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Old 16-02-2009, 01:19   #1
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Challenge: Medical Treatment at Sea

We haven't had a good old theoretical challenge for awhile so this is for the wannabe medicos' who cruise .

The situation: Retired husband and wife team on 40 foot blue water yacht. Both can handle the boat individually but in general he does more sail changing and general deck work and she runs the galley. They stand watches turn about when at sea and normally sail two handed.

They are undertaking a voyage from Cape Town, South Africa to Fremantle, Australia through the Southern Ocean. Due to the expected length and weather conditions of the voyage they have elected to take a third crew member for this trip.

Chris (the 3rd crew member) is mid thirties, fit, has some off shore experience and is looking to gain greater sailing experience.

The first three days are reasonable downwind / reaching sailing and the Agulhas bank is crossed without incident.

The first significant cold front passes on the fourth day and Chris receives a heavy blow to the side of the head (behind the ear) during an accidental gybe. Initial symptons are blurred vision, local swelling at the site of the injury and local pain. The vison returns to normal after few hours and swelling moderates into a large bruise. The local pain goes and is replaced with a severe headache.

Given that returning to Cape Town would involve at least a week of heavy windward work and now having to recross the Agulhas banks in heavy weather with the wind against the Agulhas current, what would YOU do?

Turn back, push on, divert (to where) and what treament (if any) would YOU adminster?
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Old 16-02-2009, 04:48   #2
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Originally Posted by Wotname View Post
Initial symptons are blurred vision, local swelling at the site of the injury and local pain. The vison returns to normal after few hours and swelling moderates into a large bruise. The local pain goes and is replaced with a severe headache.

...
Turn back, push on, divert (to where) and what treament (if any) would YOU adminster?


Goodness This is one that is difficult. The clue is the blurred vision. This puts it in the higher or more complicated injury category.
We check for fluid from the ears and also check to see if the pupils are dilating evenly.
If ears and eyes are ok I would have him in bed with an extra pillow to keep the head and shoulders up and him in a comfortable position (not recovery unless he likes it).
Treatment would be aspirin for the headache and for haematoma also as asprin helps with internal bleeding.

If it is an internal haemorrhage we probably wouldn’t realise and so the TV idea of boring a pressure releasing hole with the cordless drill probably wouldn’t occur before he dies. Nor would the long trip back be in time!

If the severe headache gets intolerable, the vision blurs and the patient goes down hill I would guess it is bleeding internally.

I take it we dont have HF radio to ring and ask advice...

I guess its wait and see what happens with the patient, I would hove to so we dont go further from port, or maybe even slowly come up closer to the shipping lanes.

If after 24 hours the headache is still severe and not in any way abating... and not being helped by drugs I guess its an emergency. Charge up the drill! Get the EPIRB polished up! Rehearse Abide With Me!

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Old 16-02-2009, 05:32   #3
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I'd agree with Mark, except for the aspirin. Since aspirin actually promotes bleeding, it could make the situation much worse if the patient has a cerebral contusion. His blurred vision and severe headache are only two of the possible symptoms of a potentially life-threatening head injury. The fact that he hasn't exhibited others (amnesia, confusion, increasing drowsiness, dilated pupils, etc.) is a good sign.

I wouldn't immediately do the seven day bash back to Cape Town. Mark's idea of heaving to so as not to move further from potential help is prudent. If things go bad, is Durban a potential destination, given the current and wind patterns in that region?
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Old 16-02-2009, 08:18   #4
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Simple

Bashing back to windward is likely to make things worse.

Probably not enough time for the downwind leg.

Assuming no HF or iridium, make for the nearest sealane and get the first merch to radio for advice. Even if the advice is to evacuate man, the merch is a more stable platform so could bash to windward with less problems and is faster, and is a bigger target for SAR to find.

Flashing up the Black and Decker might appeal to some, but shaving the head and seeing if there is any obvious depressions would probably be as far as I would be happy to go.
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Old 16-02-2009, 09:41   #5
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If he is bouncing on his toes and his hands are twitching up around his face he is an old boxer and he will be alright tomorrow. Keep on cruising. I agree give him asprin. Tell him to keep his chin down and his left up more. You didn't say which side of the head he got hit on. He may be dropping his right. He will learn. Keep on cruising.
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Old 16-02-2009, 11:07   #6
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My medical opinion would depend alot on the neuro exam. First off, I think it would just be risky (adventuresome?) to do extended bluewater without multiple ways to communicate with the world. If I was on the boat, I would locate the subdural (if it is one and not just a concussion) and treat it. If I was here at home, I would walk you through a neurological exam and the necessary treatment via SSB. A swelling subdural cannot wait but a concussion can present like this and doesn't need acute care. BTW a subdural does not always present under the point of impact. I agree with no asprin. How far are you from a hospital via helicopter? That would be critical in the decision making process.
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Old 16-02-2009, 11:11   #7
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Chris (the 3rd crew member) is mid thirties, fit, has some off shore experience and is looking to gain greater sailing experience.
Is Chris Male or Female? If the latter and 30 & "Fit" I would prescribe CPR, possibly mouth to mouth and also sharing body warmth in a 1 person sleeping bag. Whilst both naked. (and the Missus on watch ).....if she was capable of chasing me around the deck with a monkey wrench I would figure she was going to be ok

For me not enuf info to say seriously in trouble and given our position I figure he / she is either going to be ok (bunk rest until headache gone) or won't make it back no matter what I did, so I would press on. and keep me fingers crossed.

