ship's captain medical guide

8/19/2019 Ship's Captain Medical Guide

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F i r s t a i d

Introduction

Priorities

Gen era l principles of firsta id

Gene ral assessment ofthe situa tion

Dressing s, band ag es,slings a nd splints

First a id sat chels andboxes

Severe bleeding

Unconscious casualt y

Burns an d scalds

Suffocation (asphyxia)

Strangula t ion

Choking

Epileptic fits

Shock

Bleeding

Wounds

FracturesDislocations

Head injuries

Chest injuries

Blast injuries

Tran sporta tion

CHAPTER 1

5

IntroductionWhen a ship is in port , or nea r to port w here hospita l a nd

other expert medical a t tent ion are a vai lab le , the f i rst a id

treatment necessary aboard ship is similar to that practised

ashore. At sea, in th e a bsence of t hese fa cilities, trained ships’

of f icers are required to give types of treatment beyond tha t

accepted a s norma l f irst aid.

The conten t of t his chapt er covers the know ledge o f f irst

a id necessary for the safe and ef f icient immediate treatment

of casual t ies before they are transported to the ship’s

hospital or to a cabin for any necessary definitive treatment

of th e type described in Chapter 4.

However, anyone aboard ship may f ind a casual ty andevery seam an should know three b asic life-saving a ctions to

be given immediately while wai t ing for tra ined help to

arrive. These a re:

to g ive artif icial respiration by t he mou th t o nose/mout h

m eth od ;

to pla ce an unconscious casua lty in the unconscious

position;

to stop severe bleeding.

PrioritiesOn f ind ing a casualty :

ensure your ow n safety ;

i f necessary , remove the casual ty f rom danger or danger

f rom the casual ty (but see the note below on enclosedspaces);

give immediate treatment to t he casualty who is not

brea thing a nd/or w hose heart h as stopped, is bleeding

severely or unconscious – others can be trea ted la ter;

send for help.

If there is more t han o ne unconscious or bleeding ca sualty:

send for help;

trea t the most serious injury f irst in the order of :

• not breat h ing and/or heart s topped ;

• unconsciousness.

• serious b leeding;

If th e ca sua lty is in a n ENCLOSED SPACE:

DO NOTenter the en closed space unless you a re a tra ined

membe r of a rescue tea m acting unde r instructions;

send for help and inform the ma ster.

It must be assumed tha t t he a t mosphere in the space is

hostile. The rescue team MUSTNOT ente r unless w earing

breath ing appa ratus which must a lso be f i t ted to the casual ty

as soon a s possible. The casua lty must be remo ved q uickly to

the nearest safe ad jacent area outside the enclosed space

unless his injuries and the likely time of evacuation makes

some treatment essentia l before movement.


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6 THE SHIP CAPTAIN’S MED ICAL GUID E

General principles of first aid on board shipThe g ene ral principles are:

make a rapid examinat ion of t he pat ient to assess responsiveness and t he extent of the

injury;

check breat hing, heart a nd look for serious bleeding;

• i f breath ing has stopped , g ive a rt i f icia l respirat ion ;

• if the heart ha s stopped , give hea rt compression and a rtif icial respirat ion;

• arrest serious bleeding;

hand le the pat ient as little a nd as gent ly as possible so as to:

• prevent furth er injuries; and

• prevent further shock ;

see that the pa t ient is put in the most comfortab le posit ion possib le a nd loosen t ight

cloth ing so t hat he can breat he easi ly ;

do no t remove more cloth ing tha n is necessary and , w hen you d o, remove i t gently . With an

injured l imb, get the sound l imb out o f the cloth ing f i rst a nd then peel the clothes of f the

injured limb, which should be supported by ano ther person during t he process. If cutt ing

cloth es is indicated t o expose the injured part, do so. In removing a b oo t or shoe remove the

lace and , i f necessary, cut the upper do wn tow ards the to ecap; keep onlookers aw ay.

alwa ys remember that shock can be a g reat da nger to l i fe and one of the main objects of

first a id is to prevent t his;

you ma y have to improvise splints, ba nda ges et c. (Figure 1.23);

do not g ive a lcohol in any form;

do no t mo ve the pa t ient unti l he is f i t to be moved . Bleeding should be a rrested , f ractures

immobil ised and shock treated . See that the necessary personnel and eq uipment for

smooth and ef f icient transport are a vai lab le ;

never consider anyone to be dead unti l you and o thers agree that :

• b rea th in g h a s stopped ;

• no pulse is fe lt a nd no sounds are heard w hen the examiner’s ear is put to the chest ;

• the eyes are glazed and pupils are d i la ted ;

• there is a progressive cool ing of t he body.

(For a f urther description o f the d iagn osis of d eat h Chapte r 12).

General assessment of the situationOnce i t has been estab l ished tha t there is no immediate threat to l i fe there wil l be t ime to ta ke

stock of the situation. Reassurance and quick and effective attention to injuries and

compa ssionat e trea tment of t he injured person w ill alleviate his condition . Remembe r:

a calm and systematic approach should be ado pted ;

give nothing by mouth ;

protect the casualty f rom heat or cold , remembering that in the t ropics open steel decks can

be very hot ; never underest imate and do not treat as minor in juries:

• unconsciousness

• suspected in ternal b leeding

• s t ab or pun cture w oun d s

• w ound s near joints (see fractures);

• possible fractures

• eye injuries


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Cha pt er 1 FIRSTAID 7

Dressings, bandages, slings and splints

Standard dressing

A standa rd dressing consists of a t h ick pad o f ga uze w hich is a t tached to a b anda ge, leaving

abo ut 30cm of t ail. The dressing is packed in a pap er cover and is sterile. Therefo re, w hen t he

package is opened , i t is important that the ga uze pad should not be a l low ed to t ouch anything

(including you r f ingers) befo re it is applied to the w ound .

Stand ard dressings are available in three sizes:

Small Ga uze pa d mea sures 7.5 cm by 10 cm.

Med ium Gau ze pa d mea sures 10 cm by 15 cm.

Large Ga uze pa d mea sures 15 cm by 20 cm.

Alw ays select a dressing w ith a pa d w hich is larger tha n the

wo und w hich you have to cover up.In use the pa d is placed upon the w ound, the ta i l is taken

round the l imb and held , the ba ndag e is held ta ut a s it is

taken round the af fected part so as to ` lock ’ the ta i l in

posit ion . The ba ndag ing can then b e continued to hold the

dressing firmly in place by making turns above and below

the pa d so th at they o verlap it (Figure 1.1).

Bandages

Bandages are required to a pply and maintain pressure on a wo und to stop b leeding, to keep a

dressing in place, to provide support, and t o prevent mo vement. Wherever a stan dard d ressing is

not used i t is customary to cover a w ound in the fo l low ing wa ys:

dry dressing – sterile gauz e or lint covered by a layer of cot ton w oo l and held in place by a

rol ler or tr iangular banda ge;

non-stick dressing – sterile paraff in ga uze covered by sterile ga uze or lint and cott on w ool

and held in place as above.

NOTE: Never use cott on w oo l as the f irst layer o f a dressing. When using lint alw ays put t he

smooth surfa ce next to the skin.

Tube gauze finger bandage

Cut o f f a p iece o f tub e gauze b an d a ge

60 cm long. Lay th is on a f lat surfa ce and

make a longi tudinal cut a t one end

10 cm long th roug h bot h thicknesses of

the ba nda ge (Figu re 1.2). The t ails so

formed, ‘B’, will be used to secure the

b an d age .

Insert the applicator into the

bandage at end ‘B ’ , then push al l the

ban da ge o n to it. Then pull 2.5 cm of

th e b an d age o f f th e en d o f th e

ap plicato r (Figure 1.3). Tuck th is inside.

Hold the finger dressing in place.Insert the f inger in to the a pplicator a nd

push it gent ly tow ards the base of the

f inger. Hold the band ag e in place with

your th um b an d w i th d raw th e

applicator w i th a slight turning mot ion .

The ba nda ge w ill slip off th e applicato r

and wil l mould f i rmly to the f inger

(Figu re 1.4).

Figure 1.1

A

60 cm

10 cm

B1B2

Figure 1.3 B1 B2

Figure 1.4

Figure 1.2


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When the a pplicator comes of f the f inger, hold the banda ge a nd the a pplicator f i rmly and

turn throu gh 360 deg rees (Figure 1.5).

Re-insert the t ip of the f inger in to the a pplicator and push it once ag ain to t he base of the

fing er (Figure 1.6).

Repea t the complet e mano euvre until the ba nda ge is all used up. Then tie loosely at t he ba se

of the finger (Figure 1.7). Tape the ba se of t he dressing avo iding encircling the finger.

Triangular bandage

This is the most useful bandag e in f i rst a id . It can be used as a broa d or na rrow fo ld banda ge t o

hold dressings in place. It can a lso b e used fo r immobilising limbs or a s a sling. It is made from

calico or similar mat erial by cutting diag ona lly across a squ are o f mat erial having 1 metre sides.

The ends should alwa ys be tied with a reef kno t.

Broad and narrow fold bandages

Figure 1.8 shows how to make a broad a nd a narrow fold banda ge.

