Accident whilst at sea Thaughts and advice

[medic417]

I guess my rea question is what is accepted now, on a national level? My training, and protocol in my area, is: Dirrect Pressure, Elevate, Pressure Points, and then a tourniquet as a last resort.

Actually even National registry now tests for bleeding as direct pressure then tourniqet. No wasting time elevating. Do a little research and then work to get your protocols brought into the 21st century.

 

[Mountain Res-Q]

Actually even National registry now tests for bleeding as direct pressure then tourniqet. No wasting time elevating. Do a little research and then work to get your protocols brought into the 21st century.

I am in California, where we were once leaders in the field, but now lag behind a wee bit. Hell, we suppossedly test to national regisrty standards but kinda dropped the ball and don't realy teach it or mandate that our we have NR. The system in general needs a lot of work in that regard. Protocol aside, if that is the accepted standard (today-it'll change tomarrow) that is how I will try to conform while still upholding the protocols we still use out here. THANX...

 

[ffmedic08]

First, we are talking about the prehospital environment, not a hospital. At my level of care there are few really meaningful things that the law allows me to do. Oxygen is a comfort measure if nothing else and one of the few things I could do in this case that could make a differnce. I give O2 (even if is is 2lpm via canula) to almost everybody for those reasons.

Seconds, remeber what the intial question was. "Bearing in mind that a fishing vessel would not be carrying more than a required basic medical kit what would your actions be, the response time for the helicopter would be 15 mins to lift off and the at least 40 mins til on scene." these are fishermen without any real medical gear or capabilities (probably). If you were the medic on the helo, would you want them doseing the pateint with god knows what before you got there? It would probably be something like oral vicodin. If I were there I would want to give something, even if it would probably only take affect in abouot 45 minutes, just as the helo arrived and they wanted to give something like ms. Is a USCG Medic really gonna be familiar with drug interactions adn be willing to give anyhting on top of that? In hind sight, I would say no to all pain meds, except for the "feel good" measures that oxygen provides (probably not available on a fishing boat". Hall butt towards the helo!!!

As a basic- you often got the "WHY ARENT YOU DOING ANYTHING FOR ME" look, yell, scream or stare. Everyone sees EVERYONE getting 02 on TV... so they think thats treatment. So, give it to 'em is my theory. Makes it seem as if you are doign more for them-and as I tell some of my more "spunkier" patients- O2 helps you age better! LOL

 

[BossyCow]

I would base my treatment on the pt and the situation. I wouldn't put a tourniquet on unless there was a lot of bleeding unrelieved by other methods. With some traumatic amputations there can be enough of a crush injury to actually lessen the bleeding.

Manage the bleeding, treat for shock. Keep the pt calm, keep the injury site clean as possible. I would probably try to immobilize the arm as much as possible and get the pt ready for transport by helo. We train to place the pt into our stokes with a rope system the helo attaches to.

Without knowing how big the boat was, does the helo land and load or are we hoisting?

 

[UKEMT]

With regards to the size of the vessel as its a fishing boat there would not be enough deck space for a helo to land so it is all done via winch (SAR helo's in UK are Seakings)

On most merchant vessels we have a designated landing / winch zone that the helo can get as near as possible to the deck.

Another case was recorded to day over the radio to coastguard as well where another fishing skipper had been hit by trawling gear ding recovery and reports stated thsat his femur was broken with and open fracture.. hate to say its been a bad month for accidents esoecially with a helo transporting oil rig workers going down about a week ago with all lives lost.

 

[Afflixion]

Just to set the record straight try direct pressure and arterial pressure points but do not waste too much time on them if they do not work go start for a tourniquet. Research has shown tissue doesn't start going necrotic for 2hours and you do not have to worry about acidosis for 3hours. As for the fluid resuscitation you do not want to do too much as if I remember correctly the body will start busting clots once the bp reach 93/p so any clots you may have formed with your arterial pressure points would then be gone. In regards to the traumatic amputations the body will only keep the arteries and veins constricted for about 30-45minutes which is still pushing the limits there so you'd be best with the tourniquet as soon as you can don't try to wait as for something thats so unpredictable one minute the casualty could be fine till the next minute about 800mL of blood are on the floor. I've seen it happen before.

EDIT: but If you want you could try to go all black hawk down on them go at that little rascal artery with a pair of hemostats! doesn't everyone do that?

 

[flhtci01]

Wrap the arm (if it is salavagable) in gauze and place it in a seeled plastic bag! Place the bag in an ice bath, but do not allow dirrct contact between flesh and ice!!!

I have facilitated motorcycle trauma classes for emergency responders. Part of the class is making inexpensive quick amputation kits that can be used.

The kit consists of a couple of ziplocks, 4x4s, a couple of 10cc saline syringes and an insta-cold pack. Place the amputated part in the first ziplock, moisten the 4x4s with the saline, put 4x4s in the first ziplock and seal. Place first ziplock in second, activate insta-cold pack, place in second ziplock and seal. Place everything in cooler and send to ER.

These kits can be pre-made in various sizes from quart, gallon to 2.5 gallon.

 

[Onceamedic]

I've run on several calls in the last few months where major blood loss was an issue. The two that come to mind involved a partial amputation of the left hand just above the wrist and a meth fight where the patient had a box cutter taken to the head, neck, abdomen and back. These lacerations were full thickness - viscera was protruding out of the one in the abdomen.
The hand amputation was 60 minutes from the hospital, the laceration patient had walked 4 blocks from the scene of the assault to a relative's home, when EMS was called.
As expected, both patients were tachycardic. Both were alert and oriented. ABCs folks - ABCs. Alert, oriented and talking to us took care of A and B. The important thing here was to control blood loss, which was admirably performed by basic first responders. Direct pressure (read lots of trauma pads and kurlex) did the trick. No need for pressure points, tourniquets, etc. In the rules of treatment, start with the least invasive, lowest risk effective measure and escalate as needed. I would have used a tourniquet if that's what it took. Although tachycardic, both patients had systolic pressures over 100. O2 absolutely - we want to make sure that whatever volume is circulating is as oxygenated as possible. Even if hemoglobin is fully saturated, it is beneficial to have as much O2 dissolved in blood plasma as possible. As others have mentioned, titrate the rate to patient condition and availability of the O2. Large bore IV's (if you got 'em) and blood tubing. (also if you got 'em). With a systolic over 100, after 100ml or so, TKO. Keep assessing this patient. Vitals every 5 minutes, make sure you have exposed so that you don't have another bleeder somewhere that you have missed in the presence of distracting injuries and get the patient to the hospital as soon as you can.
Both patients are doing well.
BTW - AK, that was textbook. I totally agree with your treatment plan and admire the way you expressed it.