Funnily enough I had an injury much like that (Motorbike - also had to drive the car off my body - but apart from a wicked blow to the head not a scratch )....I could "feel" the blow on the back of my head for many months afterwards, even long after the lump had finally gone down.......and it never affected me long term
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Old 16-02-2009, 11:42   #8
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Motorbike - had to drive the car off my body
You must have very long arms and flexible legs to achieve that trick on your own!
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Old 16-02-2009, 16:29   #9
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OK, so far I see you know more about medical treatment than I do .

HF / Iridium is available IF YOU normally carry it. If you don't personally have it on a blue water 40 footer, then it isn't available.

I had never considered the cordless drill approach to treatment but maybe will consider this part of my first aid kit from now on .

Good point to either hove to or move towards shipping lanes.

DOJ (bless his socks) picked up on the male / female potential of the name Chris. I believe the rest of you assumed male (or didn't care either way). This was part of the challenge .

Moving on, 24 hours later, Chris while still a bit shaken by the event seems OK, the severe headache has eased (almost gone) after a solid 6 hour sleep and she wants to continue standing her watch . Weather while strong, remains an average of about 30 knots and you decide to push on but staying closer to shipping lanes even at the increased risk of the shipping. Next front is forecast in 36 hours with winds below 40 knots.

Another day goes by and all seems normal when Chris confides that she may be pregnant (but she doesn't know for sure). She has only missed her second period. Side note - nothing to do with DOJ.

Any alarm bells here?

Does this change or complicate you course of action?
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Old 16-02-2009, 17:24   #10
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Another day goes by and all seems normal when Chris confides that she may be pregnant (but she doesn't know for sure). She has only missed her second period.

Any alarm bells here?
Ok. lets show my "knowledge" (or lack of ) of womens stuff............I would figure may be a physical reaction to the bash on head (simply because it was a change) - whether a bad reaction or not I do not know. But for me still not enuf to go on as a definate immediate concern as could be simply a reaction to changed physical circumstances / stress / diet from the voyage......or her periods are regularly all over the place - although of course she could rule out the last one. Probably also get her to check her maths and of course at mid 30's could be a natural course of events even if earlier than average.......but I'd let the Missus raise that possibility

Quote:
Does this change or complicate you course of action?
No.

But as the next front is due in 36 hours I would put her on light duties / short watchkeeping - mainly to stop her getting bored. I figure good to have her well rested as although forecast at 40 knots - yer never know....and in any event a decent blow to the head (even not causing any serious damage) can knock the stuffing out of you physically.....most people have a tendency to say "I'm fine"........so taking the decision out of her hands and making sure she is well rested won't do any harm.
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Old 16-02-2009, 17:45   #11
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Cool - a question I can try to answer. If Chris has a subdural and you can't get a helicopter fast, she probably ain't gonna make it anyhow. Nix the drill - blood would have already clotted and wont go through the hole. You'd have to do a craniotomy and remove the clot. Aspirin's a definite no-no.

Pregnancy won't make much difference although at two months and in a forty foot boat she's likely to be puking so much that she's dehydrated - which might in fact be the best possible option you'd have for treating a subdural. If you have diuretics or steroids on board, they're worth a try. If not large quantities of coffee will stimulate her kidneys and her bowels, both of which could drop her bloop pressure significantly enough too help. If the retired husband and wife team happen to be on any blood pressure meds, those could also help.
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Old 16-02-2009, 18:06   #12
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Basic First Aid