The main w ays in which a tr iangular banda ge can b e used , e ither as a temporary dressing or

to secure or cover a prope r dressing, are a s follow s:

Hand bandage

See Figu re 1.9

Wrist and palm bandage

Place palm on the middle of a narrow fold banda ge. Take the ends and cross the ba ndag e at the

back of the ha nd , leaving out the thumb. Take turns of the ba ndag e round a nd round the w rist

and tie off at the b ack (Figure 1.10).


Figure 1.6Figure 1.5 Figure 1.7

Figure 1.8 Broad and narrow fold bandages.

(a ) Tria ng ula r b a nd a g e la id f la t . (b ) Fo lded once.

(d) Folded three t imes – narrow f old ba ndag e.(c) Folded tw ice – broad f old ba ndag e.


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Elbow bandage

Fold over the base of the bandage and place the back of the

elbow in the middle of the banda ge so that the point l ies a t the

back of the upper arm. Take the ends of the b anda ge round t he

forearm, cross them in the bend o f the elbow, a nd then t ake

them round the upper a rm – to ma ke a ‘ f igure of e ight ’ . Tie of f

a t t he back of the arm a bout 10 cm abo ve the elbow. Fold dow n

the po int an d fix it with a safet y pin (Figure 1.11).

Shoulder bandage

Stand facing the casualty’s injured side. Place the centre of an

open ba ndag e on his shoulder with the point running up the

side o f th e neck (Figure 1.12a). Fold a hem inw ards a long t he

base, carry the ends round th e middle of the a rm, cross and tie

them on the out er side (Figure 1.12b). This will secure the low er

border of the ba ndag e. Apply an arm sl ing. Turn the po int of the

shoulder banda ge already applied down o ver the knot of the

arm sling. Pull it tig ht a nd pin it in pla ce (Figure 1.12c).

Figure 1.10

Figure 1.11

(a) Place the hand on the

banda ge. Bring dow n point ‘C’

over the back of the hand t o the

wrist

(b) Turn ‘A’ over the b ack of th e

hand, under ‘B ’ and half around

the w rist .

(c) Turn ‘B’ ove r the b ack of t he

hand , over ‘A’ and ha lf around

the w rist .

(d) Take t urns w ith ‘A’ and ‘B’

round the wris t and tie of f .

(a )

(b) (c) (d)

Figure 1.12

A

C

B

A B A B

(a)

(b) (c)

Figure 1.9 Hand bandage


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Crutch bandage

Tie a narrow fold banda ge round the w aist ; a t

the middle of the back pass another one

un d er it an d a l low en d s to h an g d ow n a t th e

same level. Grasp both these ends and bring

them fo rward under the crutch . Pass one end

under the waist bandag e in f ront and t ie of f

(Figu re 1.13).

Hip bandage

Tie a narrow fold banda ge round the wa ist

with the knot on injured side. Pass the point

of ano ther banda ge up under the knot , turn af o ld a t th e b ase o f th e b a n d age a n d b r in g th e

ends round the th igh t o t ie of f on the o uter

side. Pull the point up to rem ove creases and

then fold i t down o ver the knot and f ix wi th

safe ty p in (Figure 1.14).

Knee bandage

Place the point of the ba ndag e in the f ront of

the middle of the th igh , turn a fold a t the ba se

of the ba ndag e so that i t is abo ut 10 cm below

the kneecap . Take th e ends round t he ba ck of

the joint in a f igure-of-eight and tie off in

f ront w el l above the kneecap. Fold the point

down over the knot and f ix wi th safety pin

(Figu re 1.15).

Foot bandageLay the foo t f la t on the ba ndag e. Bring point

‘A’ up over the foo t in front of t he a nkle. Take

‘B’ over the foot and behind the a nkle . Do the

same with ‘C’ . Knot in f ront of the ankle

(Figu re 1.16).

Figure 1.13

Figure 1.14

Figure 1.16

Figure 1.15

A

CB

B

AB

C


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Eye bandage

Place the middle of a na rrow fold ba ndag e d iagona l ly across

the a ffected eye so as to cover the d ressing. Take bo th end s

round the head , cross them at the back and bring them

forwa rd aga in . Tie of f over the forehead but not over the

eye (Figure 1.17).

Head and scalp bandage

Figure 1.18 is self-explanatory. It is important that the

ban da ge is placed just abo ve the eyebro w s. The ta ils ‘B’ and

‘C’ should be ta ken well under the o cciput (the bump o n theback of the head where t he neck joins the head) , and pulled

fair ly t ight before tak ing them round to the f ront t o be t ied

off . Failure to d o th is w ill result in the ba nda ge f alling off , if

the pat ient should b end o ver (Figure 1.18).

Ring pad

Spread al l the f ingers of o ne hand to form a rough circle of

the required size . Make two turns of a narrow fold banda ge

round th e ends of the f ing ers. Tw ist the rema inder of the

bandage round the circle so formed to make a grommet

(Figu re 1.19).

To pa ss a na rrow-fold band ag e under the legs or body

when t he casual ty cannot be moved –

Obtain a long piece of wo od o r a spl in t . Lay the narrow

fold banda ge on a f la t surface. P lace the splin t on top o fi t . Then fold a bout 22 cm of the b anda ge ba ck over the

splint. Holding the splint a nd the ba nda ge firmly, gently

push the w hole under the pa t ient w here i t is required

and carry on pushing unti l the end comes out on the

opposi te side. Free the bandage and draw i t through.

Withdra w t he splint. Ma ke the necessary tie.

Figure 1.19

Figure 1.18

Figure 1.17

A

C

B

A

C

B

AC

B


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Slings

Slings are usually made fro m triang ular ban da ges, or they can b e improvised. The ma in wa ys in

which to ma ke a sl ing a re as fol lows:

Large arm sling

Place the tr iangular ba ndag e on t he chest , carrying the point behind the elbow of the injured

arm. One end is then placed over the shoulder of the uninjured side a nd the other hang s down.

Gently set t le the a rm across the banda ge, turn up i ts low er end over the forearm a nd t ie i t over

the shoulder of t he uninjured side so that it fu lly takes the w eight o f the fo rearm. Finally fold

the p oint o ver the elbo w and pin it in place (Figure 1.20).

Collar and cuff sling

This is used t o suppo rt the w rist. To a pply a collar and cuff sling, bend the ca sualty’s elbow to a

right a ngle. Pass a clove hitch round h is w rist. Move his forea rm across his chest w ith his f ingers

tou ching his oppo site shoulder. Tie the ends of the ba nda ge in the ho llow just ab ove the

collarb one (Figure 1.21).

Triangular sling

This keeps the ha nd w el l ra ised and , wi th a pad und er the arm, is used to treat a f racture of the

collar b one (Figure 1.22). Place t he ca sualty’s forearm across his chest so t hat his f ingers point

tow ards the shoulder and the centre of the palm rests on the breast bone. Lay an o pen banda ge

on the f orearm w ith one end (C) over the hand and t he point w el l beyond the elbow (A). Steady

the l imb and tuck the base of the banda ge w el l under the hand and f orearm so that the low er

end (B) may be brought under the bent e lbow and then upwards across the back to the

uninjured shoulder, where it is tied to end (C) in the hollow ab ove the co llar bo ne. The point o fthe ba ndag e (A) is then tucked wel l in , betw een the fo rearm and ba ndag e in f ront , and the f old

thus formed is turned backwa rds over the lower pa rt of t he upper arm and pinned .


Figure 1.20 Figure 1.21


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Improvised slings and supports

The aff ected ha nd or a rm can be supporte d, w hen no sling is readily ava ilab le, by simple

metho ds, some o f w hich are illustrate d in Figure 1.23.

Splints

Sets of splints of various lengt hs are included in ships’ stores. When pro perly applied to a limb,

they rel ieve pain by immobil ising the f ra cture and prevent further da mag e to the surrounding

muscles, blood vessels and nerves. The sharp end s of the bon e are prevent ed fro m piercing t he

skin and turning a closed f racture in to a n open f ra cture with i ts a t tendant dang ers.

When choosing a splin t i t should be long eno ugh a lmost to reach the join t below and t he

joint abo ve the site of t he fra cture. The only exception to this rule is the splint used in fracturesof t he th igh b one. This should be long enoug h to stretch f rom t he ankle to t he armpit .

All splints must be fixed to t he limb in at lea st four places – ab ove an d below the site of t he

f racture and at both ends. Although w ooden splin ts are general ly used in f i rst a id , subst itutes

can be used in emerg ency situat ions. These can be in the form o f suitably sized pieces of w oo d

or meta l , folded cardboard , new spapers or maga zines, or pieces of st ick or broom hand les

fastened tog ether to g ive the necessary wid th .

Whatever is used , the spl in t must be padded so that there is a layer of sof t ma teria l about

11/2 cm thick betw een t he splint a nd t he skin. Unpa dded splints w ill cause pa in and p ossible

dama ge to the skin .

Figure 1.23

Figure 1.22

A

C

B

CB


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Inf latable splint s are a useful method for temporarily immobilising limb fractures but areunsuitab le for f ra ctures which are more tha n a short d istance above the knee or e lbow as they

canno t pro vide sufficient immobilisat ion in these places. The splint is applied to the limb a nd

inf la ted by mouth . Other method s of in f la t ion can ma ke the splin t too t ight a nd thus slow

dow n or stop the circulation. Inflata ble splints can be a pplied over wou nd dressings.

The splints are ma de of clear plastic and a ny bleeding from a w ound ca n easily be seen.

