care 1s in action Naturally the person in charge of medical care s role in an acute and severe situation is very different from his role in a minor injury formerly known as banality The use of MLS will always ensure a uniform first aid procedure The person in charge of medical care and the Radio Medical share a common grounding The nuances between MLS regarding illness and MLS regard ing accidents will be described later and 3 examples of MLS in practice will be given MLS the holistic understanding 1 Safety The person in cha
74. the fall with his hands hits part of his back loin Maritime Life Support and back of his head on the bitt astern He experiences a brief loss of consciousness and does not recall what he did minutes Examples of MLS in practice before the fall This small coaster does not have a sickbay on board There fore treatment will be performed where the person in charge of medical care has placed a cabinet for medication and equipment As the person in charge of medical care 1s the person in charge of the bridge extra crew is called to duty so he can be relieved The person in charge of medical care s actions Stop the accident emergency evacuation As the ship assistant has walked away from the site of the ac cident the accident 1s considered over To stop the bleeding the assistant holds a work glove to the wound He is calmly placed in a lying position while the person in charge of medical care produces his mobile medical equipment Center of Maritime Health Service 9291AJ9S YLJCOH OWIVACW jo 1913u825 NU cn ee Center of Maritime Health Service 44 ABCDE A Injury or blows to the head back of the head or neck Sup port the head as much as you can and place a cervical collar on the assistant As he is conscious and able to breathe freely only slightly out of breath and speak about the incident the person in charge of medical care concludes that the airways are free and a nasal cannula with a flow of 6 l min is p
75. ure and pupil reaction are monitored every 2 hour and entered into the Radio Medical record The colleague who found the assistant explains what he saw on deck Information on the assistant s general well being on board possible medication and possible signs of discomfort prior to the incident 1s forwarded to Radio Medical As the assistant 1s evacuated the crew speaks about the incident The good col league is not left in the lurch 3 Example of MLS Background accident causing a minor injury During cooking the chef cuts himself on the finger pad of the thumb and it bleeds heavily The chef holds a dishcloth to the wound and contacts the bridge immediately to receive treatment from the person in charge of medical care 49 The person in charge of medical care s actions Stop the accident emergency evacuation A When the chef arrives at the bridge he looks a little pale but seems otherwise unaffected by the situation The person in charge of medical care asks the chef to take a seat and explain what has happened Slightly out of breath he speaks about how annoyed the situation makes him while the person in charge of medical care notes that the chef s airways are free B The chef s breathing is normal he does not have shortness of breath or a sensation of pressure in the chest C The pulse and capillary response are normal the skin feels dry and warm but the chef s face i1s still a little pale The person in cha
76. use for treatment e g Instruments for sewing It can also be airborne infection through coughing and sneezing or through prick on contaminated needles 61 Infection gate can be all the body s natural openings and wounds Infection recipients may be all of us Particularly susceptible are burn patients sick and elderly people Infection occurs most often in one of these four ways e Through contact when either touching each other or tough ing an object with microorganisms on which is passed on to another person e Through the air by coughing and sneezing where microor ganisms are blown into the air e Through food through food or water with microorganisms in e Through blood at pricks or cutting such as an accident with needles Why should you wash your hands It is really quite simple Hand hygiene is about Preventing transmission to clean areas Preventing the spread from unclean areas Hands are our most important tools It is with them we welcome you examine treat nourish soothe and express our care But it 1s also the hands that give the infection to yourself and others Did you know that 60 9o of the population has the bacteria staphylococcus on their skin without getting sick of it But you can transfer the bacteria for example to a patient s wound and thus give him an infection It is among other things there fore we ensure hand hygiene before we nurse and treat patients
77. w twice effectively using mouth to mouth or ventilation bag 15 l minute Pressure depth must be 5 6 cm Compression frecuency 100 til max 120 per minute f there 1s a heart starter on board give CPR until the electrodes are on the patient Then follow the machine s directions Continue CPR and contact Radio Medical Crew members take turns in the CPR Recomended every 2 min Vital signs but irregular breathing Continue to blow with ventilation bag or mouth to mouth until breathing is stabilized If you have to leave the patient Place the patient in a recovery position NB For juniors and adults the pressure spot is on the middle of the sternum A heart starter can only be used with child pads on juniors an must not be used on children under the age of 1 year 44 Expose the chest and give 30 compressions on the middle of the sternum pressure depth 5 6 cm Blow twice into to mouth or use a ventilation bag with 15 l oxygen minute 921A19S Uu1 JP9H WIZIJEWN Jo 193u82 42 43 M cn ee Examples of MLS Background MLS accident A 24 year old ship assistant contacts the bridge He has a lacera tion in the back of his head and a lot of blood is dripping from a 3 cm long wound The assistant 1s not feeling well he is dizzy and a bit confused has a headache is pale and out of breath when he tells about the accident He is working when he slips on the deck He does not have time to relieve
78. which of course only means that the person in charge of medical care must organize his equipment and medi cation in an alternative way Treatment in sickbay hospital involves a reassessment of the ill injured patient s condition using ABCDE and subsequent fol low up on information for the consultation with Radio Medical The Radio Medical Record is the written document used as a guideline for the information that generally must be gathered in case of illness and accidents but it must not hinder the com munication with Radio Medical There is never a wrong time to contact Radio Medical but it is very important that concrete and objective data is communicated during the first consulta tion The secondary problems are the problems dealt with once the life threatening condition subsides Follow up on previous actions e g if there 1s flow in the oxy gen cylinder if the drip is working if the dressings need to be changed cleansing of minor wounds follow up on psychological first aid and the basic care of the patient Specific procedures will be performed after consultation with Radio Medical and decisions on further treatment evacuation are made see the Medical Manual 921A19S YLLCOH OWIVIAeW Jo 19 U 9 Center of Maritime Health Service Cardiopulmonary Resuscitation Cardiopulmonary resuscitation or resuscitation on board ships follows the guidelines of the Danish Counsel for Resuscitation ww w genoplivning dk
79. zziness Indisposition and headache Reduced perspiration Fatigue dizziness e Sparse dark coloured urine Nausea and vomit Fast pulse Abdominal pain and muscle pain e Body temperatures of gt 41 are seen Symptoms at a later stage Affected consciousness and cramps Low blood pressure The person is warm moist and red Collapse unconsciousness may occur Action Action Move the patient into the shade Bring the person into the shade Offer a beverage not a cold beverage though Offer water to drink If the patient is dressed remove as much clothing as possible n case of shock NaCl will be given in consultation with Cool the skin with cold cloths Radio Medical It is a good idea to cool feet joints and wrists as it is important Keep a fluid chart to cool the body down slowly Healthy adults with a fully working body temperature regulator sel Contact Radio Medical and follow the prescription dom suffer sunstroke but children and elderly people are more likely to suffer sunstroke after a long stay in direct sunlight The head skull is superheated symptoms and actions are the same as with heatstroke Contact Radio Medical and follow the prescription NB Always observe your fluid balance during stay in a warm climate Center of Maritime Health Service 9291AJ9S YLJCOH 9uniirjeJy jo 1913u825 pU MM NN Center of Maritime Health Service 124 First Aid after Insect Stings and Reptile

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