Keep him supine, ice or cold pack on injury. Good to check pupils = equal, reactive. No Loss of Consiousness, treat for poss. concussion. Record the time and monitor B.P. and heartrate. If he really has a bleed going on...try for the bird, buts its likely the end. And I realize how complicated it really can get...
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Old 16-02-2009, 22:10   #13
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Like newt (I think), I'm an MD. I have cared for a lot of head-injured patients. If it's a simple concussion or contusion, rest and observation is all that can be done. I agree that aspirin is a poor choice and has no place in this situation. For an intracranial bleed with deteriorating mental status, forget the cordless drill. It's true that the bleeding may not necessarily be at the point of impact. This is a medical emergency. The injured person needs a neurosurgeon, and right away. This might well be a non-survivable injury if not handled by an expert. Even though I have a lot of experience and have participated in the care of intracranial hematomas for many years ( I currently work at a large trauma center in the operating room), I do not think that I would have a reasonable chance of successfully treating such a patient without proper diagnostic facilities (CT scanner, for one). An improper approach ("flying blind") might actually make the situation worse (brain herniation). Sorry, this hypothetical incident is serious and could only be treated conservatively in the field until getting access to specialized medical care.
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Old 16-02-2009, 22:54   #14
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OK, I'll chime in here. Before going tangental on pregnant females, I'd like to make a few comments about the original scenario. Head trauma is a very serious issue, especially in a remote setting.

Wotname left out a key peice of information: When the original accident happened, did Chris loose conciousness, and if so, for how long (seconds? minutes? hours?)? And/or did she have any amnesia after the event. The first question to ask is did Chris sustain a significant traumatic brain injury? It would be quite rare for a bump on the noggin to cause a serious brain injury without causing at least some loss of conciousness, or amnesia. (Not impossible, but rare, and in a remote setting with limited resources we have to play the odds.)

If Chris did have some loss of conciousness, or amnesia, then our concern becomes does she have a bleed going, which could cause an increase in ICP ("intercranial pressure")? We are interested in early signs of increasing ICP. These would be chages in mental status, severe or increasingly severe headache, or severe vomiting. These are "Red Flag" signs of increased ICP. In this case your only real option is to evacuate to a hospital ASAP. I'm not knowledgable about sailing in that part of the world, so I'll let others comment on the feasiblility or options for an evac. We can protect the airway, and otherwise try to keep Chris as comfortable as possible, but outside of a hospital there is really very little that can be done to treat the underlying injury. Except maybe prayer to whatever deity you subscribe to.

Several people have mentioned looking for unequal or unreactive pupils. Unfortunately, these tend to be a late sign of increased ICP. If you see that, Chris is probably FTD (ambulance speak for "fixin' to die"). In town with a trauma center close by she might still have a chance, but in a remote setting she's probably doomed.

Someone mentioned giving aspirin. This is a VERY VERY BAD IDEA! Aspirin tends to reduce the tendency of blood to clot. It would likely make any bleeding inside the head get worse. Don't give aspirin for a known or suspected head trauma.

One other thing to consider is whether there could be a C-spine (neck) injury. That would definately be a possibility in any severe blow to the head. If there is C-spine damage, it could cause paralysis or death if not handled properly.

I presume people were kidding about trying to drill a hole? As someone has already pointed out, the bleed may not be exactly under the site of the bruise on the head. In fact in, in some cases the most severe brain injury may be on the opposite side of the head (a "coup contrecoup" injury). If she wasn't doomed from the original injury, having some idiot sailor start drilling random holes in the head will probably finish the job.

Head trauma in a remote setting is a very bad deal. In reality there is very little than can be done outside of a hospital. In any good remote medicine class (whether it is called "Shipboard Medicine", "Wilderness First Responder", or whatever), the instructor should tell you that some injuries that are survivable in an urban setting are probably fatal in a remote location. As one instructor here in Alaska once told me: "In some remote situations, a team of huskies might be more valuable than a team of surgeons!" The huskies might at least help you get more quickly to a location where the surgeons could do you some good!
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Old 17-02-2009, 01:07   #15
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Someone mentioned giving aspirin. This is a VERY VERY BAD IDEA! I presume people were kidding about trying to drill a hole? In reality there is very little than can be done outside of a hospital.


I tried to answer the question without referring to my book
Of course the drill hole is serious. Its been done before on HF Radio advice. Using this senario where I didn't have HF radio at hand it gets more difficult and I think I said I would let the person die without tring to drill.

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I'm an MD. . The injured person needs a neurosurgeon, and right away. .


The person ain't gunna get a Neurosurgeon or anyone else! Thats the point in this exercise. They are 4 days solid running South East of Capetown that puts them about 600 - 800 miles into the deep blue.

When we were doing our Remote First Aid course the instructors continually said "Ring an ambulance". It was very difficult, even on the Remote First Aid course that the Ambulance just isn't around the corner.

If someone gets injured half way between South Africa and Australia or between New Zealand and the Horn in the Southern Ocean then they are going to have to survive with just the people on board helping.

An aside: we got a doctors prescription for a Penthrox inhaler as its something we could use if someone is injured on deck to give them enough pain releif to get them down the companionway... or for setting a fracture etc.... Fine, except the thing cost $350!
Medical Developments International

Being a cruising sailor can be difficult. Sure I won't ever be down the Southern Ocean but many cruisers do very lobng legs such as the 3,000nm Galapagos to Marquesas. Ain't no doctors on that one either...


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