Needless to say, all sharp objects and sha rp edg es must be kept w ell clear of the plastic to avoid

a puncture.

In f la tab le splin ts may be used to transport a pat ient a bout the ship or during moving to

hospital. They should not be left in place for more tha n a few hours. Other means of

immobilising the fra cture should be used af ter tha t period.

Remember that the sound leg is a very good splint to which an injured leg can be secured

pending more elaborate measures, and, similarly, the arms can be immobilised against the

trunk. If the pat ient is to be mo ved by Neil Robertson stretcher, no add itional splints may benecessary du ring first aid.

First aid satchels or boxes

These should conta in at least the items required by MSN 1726 for th e ‘f irst a id kit’ . One should

be kept close to the ship’s medical store for swift t ransfer to t he site of an a ccident . If you ha ve

more tha n one, t he other(s) should be placed aw ay f rom the medical store so tha t i f the store is

destroyed by fire you h ave a n ea sily reached first aid kit. These kits should be checked

freq uently and re-stocked as required.

Severe bleeding

lay the casual ty dow n;

press w here the b lood come s from, using a clean h and kerchief , dressing or cloth;

press w ith your hand o r f ist on t he w ound if not hing else is available. If possible we ar

disposable gloves.

if the arms or legs are wo unded , lif t th em up to a near vertical position a s this w ill help to

stop t he blee ding (Figu re 1.24);

tie a dressing firmly round the w ound t o maint ain the pressure;

i f b lood continues to come through the dressing, apply another banda ge on the top o f the

first one . Banda ge mo re firmly.

keep the injured part a s still as possible and t he casualty a t rest becau se movement d isturbs

(and destroys) the b lood clot;

aft er bleeding ha s been contro lled, rest the limb as show n in Figure 1.24;

this trea tmen t applies eq ually to bleeding from a n amput at ion site. Here pressure should

be applied over and a round the end of the stump.

Figure 1.24


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Unconscious casualtyThe immediate t hreat to life may be:

breath ing obstructed by the tong ue fa l l ing ba ck and

blocking the throa t ;

stopped heart .

Check fo r br eathin g at once – Look/Listen /Feel

look for movements of the chest and a bdomen;

feel for a ir on your cheek

l is ten for breath ing w ith your ear over the mouth and

no se (Figure 1.25);

not e the colour o f fa ce and lips – norma l or blue/grey

t inge?

I f breathing :

place the casualty in the un conscious or recovery

po sition (Figure 1.26);

NOTE: no pillow s should b e used un der th e hea d;

pull up the leg a nd the a rm on the side to w hich

the he ad is facing, pull up the chin;

stretch ot her arm out as pictured

For subsequent t reatment of an unconscious

patient see Chapter 3 .

Not b reath ing:

With the ca sualty lying fla t on his back, open t he airw ay

by making sure that the hea d is tilted ba ck w hilst lif ting

the chin upw ards a nd fo rwa rds (Figure 1.27), which will

move the tong ue forwa rd and clear the a irwa y.

Open the mouth a nd mop out any obvious obstruct ions

such as blood , vomit or secretions. If dent ures are wo rn

only remove them if they a re broken or displaced. Use

your f ingers, a hand kerchief or a clean piece of clot h.

These actions may relieve the obstruction t o brea thing .

The casualty may g asp and sta rt to brea the na tura lly. If so,

place in the unconscious position.

Sti l l not b reathing:

Begin a rtif icial respirat ion at once – seconds count .

Open the a irwa y by making sure tha t the head is t i lted

back whilst l i f t ing the chin upwa rds and forw ards.

w ork from the side in a convenient po sition;

pinch the casualty’s nose with your index finger a nd

thumb. Af ter tak ing a ful l breath , seal you l ips about t he

patient ’s mouth and b low in to h is mouth unti l you see

the chest rise. This should t ake a bout 2 seconds fo r full

infla tion . (Figure 1.28)

give tw o effe ctive inflat ions quickly, then not e if the

colour of t he fa ce and lips is improving.

Figure 1.25

Figure 1.26

Figure 1.27

Figure 1.28

The un conscious positio n


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If there is improvement :

continue the a rt i f icia l respirat ion , mainta in ing a ra te of

about a do zen in f la t ions each minute . It ma y help your

t iming to count to f ive , s low ly, betw een in f la t ions;

see section abo ve on ‘If breat hing’.

If there is no improvement :

liste n fo r hea rt soun ds (Figure 1.29);

fee l the pu lse at t he ne ck (Figure 1.29);

I f no heart beat is fe l t , the heart has stopped . A tra ined

first-aider must begin chest compression at once. Unless

circulat ion is restored, the bra in will be w ithout o xygen andthe pe rson will be de ad in fo ur to six minutes:

the casualty must be lying on his back on a h ard surface,

e.g. deck, otherw ise the comp ression w ill be lost;

place your han ds tog ether a s show n in Figure 1.30;

press (1/2 second dura tion, 100 times a minut e) f irmly and

rapid ly on the middle of t he lower ha l f of the b reast

bone suf f icient to produce a dow nwa rd movement of

ab ou t 4 cm (Figure 1.31);

artif icial respirat ion (Figure 1.30) must a lso be carried ou t

w hen giving heart compression since breat hing stops when

the hea rt s tops. It can be g iven by o ne person, a l ternately

compressing 15 times and t hen filling t he lungs with a ir

tw ice or, ideally, by two people – one giving heart

compression and t he ot her giving artif icial respiration, a t a

ratio o f 5 chest compressions to 1 lung inflat ion;

i f the heart s tarts to beat the colour of the face and l ips

w ill improve a nd t he eye pup ils will get smaller;

listen ag ain fo r heart sound s and fee l for a neck pulse. If

they are hea rd , stop heart compression but continue w ith

artif icial respirat ion until natura l breathing is resto red.

When you are sat isf ied that the heart is beat ing and

unassisted breathing is restored, transfer the casualty by

stretcher, in th e unconscious position, to the ship’s hospital

or a cab in for further treatment . See Chapter 3 for continued

nursing ca re.

Unfortunately these measures are not always successful.

Failure to restart the heart after cardiac arrest is common

even in the best environment, such as a fully equipped

hospital. It may be necessary to decide to stop artif icial

respiration and chest compression. If in doub t SEEK RADIOMEDICAL ADVICE.

Figure 1.29

Figure 1.31

Hard surface

Figure 1.30


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Burns and scalds

Clothing on fire

by far the b est wa y to put o ut a f ire on a person is to use a dry powd er f ire extinguisher at once;

i f a dry pow der ext inguisher is not a vai lab le , then lay the person dow n and smother the

f lames by wrapping h im in any avai lab le materia l (not ma de of man-made f ibre), or throw

buckets of wa ter over him, or use a ho se;

make sure a ll smouldering clothing is extinguished.

NOTE: The po w der from a f ire extinguisher will not cause much, if any, eye da mag e. Most

people shut their eyes tight ly if sprayed w ith pow der. Any pow der wh ich get s in the eye should

be w ashed out immediately a f ter the f i re ha s been extinguished and while cool ing is being

undertaken.

Heat burns and scalds

all heat burns should be cooled a s quickly as possible with running cold w at er (sea or fresh)

for a t least ten minut es, or by immersing in cold wa ter and keeping the injured part in

mot ion; cooling o f extensive burns (>15%) should be avoided as hypo thermia w ill result.

i f i t is not po ssib le to cool the burn on the spot , the casualty should be ta ken to w here

cool ing can be carried out ;

t ry to remove cloth ing g ently but do no t tea r of f any w hich adheres to t he skin ;

then cover the bu rned area s with a dry, non-fluffy, dressing w hich is larger tha n the burns

and ba ndag e in place;

further treatment as in Chapter 4 .

Electrical burns and electrocution

make sure you do not become t he next casualty w hen approa ching a ny person w ho is inconta ct with electricity:

if possible, switch off the current;

otherw ise , insulate yourself . Remove your w atch a nd rings, wear rubber boo ts or stand o n

an insulat ing mat , th ick DRY newspaper or w ood ;

alterna tively, pull the ca sualty from th e source of supply with a n insulat ed flex or push him

aw ay w ith a strong non-conductor, such as a piece of DRY woo d ;

check immediately for breath ing and heartbea t :

• i f not breath ing, g ive a rt i f icia l respirat ion ;

• if heart is sto pped, g ive chest compression a nd a rtif icial respiration;

send for help;

w hen the casualty is breat hing, cool any burned area s and a pply a clean, dry, non-fluffy

covering to the b urned area .

Chemical splashes

remove conta minated cloth ing. Drench w ith wa ter to w ash the chemical awa y;

carry on wa shing fo r a t least ten minutes. If you a re in any doubt t hat the chemical has been

completely cleared f rom the sk in , repeat t he w ashing for a further ten minutes;

give priority to w ashing the eye s if aff ected, as they a re particularly vulnerable to chemical

splashes. If only one eye is aff ected, incline the hea d to t hat side to p revent the chemical

f rom running across in to the other eye.


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Suffocation (Asphyxia)Suffocat ion is usually caused by g ases or smoke:

remember that da ngerous gases may have no smell to w arn you

of t heir presence;

do no t ent er enclosed spaces without the proper precautions;

do no t fo rget t he risks of f ire an d/or explosion w hen dea ling

with in f lammable g ases or vapours;

get the casual ty in to the f resh a ir ;

give artif icial respiration if not brea thing;

chest compression ma y be required if the hea rt stops;

w hen brea thing is restored, place in the unconsciousposition;

oxygen may be administered la ter i f carried on boa rd .

Strangulation Immediately remove the cause;

t reat a s for suf focat ion abo ve;

give prote ctive supervision if there is any rea son to

suspect th at the injury w as self-inflicted.

ChokingChoking is usually caused by a large lump of food which

sticks at t he ba ck of the t hroa t an d obstructs breat hing. The

person the n becom es unconscious very quickly and w ill die in

4 to 6 minutes unless the o bstruction is removed .

Choking can be mistaken for a heart a t ta ck. A person w ho

is choking :

may have been seen to be eat ing;

cannot speak or breathe;

w ill turn blue a nd lose consciousness quickly because of

lack of o xygen;

can signal his distress (he can not speak) by grasping h is

neck betw een finge rs and thum b. This is know n as the

‘Heimlich sign’ and , if understoo d by a ll personnel,

should re duce t he risks involved in cho king (Figure 1.32).

Up to f ive f i rm slaps on t he ba ck, betw een the shoulder

blade s, may dislodg e the obstruction. If not:

If t he casualty is consciou s, stand behind him, place yourclosed f ist a gainst the place in the upper abdo men w here

the ribs d ivide and grasp your f is t wi th the other hand .

Press suddenly and sharply into t he casualty’s ab dome n with

a hard quick upw ard t hrust, f ive times if necessary.If unsuccessful continue in cycles of f ive ba ck blows to f ive

ab do mina l thrusts. (Figure s 1.33 a nd 1.34).

If th e casualt y is un consciou s , place him face upw ards, keepingthe chin well up and t he neck bent ba ckwa rds. Kneel astride

him, place one hand over the ot her with the heel of the low er

hand at the place w here the ribs divide. Press suddenly and

sharply into th e abdo men with a ha rd, quick upw ards thrust.

Repeat several times if necessary (Figure 1.35). When the foo d

is dislodged remo ve it from the mo uth a nd place the casualty

in the unconscious position.

Figure 1.32

Figure 1.33

Figure 1.34

Figure 1.35


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Epileptic fits – convulsionsThe fit ma y vary from a mome nta ry loss of con sciousness (petit ma l) in which the pa tient ma y

sway but does not actual ly f a l l, to a ma jor a t ta ck (grand mal) as follows: the pat ient suddenly

loses consciousness and fa lls to the grou nd, possibly with a cry; he remains rigid for some

seconds, during which he stops breathing and the face becomes flushed; the convulsion then

starts with irregular, jerky movemen ts of the limbs, rolling of t he eyes, gnashing of t he teet h,

with perhaps some f roth ing a t t he mouth . He ma y lose control and pa ss urine or f a eces. Af ter a

variable time, but usually in a few minutes, the convulsion ceases and h e falls into w hat app ears

to be a deep sleep.

Treatment

prevent the p at ient from hurting h imself in the convulsive stag e;

never restrain him forcibly, as this may cause injury, but remo ve hard objects and surround

him by pillow s, cloth ing or ot her soft mat erial;

af ter t he fit is over, check for injuries. Assuming the pat ient is uninjured, let h im sleep it o ff .

He may be rather confused and dazed when he comes round . Reassure h im and do not

leave h im until you are sure he is awa re of h is surroundings and knows w hat he is doing.

In the event of the pa t ient having several f i ts , one af t er the o ther, i t may b e necessary to g ive

him an a nti-epileptic drug such as Diazepa m. SEEK URGENT RADIO MEDICAL ADVICE.

Shock and circulatory collapse

Shock occurs when the b ody’s circulato ry system is unable to distribute oxygen e nriched b lood

to a ll part s of the bod y. If untrea ted , the bod y’s vital orga ns (brain, heart , lungs, kidneys) can

fail, lead ing to collapse, unconsciousness and e ventua lly deat h.

Causes

The commo nest cause is loss of bo dy fluid from t he circulation. It can result, either fro m externa lor internal bleeding , (e.g. a s occurs in fractures of t he thigh ), the f orma tion of large blisters and

the w eeping o f f luid from large b urns and from d ama ged blood vessels in crush injuries. Shock

can also be found in severe heart attacks, and in certain diseases characterised by excessive

vomiting and d iarrhoea.

The first-aider should a lwa ys be on t he look-out fo r this condition as it can de velop even

w hile the ca sualty is under close observation a nd it ma y be missed. Fear, pain an d exposure to

cold make shock worse.

Symptoms and signs

The pa tient:

w ill usually lie still, ta king little not ice o f his surroundings

w ill complain of fe eling fa int, cold and thirsty. He may shiver;

his l ips and t he edg es of the ears may be b lue;

his skin w ill be pa le, cold and clamm y;

his pulse will be rap id and w eak;

his respirat ion w ill be rapid and shallow a nd, as shock deepens, he will give freq uent sighs;

he may start to vomit ;

if untreat ed, he may lapse into unconsciousness and la ter die.


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Treatment

The primary aim is to t reat w hat ever condition is causing the shock;

lay the pat ient f la t and , i f in juries permit , e levate the feet a nd legs so tha t b lood f lows to

the hea rt and b rain (see note below on exceptions to this rule);

do no t mo ve him unless in a posi t ion of da nger;

stop a ny bloo d loss. Cover burns a nd scalds. Immob ilise fra ctures.

loosen any tight clothing w hich restricts breathing mo vement;

keep wa rm but do not overheat .

deal w i th any pa in . Morphine may be g iven a s necessary

give small sips of w at er if t here is no suspicion of ab domina l injury but NEVER give fluids to

an unco nscious casua lty. A ba dly burned or scalded person ma y require much more fluid; move to a place of safet y as gently as possible. Roug h hand ling w ill increase the pa in and

the sho ck.

Exceptions to the lay flat rule:

if there is an injury to t he fa ce, mouth or jaw w ith a lot o f bleeding, place in the unconscious

posit ion with the head t urned with the d amag ed side underneath a nd , i f possib le , wi th a

head -dow n tilt. This w ill prevent bloo d running dow n into the t hroat and lung s;

if there is a pene tra ting w ound o f the chest, or if breathing is diff icult, prop up to a ssist

breath ing;

if unconsciousness occurs, put into t he unconscious position w ith as little disturbance a s

possible to t he injured part.

Bleeding

External bleeding

Bleeding from small blood vessels occurs when there is a minor cut o r abra sion o f the skin. Bloo d

ooz es from the w ound ; it usually stops by itself or w hen a d ressing is applied. It is gene rally of

no consequence.

In large a nd deep w ound s, the bloo d w ells up in a stea dy stream. The volume of bloo d loss

depends on the number of b lood vessels dama ged a nd , a l though i t may appea r a larming, i t is

not usually dange rous, unless allow ed to continue.

When large arteries are damag ed , bright red b lood w ill spurt f rom the w ound in t ime with

the heart bea ts. This bleeding is usually profuse a nd t he pa tient’s life w ill be end ang ered. This is

a ra re situat ion .

In all cases of external bleeding, fo llow the t hree cardinal rules:

lay the pat ient dow n;

lif t up th e aff ected pa rt if possible;

press f irmly w here the b lood come s from. Use a d ressing or a clean cloth o r hand kerchief

but, if non e should be a vailable, use the ba re hand or f ingers. When po ssible disposab le

gloves should be wo rn to protect yourself .

This procedure w ill stop the flow of b lood.

When b leeding ha s been controlled , apply a standa rd dressing to the w ound a nd ba ndag e

firmly and w idely in position. There may be a slight sta ining of bloo d throu gh t he dressing,

which is of little consequence, but if blood soaks quickly through the pad it is a sign that the

bleeding ha s not been prop erly controlled. If this hap pens, do not d isturb the d ressing, but put

ano ther stand ard dressing o n top a nd ba nda ge mo re firmly. This w ill usually stop t he bleeding.

Very occasionally, a third dressing may be req uired.

Do not d isturb the d ressings until you are prepa red to und erta ke definitive treat ment . The

bleeding stops because of the fo rmation of a clot . I f you remove t he dressing, the clot w i ll break

and b leeding w ill start a ga in .


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Special types of external bleeding

From an open f racture

The bleeding comes mainly f rom a round the break and not f rom

the bone.

do no t a t tempt to elevate t he part , th is wi ll cause further pain

a n d d a m a g e ;

app ly a dressing, sterile if possible, padd ing aro und th e

w ound . Firm banda ging w ill apply the necessary pressure to

the t issue around the exposed bo ne ends.

From a too th socket:

The socket may bleed a fte r the extraction o f a t oo th. Thiskind o f bleeding is seldom serious. At least tw o-thirds of t he

‘blood ’ which is spat o ut w ill be saliva, so the b lood loss is

unlikely to be great ;

i f the gum ma rgins are splayed out , squeeze them g ently

tog ether to close up the to oth socket ;

fold a piece of ga uze tightly and place it in the socket so tha t it

is standing proud o f the level of the remaining t eeth;

the casua lty should close his mouth, biting firmly on th e ga uze

in the to oth socket. The pressure should be ma intained f or

20 minutes. If the socket is still bleeding o n remo ving the

ga uze pad , the procedure should be repeated a s of ten as is

necessary (Figure 1.36).

From th e ear passage:

This is usually caused b y a he ad injury or by bla st:

place a large pad over the ea r and ba ndag e i t in posi t ion ;

keep the af fected ear downw ards;

if the casualty is unconscious, place in the unconscious

posit ion with the af fected ear downw ards;

never plug the ea r passag e with cotto n wo ol or other mat erial.

From t he nose:

the casual ty should si t wi th h is head o ver a ba sin or bo wl

w hile pinching the soft part o f his nose firmly for 10 minutes;

(Figu re 1.37);

he should then release the pressure slowly;

i f b leeding ha s not stopped , he should repeat the ma noeuvre

for a furthe r 10 minutes;

it might be necessary to do t his for a t hird time;

if bleeding has not stoppe d af ter half-an-hour, it might t hen be

necessary to pa ck the no se with ribbon g auz e. (See Chap ter 4)

From the l ips, cheek and t ongu e:

press on bo th sides of th e lip, cheek or to ngue t o stop

bleeding;

use a piece of ga uze or a swa b on each side to help mainta in

pressure a nd stop the fingers slipping (Figure 1.38);

pressing is usua lly most ea sily done b y the casua lty with

direction from ano ther person, or helped by looking in a mirror.

Figure 1.36

Figure 1.37

Figure 1.38

A

C

B


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Internal bleeding

Internal bleeding may be caused by injury, disease, or by the action of certain poisons. Any

severe injury to t he bod y will cause bleeding of va rying degree . Bleeding ma y be limited to the

soft tissues, such as muscles, but w hen a bone b reaks there is alw ays bleeding a t the fracture

site. Minor injury will aff ect only the superficial tissues and th e bleeding may b e limited to sma ll

amo unts w hich will app ear a s bruising. Grea ter force w ill result, in addition t o bruising, in the

forma tion of a collection of bloo d w ithin the deepe r tissues (a haema tom a). This causes painful

swelling of the a f fected part and may be d i f f icult t o d ist inguish f rom a f racture . Whatever the

nat ure of such injuries, the bloo d loss very rarely enda ngers life.

In cont rast, bleeding from injury to interna l orga ns is alw ays very serious and ma y quickly

enda nger life. Such bleeding is alw ays concealed and its presence has to be ded uced from th e

histo ry of th e injury, a rising p ulse rat e an d th e signs and sympto ms of shock which occur rapidly.

The abd ominal organs are poo rly protected by the abdo minal wal l and t hey are part icularlyliab le to injury by d irect o r crushing f orces. These interna l injuries require expert t reat ment

urgently and every ef fort must be made to del iver the casual ty to medical care . Alwa ys get

RADIO MEDICAL ADVICE. There is l it t le tha t can be do ne ab oard because a b lood transfusionmay be needed .

If internal bleeding is suspected:

put in bed with a head-down t i l t ;

if conscious an d in pa in or restless, give morph ine 10 mg;

cover with only one b lanket ;

record the pulse rate at 10 minute intervals. A fa lling rate ma y indicat e tha t the b leeding

ha s sto ppe d (Figure A);

give fluid per rectum (Chapter 3);

if the injury is abd omina l, allow the pa tient t o suck flakes of ice. With bleeding fro m oth er

parts of the b ody, sips of w ater ma y be given;

trea t for shock.

Coughing up or vomiting blood

NOTE: remember tha t bleeding ca n occur from the ba ck of t he nose, a t oot h socket, bleeding

gums, e tc . It is important that th is should not b e confused with b leeding f rom the stomach or

lungs.

Coughing up of blood

In some lung diseases and cases of injury to t he chest, blood ma y be coug hed up. Except in cases

of injury this is seldom fa ta l.

Treatment is the same a s for in ternal b leeding w ith the exception tha t t he pat ient should be

placed at rest with the head and shoulders raised. It is not usually necessary to give fluid per

rectum. For furth er care see Chapt er 4.

See Examinat ion of sputum (Chapter 3).

Vomiting blood

Blood may be vomited i f the stoma ch is in jured by a wo und of the a bdomen o r i f b lood collects

in the stoma ch as a result of a bleeding pep tic ulcer. In the lat ter case the pa tient ma y sudde nly

vomit a quantity of dark brown fluid like coffee grounds. He feels faint and looks pale. If the

bleeding a nd vomiting cont inue he w ill suffer increasingly from shock.

Treat ment is the same a s for internal bleeding. For further trea tment of t his condition, see

Chapter 7 . If there is a wo und of t he abd omen, th is should be treat ed .


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WoundsA wound at any si te in the body poses three problems:

control of b leeding;

prevention of shock

prevention of in fect ion

There a re some simple rules:

never wash the w ound – except in cases of a n animal b i te

never try to remove pieces of meta l or glass from a w ound un less they a re superficial and

can be ea sily lif ted o ut. If pieces can be removed , do it by g rasping the ma terial with sterile

ga uze or use sterile forceps, if available;

do not po ur ant iseptic in to a w ound;

as soon as possible, cover the w ound w ith a suitable dressing.

Bullet or metal fragment wounds

In this type o f injury, loo k for and trea t a ny exit wo und. This is usually larg er tha n the e ntry

wo und. Remember that there may be underlying bo ne f ractures and t hat the bul let or metal

f ragment may ha ve been def lected f rom t he bone t o cause serious in ternal damage, t he only

signs of w hich may be increasing shock.

Figure A Haemorrhage – the falling temperature and the rising pulse rate


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Chest wounds

A superf icia l chest w ound should be treat ed a s for any w ound elsewhere but a penetrat ing

wo und (a sucking wo und) of the chest must be sealed immedia te ly , otherw ise air is draw n intothe chest cavity and the lungs cannot inflate as the vacuum inside the chest is destroyed.

A useful dressing fo r a sucking w ound ca n be mad e from a pa raff in ga uze dressing. Place the

paraf f in gauze o ver the wound, smooth the foi l on to the chest wal l and seal three edges only w ith zinc oxide adh esive plaster. In emerg ency, a suita ble dressing may b e improvised fro m

petroleum jelly, gauze and kitchen foil or polythene or, alternatively, a wet dressing may be

used to provide a n airtight sea l. If not hing else is available, use the casua lty’s ow n blood stained

clot hing to p lug the w ound t empo rarily. The aim is to prevent air entering t he chest but to

allow it to escape if necessary.

The usual rules ab out sto pping bleeding b y pressing w here the bloo d comes from also apply.

Start a p ulse chart soon t o check on p ossible interna l bleeding in a ll chest injuries. The

respirato ry rate shou ld also be recorded . See also sections on chest injuries.

Conscious casualties should be placed in the half-sitting-up position because breathing is

easier in this position.

NOTE: DO NOT GIVE MORPHINE to a pat ient w i th th is type of w ound, even i f he is suf feringfrom a lot of pa in, as the morphine will increase the b reat hing diff iculties.

G e t RADIO MEDICAL ADVICE.

Abdominal wounds

A superficial abdominal wound will require the

same treatment a s any wound, but for more serious

wo unds, if the a bdominal contents do no t p ro t rude ,cover the w ound w ith a large standard dressing and

place the casualty in the half-sitting-up position

(Figure 1.39). In t his position t he w ound w ill not

ga pe ope n. As the ab dom inal muscles are slack, the

abdo minal contents w i ll not bulge t hrough. I f the

w ound runs more or less vertically, it may b e best to

lay the man f la t .

If the abdo minal contents do p ro t rude th roughth e w oun d , DO NOT ATTEMPT TO PUT THEM BACK.Cover with a loo sely applied large sta nda rd dressing

or dressings until further treatment can be given.

Shock w ill develop quickly and shou ld be trea ted a s

described previously, with the following important

exceptions:

prop up if ne cessary;

DO NOT give anything by mouth. If thirsty, the lips should be mo istened ; not hing mo re.

(See a lso Crush w ounds and Stab w ounds below) .

G et RADIO MEDICAL ADVICE.

Head wounds

The w ound i tself should be treated in the same w ay a s any other w ound. Scalp wo unds of ten

bleed briskly. A firm bandage will usually arrest the bleeding, but some ingenuity may be

required in applying the ba ndag e so as to keep it f i rmly on the head and t ransmit the necessary

pressure to the pad. Firm pressure by the fingers over the pad for a few minutes before it is

f inally f ixed in position will help to stop th e bleeding.

The possibility of bra in dama ge is of grea ter importa nce and t w o rules should be observed:

morphine should be given only if conscious an d in much pain fro m more serious injuries

elsewhere;

if unconscious, put in the unconscious position and give the t reat ment d escribed in

Chapte r 4.

G et RADIO MEDICAL ADVICE.

Figure 1.39


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Face and jaw wounds

There may be dang er of suf focat ion a s a result o f b lood running in to the throa t . Lay f la t in the

unconscious position (Figure 1.26) w ith the more da mag ed side undernea th. If the ca sualty is to

be removed b y stretcher, see that h e remains in that po sition. With severe wo unds there ma y be

loss of the power of speech. Give reassurance; speech will probably return to normal when

heal ing has ta ken place.

Palm of the hand wounds

A deep wound of t he palm of t he hand may cut the large artery in th is area . If th is occurs:

stop the b leeding b y pressing where t he b lood comes f rom;

cover the wound with a sterile gauze dressing and a sk the pat ient to g rasp f i rmly on a

rolled-up 7.5 cm band ag e;

a hand banda ge, f i rmly applied , wi ll hold the dressing in place and w ill maintain the

pressure necessary to control the b leeding.

Crush injuries

Limbs

After a crush injury, at f irst the re may be very little to see. How ever, considerable da mag e ma y

have bee n done t o the mu scles and o ther soft t issues and g ross swelling may ta ke place lat er.

Shock, wh ich may be very severe, may a lso de velop.

t rea t an y w oun d ;

the a ffected limb should be immobilised and support ed in its most comfo rtab le position;

trea t shock as described but :

• do not g ive large a mounts of f luid a t once as the casualty w i ll vomit ;

• g ive f requent small amount s of wa ter only.

GET RADIO MEDICAL ADVICE.

Chest

Crushing of t he chest may stop brea thing a nd then a rtif icial respiration w ill be required.

If ribs have bee n fractured , treat a s described und er fractures.

See also section o n chest injuries.

Abdomen

Severe crushing of th e abd omen ma y cause rupture of t he internal orga ns and/or internal

bleeding. If you suspect tha t th is has occurred, Get RADIO MEDICAL ADVICE. See ge neral ad viceon ab dominal wounds at beginning of th is sect ion and stab wo unds below.

Stab wounds

Stab wounds are especially dangerous because the underlying structures will have been

penet rate d and infection w ill have been carried into the de ep tissues.

Chest:

if the lung ha s been penetra ted , it w ill collapse giving rise to breat hlessness and co ughing

of bright red f rothy b lood ;

a sucking wo und can be created ;

th e h ea r t can b e d am ag ed .

G et RADIO MEDICAL ADVICE

see a lso section on chest injuries.


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Abdomen

Depending o n the position of the w ound (see Anat omy Diagra ms, Annex II), an org an ma y be

pierced, giving rise to pe ritonitis and internal bleeding. See genera l advice at b eginning o f this

section. Get RADIO MEDICAL ADVICE.

Limbs

Muscles, nerves and b lood vessels may b e cut. Bleeding, bo th interna l and e xternal, w ill occur.

Whatever the si te of the stab w ound, the immediate trea tment is the same:

stop externa l bleeding by pressure

prevent furth er infection by applying suita ble dressings

trea t shock if necessary.

Fractures

A fracture is a broken bo ne. The bone ma y be broken into tw o or more pieces w ith separat ion

of the f ragments or i t may ha ve one or more f issured cracks without any separat ion .

Most f ractures are caused by d irect fo rce, but fo rce may be transmit ted through t he body t o

cause injury indirectly elsew here. Tw o classical examples are: a fa ll on the o utstretched hand ,

causing a f racture of the col lar bone; a nd a f a l l f rom a height on to the heels, causing a f racture

of th e ba se of the skull.

A much less commo n type is a stress fracture. The bo ne become s wea kened in a w ay

comparable to met al f a t igue. Sudden, strong muscular ef fort may snap the bone.

In simple terms, a fracture ma y be ope n to infection or closed to infection.

A closed fracture

There is no communicat ion bet ween the f racture a nd the surface of the bo dy.

An open fracture

There is communicat ion b etw een a skin wound and the f racture . Open f ractures are a lwa ysserious because germs may enter through the w ound t o cause in fect ion of t he broken bone a nd

the surround ing tissues.

NOTE: A skin w ound may b e present bu t, unless it is deep eno ugh t o rea ch the b roken bon e,

the fracture is still closed. Open or closed fra ctures are somet imes complicated b y d am age toimporta nt structures such a s the bra in, lung , blood vessels or nerves.

Principles of treatment

It is not possible to set fractu res on bo ard ship. Indeed , many fractu res may not req uire sett ing

and unskilled attempts might prejudice healing. First aid measures should ensure adequate

immobil isat ion . Wherever a f racture case has to be kept on b oard f or more tha n tw o or t hree

days, the join ts above a nd below the f racture site should be gent ly put through a ful l range o f

movements, morning a nd night .

Lasting d ama ge ma y result if a joint surface is involved in the fra cture and in a ll cases w here

this is suspected , RADIO MEDICAL ADVICEmust be sought .Antib iot ic treatment must a lwa ys be given as soon as an open f racture is d iag nosed or

suspected.

Examinat ion

The follow ing signs and sympto ms will indicat e tha t the b one is proba bly broken:

a hea vy b low o r other force has been applied to the body o r l imbs. The casual ty or others

may have heard the bone break ;

intense pain, especially on pressure or moveme nt a t the site;

swelling. The site ma y be sw ollen and /or bruised. This may be d ue t o inte rnal bleeding ;

loss of use. The casualty ma y be una ble or unw illing t o use the injured part because of the


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pain. He may a lso experience severe pain if an a tte mpt, even very gent ly, is mad e to h elp

him make the m ovement . Wat ch his fa ce for signs of pa in. Occasionally, if the broken end s

of a bone a re impacted tog ether, the person may be a b le to use the part but usual ly only

with a f a ir amount o f pain ;

distort ion . Compare goo d a nd ba d l imbs or sides of the body to see if the part is swo llen ,

bent , tw isted o r shortened ;

irregularity. The irregular edg es of a b roken bone ca n sometimes be seen in an ope n

fracture. They ma y be seen o r felt unde r the skin in a closed fra cture;

unnatura l movement and gra t ing of bo ne ends.Neither of these symptoms should besought del iberately. A limb may feel l imp and wo bbly and g rat ing ma y be fe l t w hen trying

to a pply support t o the limb. In either of the se situat ions, the bone is certa inly broken.

General treatment

bleeding should be treated as described ;

rest the a ffected p art b y immobilisation. This prevents further da mag e, relieves pain and

stops further bleeding;

all fractures or suspected fra ctures must be immobilised before ma king a ny att empt t o

move th e casualty. This can be d one using w oo den, improvised or inflat ab le splints, or by

fixing a limb to the bo dy, or – in the case of t he legs – by lashing o ne to the o ther.

Immobilise a limb in t he po sition in w hich it is

found, if it is comfortable. If it does become

necessary to move an injured limb, because of

poor circulation or for any other reason, f irst

apply traction by pulling the limb gently and

f irmly aw ay f rom the body before a t tempting to

move it (Figure 1.40).

Keep pulling until it has been securely

immobilised and then release the traction veryslow ly. Sudden release can ca use pain.

Circu la t ion of the b lood in a f ractured l imb.Check that the circulation t o t he limb is intact. To

do t h is, press on the na i l of t he thumb o r of the

big toe. When circulation is normal the nail

becomes white when pressed and pink when

released. Continue checking until you are

satisfied that all is w ell. Dang er signs are:

blueness or w hiteness of f ingers and to es;

coldness of the parts below the f racture ;

loss of f eeling below the injury. Test for t his by touching lightly on f ingers and toe s and

asking the casual ty i f he can feel anything;

ab sence of pulse.

If there is any do ubt a t a ll ab out the circulation, loo sen all tight an d limb-encircling d ressings

at once and stra ighten out the l imb, remembering to use tract ion when doing so. Check circulat ion again. If the l imb does not become pink and w arm and you cannot detect a pulse ,then medical help is urgently necessary if amputation is to be avoided. Get RADIO MEDICALADVICE.

remember tha t fractures can cause severe internal

b leeding ;

alwa ys look for and treat for shock;

morphine may be necessary to control pain.

Figure 1.40


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Collar bone, shoulder blade and shoulder

Fractures in these areas are of ten t he result either of a fall on

the o utstretched ha nd o r a f a l l on to the shoulder. Direct

violence to the parts is a less common cause of these

fractures.

P lace loose padding about the size of a f is t in to the

armpit. Support the arm u sing a triang ular sling (Figure 1.41).

Then t ie the arm to t he body, using a narrow fold banda ge.

Keep the casualty sitting up as he will probably be most

comfort ab le in this position.

Upper arm

Upper arm f ractures are usua lly caused by direct violence.Bind the upper arm to the body, using a broad fold

banda ge. Bend the elbow gently and a pply a col lar and cuf f

sling (Figure 1.42). Keep t he casua lty sitting up so t hat the

weight o f the a rm can supply tract ion to the lower f rag ment .

Alterna tively, upper a rm fractures ma y be splinted . Bend

the elbow gently. Use three well padded splints. Place one

behind the upper arm, one in f ront and t he th ird f rom the t ip

of th e shoulder to the elbow . Banda ge th e splints securely in

place. Support the a rm with a collar and cuff sling (see also

Fig ure 1.21).

Elbow

Fractures in this area can be e specially dang erous because of

damage to b lood vessels and nerves around the elbow.

Check circulation a nd fe eling in the fing ers. If th e f inger t ips

are w hite or b lue and feel ing is absent or a l tered , the elbow

must be straight ened a t once. Tell the casua lty to lie dow n.Be gentle . Apply tract ion o n the ha nd and forearm. Bring t he

arm and forearm slowly and carefully to the casualty’s side.

Now place plenty of loose padding betw een the arm and t he

body and also around the a rm. Then b ind the forearm to the

bod y by encircling ties. Check the circulat ion ag ain w hen you

have m ade the encircling t ies. If the circulation is poor, the

ties should be loosely secured until the casualty has to be

move d (Figu re 1.43).

Figure 1.42

Figure 1.43

Figure 1.41


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Forearm and wrist

Fractures in this area commonly result from a fall on the o utstretched hand. Bend the elbow until

the f orea rm is across the bod y. Then a pply an a rm sling (Figure 1.20). Remove an y finge r rings.

Later , apply two wel l padded splin ts to the back and f ront of the fo rearm and secure f i rmly,

using na rrow fo ld banda ges. Support the arm w ith a broa d a rm sling. For f ractures of the w rist

bones, put a broad , w el l padded spl in t on the f ront o f the forearm and t he palm of the hand .

Put plenty of padd ing on the b ack of the fo rearm and ha nd and secure. Use a broad arm sling

for support .

Hand and fingers

Fractures of the hand bones (metacarpals) and the f inger bones are a common resul t of

shipboa rd accidents and expert t reatment may be many da ys awa y. As f ixat ion in a stra ight

splint is only permissible for a short time, the t reat ment de scribed in the following pa rag raphsshould be undertaken i f the casual ty has to be kept on board . Always remove rings

immediately.

The hand b ones (metacarpals):

apply a crepe bandag e around the ha nd and w rist f irmly enough to support the injured

part but not so t ight a s to prevent movement of the w rist and f inger join ts ;

check tha t circulation t o th e fingers is present;

elevate the ha nd by placing the a rm in a t r iang ular sl ing to reduce the swel ling;

encourage t he casual ty to mo ve the w rist and al l the f inger join ts f requently.

The fingers:

strap the f inger to t he ad jacent f inger, using zinc oxide

ad hesive pla ster (as show n in Figure 1.44);

be careful that you do not prevent movement of the

finger joints. Do not put t he plaster directly over thefracture ;

to a void swel l ing, e levate the ha nd by putt ing the a rm in

a triang ular sling;

encourage t he casual ty to mo ve al l the f inger join ts .

Open fracture of th e f ingers:

stop the b leeding and apply a dressing to the w ound;

if the dressing prevents strap ping to th e adjacent f ing er,

use as a splint, a strip of aluminium or other soft met al

2 cm w ide and long enoug h to stretch f rom the t ip of the

f inger to just below the w rist join t ;

immob ilise the finge r in the position show n in Figure 1.45.

This is don e by bend ing the splint to conf orm w ith the

joints , using the same f inger of the unda maged hand a s a

pat t ern , and ta k ing care to ensure tha t the splin t wi l l notd ig in to the ba ck of the ha nd or in to the w rist ;

pad the spl in t w i th tw o layers of e last ic adhesive

banda ge a long i ts length . Turn the ba ndag e over the

ends to prot ect the skin;

f ix the splint to t he finge r with zinc oxide plaster cut to

suitable widths;

give stand ard a ntib iot ic treatment .

Figure 1.44

Figure 1.45


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Crush injur ies to th e hand

Severe crushing injuries to the hands may cause multiple open or closed fractures of the

metacarpal or f inger bones. Other wo unds are l ikely to be present .

stop the bleeding a nd apply dressings;

pain w ill be severe. Give ana lgesics (Morphine if necessary);

if hospita l treatme nt is not a vailable quickly, read th e section on def initive treat ment of

wo unds and t reat a ccord ingly.

Hip to knee

A broken thigh b one is a po tent ially serious injury. It cau ses significant internal bleeding into

the mu scles of the t high a nd, w ith the a ssociated pain, shock very quickly develops. If it iscombined with other serious injuries, the blood loss may be so great as to require blood

replacement. Get RADIO MEDICAL ADVICE.

a brea k of the neck of the t h igh bone causes shortening of t he injured leg and t he casual ty

w ill lie with the w hole low er limb a nd foo t f lopped o utw ards. There w ill be severe pain in

the region of the h ip;

f ractures of t he shaf t of the th igh bo ne exhib i t the usual s igns and symptoms of a f racture .

Severe pain is a no rmal fea ture.

If you th ink tha t the t high is broken:

f irst, pad betw een the t highs, knees, calves and an kles, using folded b lankets or any oth er

suitable soft material;

bring t he go od leg to the broken leg . Do t h is slow ly and careful ly ;

bring t he feet tog ether. I f a t tempting to d o t h is causes pain , apply tract ion to t he injured

leg gently and slowly, and t hen try ag ain ;

t ie encircl ing b anda ges: around bo th feet ; hal fwa y betw een the knees and the a nkles; justabove t he knees; and at the upper th ighs. Avoid making a ny t ies over the site o f the

fra cture (Figure 1.46);

the shoe on the a f fected side can no w be removed so tha t you can check the circulat ion in

the t oes – i f necessary, loosen any b anda ges – and then replace the f igure-of-eight ba ndag e

around the a nkles and feet ;

t reat for shock and pain – morphine w ill be needed .

Kneecap

This fracture ma y be caused by direct violence or as a result of a sudden stress on the b one.

It is commo nly a closed fractu re. When a n open fra cture occurs, the w ound shou ld be treat ed

before spl in t ing is undertaken and antib iot ic treatment should be given .

place the casua lty in a half-sitting-up position and put supports behind his back to ma intain

this. Raise the leg a nd hold it in a comfort ab le position.

Figure 1.46


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choose a splin t long eno ugh to reach f rom the buttock to beyond t he heel , pad i t w el l and

apply it a long the back of the leg . Put addi t ional padding behind the hol low a t the heel so

as to l if t i t o f f the splin t , and a lso behind the knee;

secure the spl in t in place with ba ndag es round the t h igh , round the low er leg just below

the knee and w ith a f igure-of-eight banda ge a t the a nkle , and elevate the leg on a suitab le

suppo rt (Figure 1.47).

When th e casualty is moved t o th e cabin or to the ship’s hospital, he should be kept in a sitting

posit ion w ith the leg elevated .

When medical at tent ion will not be ava ilab le for some time and it is obvious tha t the re is a

wide ga p betw een the f rag ments of the knee cap, carry out the procedure described a bove, but

put a f igure-of-eight ba ndag e round t he knee, beginning a bove the knee cap and f in ishing

over pa dding app lied just below it (Figure 1.48).

This method w ill draw the f rag ments toget her and ho ld them in place. Check that the

circulat ion is inta ct.

Knee to foot

Lower l imb

These should be t reated in the same w ay a s f ractures of t he th igh . See a lso below for f ractures

of bot h legs.Ank le

An ankle fracture which is stable and

without any deformity can be given

adequate but temporary f i rst a id by

placing the injured ankle on a

number of pi l low s to keep i t a t rest

(Figu re 1.49).

In more serious fractures of the

ankle it is usual to f ind a g ood deal of

defo rmity and swelling, and splinting

may b e necessary.

remove th e casualty’s shoe an d sock;

obta in two spl in ts , long eno ugh to stretch f rom just below the knee to the sole of the foo t .

Pad these wel l to a l low fo r the deformity and swelling, and apply them to bo th sides of the

leg;

f ix them in place with a f igure-of-eight b anda ge t o the foot and place other ba ndag es just

below the knee and a bove the ankle ;

check tha t t he circulation is intact.

Heel bone

These fractures usually occur w hen the casualty ha s fallen from a h eight a nd land s on his heels.

As force has been t ransmitted upw ards, there ma y be mo re serious fractures elsew here, e.g. spine

and b ase of t he skull, and the pa tient should be ca refully examined t o exclude these.Treat a s

above, for f ractures of t he ankle .

Figure 1.47 Figure 1.48

Figure 1.49


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Bones of t he foot

Severe injuries are usually the result of he avy w eights being

dropped on to unprotected feet or of crushing. Fractures of the

toes may occur when they a re stubbed aga inst some hard o bject .

remove the bo ot o r shoe a nd the socks carefully;

t rea t an y w oun d .

keep the foot e levated and use pi llows to keep i t in a

comfortab le posit ion .

Both legs

As there is no g ood leg to act a s a splin t for the o ther, external

splinting w ill have to be used. There ma y be considerable bloo dloss if bot h legs are broken.

have w ell padded splints ava ilable. These should reach fro m

the th igh to the ankles on the o utside of bo th the legs for

below t he knee f ractures, and f rom the a rmpit to the a nkles

for ab ove the knee f ractures;

pad betw een the th ighs, knees, calves and ankles;

bring bo th feet tog ether as gently as you can , using tra ct ion

if necessary.

t ie a f igure-of-eight ba ndag e round the feet a nd a nkles to

keep the feet tog ether;

apply the padded splin ts to t he outside of bot h legs;

t ie enough encircl ing b anda ges to keep the splin ts and the

legs secured firmly tog ethe r. Avoid making a ny ties over the

site of a ny brea k (Figu re 1.50);

check the circulation in bo th fe et a s described for th igh

fractures;

move th e casualty in a Neil Robe rtson stretcher.

Jaw

Normally, fractures of the low er jaw give little tro uble.

the casual ty sits w i th the teeth clenched , of ten refusing to

speak much on a ccount o f the pa in ;

the spasm of th e jaw mu scles caused by pain keeps the teet h

clenched a nd jaw immobilised;

a ba nda ge, tied a s in Figure 1.51, will support the low er jaw.

A major haza rd arises when bo th sides of t he lower jaw are

f ractured . In th is case , the jaw w ith the tongue a t ta ched on the

inside of i t , can move backwards and may obstruct the a ir

passage.

hoo k a f inger, yours or the casualty’s, over and beh ind the

lower f ront teeth a nd pull the jaw, and w ith it the tong ue,

forwards;

if possible, arrange f or the casualty to sit up w ith his hea d

forwards;

if he cannot sit up, on account o f ot her injuries, place him in

the unconscious position a nd someon e must stay with him,

keeping the jaw pulled fo rwa rd , i f necessary, and wa tching

carefully for any sign of obstructed breath ing.

Figure 1.50

Figure 1.51


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Spine

Alw ays suspect a f racture of th e spine i f a person has fa l len a d ista nce of over tw o met res.

Check careful ly how the injury happened . Ask i f there is pain in the back . Most people w ith

f ractures of t he spine have pa in but a very few DO NOT. I f in doubt , t reat the injury as a

f ractured spine.

A FRACTURED SPINE IS POTENTIALLY A VERY SERIOUS INJURY. IF YOU SUSPECT AFRACTURED SPINE, TELL THE CASUALTY TO LIE STILL AND DO NOT ALLOW ANYONE TOMOVE HIM UNTIL FIRST AID TREATMENT HAS BEEN COMPLETED.

Any careless movement of a casualty w i th a f ractured spine could dama ge o r sever the spinal

cord, resulting in perma nent p ara lysis and loss of f eeling in the legs, and d oub le incontinence

for life. He can, how ever, be safely rolled over onto o ne side or the oth er because, if this is don e

very gently a nd caref ully, there is very little movemen t o f the spine.

First, estab lish whet her the spinal cord has been d ama ged . To do this: ask the casualty if he can fe el any ting ling o f the f eet o r legs. Tingling usually means that

there is some pressure on t he spinal cord;

ask him to mo ve his toes. If he is unab le to d o t his, then para lysis is present a nd indicates

severe dama ge t o t he spinal cord ;

run your f ingers light ly over the skin of the lowe r legs and fee t. Absence of sensat ion

indicat es severe dama ge to t he spinal cord.

If any of t hese are found , get RADIO MEDICAL ADVICE.

next , place padding bet ween t he legs;

t ie the feet a nd ankles tog ether with a f igure-of-eight banda ge a nd get the casual ty ly ing

st il l and stra ight . Use gentle tract ion on the hea d and on the feet to stra ighten him out . Do

not bend him. Take you r time;

t ie a narrow fold banda ge a round the casual ty a t the level of h is e lbow s and mid th ighs.

This meth od keeps th e casua lty rigid (Figure 1.53);

place pads to f i l l and support the ho l low s of the spine at the small of the ba ck and a t the

ne ck (Fig ure 1.52);

he can no w lie safely in this position for a s long as is necessary. So do not be in a hurry to

move him;

prepare a st i f f support ing stretcher ready fo r the pat ient . There may be a need to st i f fen

the Neil Robertson stretcher with broom hand les. A canvas stretcher wi l l not d o u nless i t

has st i f f woo den bo ards la id transversely over the canvas to provide a r ig id support for

the b ack . Tw o pa ds must be provided to support and f i ll the hol low s of the spine in the

small of the ba ck and behind th e neck . The ba ck pad should be larger tha n the neck pad

(Figure 1.52);

Figure 1.52


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when the stretcher has been prepared

and is alongside the casua lty, the next

job is to lif t him onto t he prepared

stret cher as de scribed in Figure s 1.53 to

1.58;

NOTE: In Figu res 1.54 t o 1.58 t he

encircling b and ag es show n in Figure

1.53 round the t h ighs and at the

elbows have been o mitted for clari ty.

See also Note s at end o f this Section;

to l i f t the casual ty, have at least two

people g rasping ea ch side of the

blanket and one person at the head

and one at t he feet to provide in line

support. Those lif ting t he bla nket

should be spaced so that more lif ting

pow er is avai lab le a t t he body end ,

w hich is heavy compared to t he legs.

A further person is required to push the

prepared stretcher under the casualty

w hen h e is lift ed (Figu re 1.57);

lif t t he casualty very slow ly and

carefully to a height of about hal f a

metre. The heig ht shou ld be just

enoug h to slip the stretcher under the

casualty. Be careful, take time, keep

the casualty straight (Figure 1.58);

slide the stretcher between the legs

of t he person w ho is support ing the

ankles. Then mo ve the stretcher

tow ards the hea d end unti l it is exact ly

undernea th the casua lty. Adjust the

posit ion of the pa ds to f i t exact ly

under the curves in the small of the

back and neck;

lowe r the ca sualty very, very slow ly on

to t he stretcher. Mainta in suppo rt

until he is resting firmly on the

stret cher (Figu re 1.58);

the casual ty is now ready for removal .


Figure 1.56 Prepare the b lanket for l i ft ing

the casualty – roll the ed ges t ightly.

Figure 1.55 Roll the casualty g ently over

Figure 1.53 Place a half rolled blanket

alongside the casualty.

Figure 1.54 Roll the casualty gently ont o

his side – the att endant closest to his

head , or a third at t endant , must support

the casualty’s head.


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When the casualty has been very carefully transported to a

matt ress on the d eck, or other very f irm bed, w here he may

remain undisturbed flat on his back, the most

important single po int is to keep him a s still as

possible. He must continue to be

supported with pillows, etc., as described

later in the text. Every care and a ttent ion,

and encouragement must be given to help

him to rema in still, w hether or no t a ny para lysis is

present. Bags f illed with sand should be placed as

necessary to prevent the body or limbs rolling. A urine

bott le should be constant ly available, and a cat heter should

be used to relieve him if necessary. He should pa ss any fae ces

on to cot t on w ool or other materia l : he must not b e l if ted onto a bed pa n. His back should be t reat ed, so far a s possible, to

prevent sores. He must be put ashore at the very earliest

possible moment . Get RADIO MEDICAL ADVICE.

NOTES:

(1) As there are a number of people

helping a nd since i t is important to t ake

great care in handling the casualty, i t

may be helpful to have a person read

out the particular instruction before

each opera tion is carried out.

(2) At lea st seven peo ple are req uired to

carry out t his ma noe uvre. In ships w ith

small crew s, there ma y be insufficient

numbers of men available. In this case,

do not a t tempt t o move the casualty but

carry out the instructions given abo ve on

immobil ising him and padding the na turalcurves of the spine. The casua lty should

then be kept w arm, his pain should be treated

(see section on a na lgesics and, if he is on the d eck, he should b e

protected from the elements with suita ble wa terproof coverings.

Neck

Injuries to the neck are often compression fractures of the

vertebrae due, for example, to a person standing up

suddenly and bumping his head violently, or by something

falling on his head. Falls from a height can a lso prod uce neck

injuries. Treat ment is similar t o t hat described ab ove fo r

fractures of t he spine, because the neck is the upper pa rt of

the spine.

the casual ty should be la id f la t , i f not a lready in th is

position, and should be kept still and stra ight;

a semi-rigid neck collar should then be a pplied gent ly to

stop movement o f the neck while an assistant stead ies

the hea d. An improvised neck collar can be mad e quite

easi ly f rom a newspaper. Fold the new spaper so t hat the

wid th is about 10 cm at t he f ront . Fold the bott om edg e

over to p roduce a slightly narrow er back. Then fo ld this

around the neck with the t op edge under the chin and

the bott om edge o ver the top o f the col lar bones;

t ie a ba ndag e, scarf or a necktie over the newspaper to

ho ld it in place. This w ill keep th e ne ck still (Figu re 1.59).

Figure 1.58

Figure 1.59

Figure 1.57


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Chest

See Fract ured ribs.

Pelvis

A fracture of t he pelvis w ill result from d irect violence in the pelvic area o r from a fall from a

height w hen the casualty has landed o n bot h feet wi th t he legs held st i f f ly. The main da nger of

this injury is of da mag e to t he pelvic orga ns, especially the blad der and the uret hra (the pipe

which leads f rom the b ladder t o t he t ip of the penis).

the casualty w ill complain of pa in in the

hip, groin and pelvic area s and,

perhaps, a lso o f pa in in the lower ba ck

and butt ock areas, made wo rse bymoving o r coughing;

he w ill be unable to stand , despite

there being n o injury to the leg s;

he may wa nt to pa ss urine a l though he

may be unable to do so. I f urine is

passed, it may be blood -stained.

there ma y be signs of interna l bleeding ;

the compression test is useful. Press

gently on the f ront o f both h ip bones in

a do wnw ard and inward d irect ion so as

to comp ress the p elvis. This will give rise

to sha rp pain if it is broken. Some

movement of t he pelvic bones may also

be fe lt if the re is a f ractu re (Figure 1.60),

but do not continue pressing in a n

at tempt to elicit this sign, as furtherdama ge may be caused .

If you th ink tha t the pe lvis may be fractured , tell the casualty:

n ot to m ove ;

not t o pa ss any urine if he can a void it. If urine is passed, look for staining w ith blood .

Remember that :

if the bladd er or urethra is dama ged , urine can leak into the t issues;

bleeding into t he surrounding tissues and into t he pelvic and low er abd ominal cavities may

be severe. A pulse chart must be sta rted immediat ely to check for interna l haemorrha ge.

lay the p at ient in his most comforta ble position. This will usually be on his back. If he w ant s

to bend the knees, support them with pi l low s. Place padding betw een the legs;

apply a broad fold banda ge round bot h knees and a f igure-of-eight ba ndag e around the

a

ship's captain medical guide

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