7.4 Elementary First Aid, CPR, Bleeding Control & Medical Emergency Response

7.4 Elementary First Aid, CPR, Bleeding Control & Medical Emergency Response

Medical emergencies aboard merchant ships present unique and hazardous challenges. Operating far out at sea without immediate access to shoreside medical infrastructure, seafarers depend on their own training and rapid interventions to preserve life, prevent condition deterioration, and promote recovery. Under the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers (STCW 1978, Regulation VI/1, Table A-VI/1-3) and Directorate General of Shipping (DG Shipping) training mandates (Training Circular 01/2018 Annexure 2H, Part 8, and TC 30 of 2004), General Purpose (GP) Ratings must master Elementary First Aid (EFA) practical competencies. Ratings act as first responders during shipboard medical crises, executing primary evaluations, high-quality Cardiopulmonary Resuscitation (CPR), hemorrhage control, shock stabilization, fracture immobilization, burn mitigation, and safe casualty transport through confined spaces.

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1. Primary Assessment & Triage Priorities: The DRABC Protocol & AVPU Scale

When encountering a casualty aboard ship—whether from an engine room machinery accident, electrical contact, fall from height, or enclosed space collapse—the first responder must check safety, call for help and immediately control life-threatening bleeding while using the DRABC Protocol:

+-----------------------------------------------------------------------------------------+
|                                THE DRABC TRIAGE PROTOCOL                                |
+-----------------------------------------------------------------------------------------+
|  [ D - Danger ]      --> Assess physical hazards; verify atmosphere; protect self first.|
|  [ R - Response ]    --> Evaluate level of consciousness using the AVPU scale.          |
|  [ A - Airway ]      --> Open airway (Head-Tilt Chin-Lift or Jaw-Thrust if trauma).     |
|  [ B - Breathing ]   --> Look, listen, and feel for normal breathing for <= 10 seconds. |
|  [ C - Circulation ] --> Recheck bleeding/perfusion; CPR if not breathing normally.      |
+-----------------------------------------------------------------------------------------+

The DRABC Sequence

1. D — Danger: Prioritize rescuer safety before approaching the victim. Check for active electrical wires, escaping steam, toxic gas leaks ($H_2S$, hydrocarbon vapor), oxygen deficiency, moving crane loads, or fire.

   Caution

   Never enter an enclosed space (such as a ballast tank, cargo hold, pump room, or duct keel) to rescue a collapsed crewmate without donning an SCBA, securing a lifeline, and stationing an attendant outside. Entering unprotected risks immediate asphyxiation and creates multiple casualties.

2. R — Response: Assess the casualty's neurological responsiveness using the AVPU Scale:
   • A (Alert): Fully conscious, spontaneously opens eyes, answers questions logically, and follows commands.
   • V (Voice): Responds only to verbal commands or loud auditory questions.
   • P (Pain): Unresponsive to voice; responds only to noxious painful stimuli (e.g., firm trapezius muscle squeeze or sternal rub).
   • U (Unresponsive): No response to voice or an appropriate painful stimulus; muscle tone does not determine this category.
3. A — Airway: In an unresponsive casualty, muscle relaxation allows the tongue to fall backward and block the pharynx:
   • Head-Tilt, Chin-Lift: Standard non-trauma method. Place one palm on the forehead to tilt the head gently back; place fingertips of the other hand under the bony point of the chin and lift upward.
   • Jaw-Thrust Maneuver: If trained, use this with minimal neck movement when cervical injury is suspected. Kneel at the head, place fingers behind the lower-jaw angles and lift the jaw forward. If this fails to open the airway, use head-tilt/chin-lift as needed: an open airway takes priority over neck-motion restriction.
   • Inspect the mouth; clear visible vomitus, loose dentures, or foreign debris using a gloved finger sweep.
4. B — Breathing: Maintain the airway open and evaluate respiratory activity for no more than 10 seconds:
   • Look for rhythmic rising and falling of the chest.
   • Listen close to the casualty's mouth for breath sounds.
   • Feel for exhaled airflow against your cheek.
   • Agonal Gasps: Infrequent, noisy, gasping respiratory efforts are an agonal reflex of cardiac arrest—not normal breathing. Treat immediately as absent breathing.
5. C — Circulation & Massive Hemorrhage: Reassess bleeding and circulation; control life-threatening bleeding immediately when found, without waiting to reach this step. If unresponsive and not breathing normally, initiate adult CPR immediately and ensure the emergency alarm has been raised.

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2. Cardiopulmonary Resuscitation (CPR) & Automated External Defibrillator (AED)

Cardiopulmonary Resuscitation sustains artificial perfusion of oxygenated blood to the brain and myocardium during sudden cardiac arrest.

                    ADULT BASIC LIFE SUPPORT (BLS) ALGORITHM

           Unresponsive Casualty with Absent or Abnormal Breathing
                                      |
                                      v
     [ Sound Medical Emergency Alarm & Request Master, Ship's Hospital & AED ]
                                      |
                                      v
                  [ Deliver 30 Hard, Fast Chest Compressions ]
                    - Depth: 5 to 6 cm (2 to 2.4 inches)
                    - Rate: 100 to 120 compressions per minute
                    - Allow full, unhindered chest recoil
                                      |
                                      v
                        [ Deliver 2 Rescue Breaths ]
                    - 1 second per breath with visible chest rise
                    - Pocket mask with one-way non-return filter
                                      |
                                      v
                          [ Attach and Deploy AED ]
                    - Dry skin; place pads anterolaterally
                    - Stand clear during analysis and shock delivery
                    - Resume 30:2 CPR cycles immediately

High-Quality Chest Compression Technique

• Positioning: Start CPR where the casualty is found when safe, with the casualty supine. A firm surface improves compressions, but do not delay CPR to move someone from a bed to the deck. Kneel beside the chest and achieve effective compression depth.
• Hand Position: Place heel of one hand on center of naked chest (lower half of sternum); interlock fingers of second hand on top.
• Body Posture: Keep arms straight, elbows locked, and shoulders positioned directly over the casualty's sternum, using upper body weight to drive compressions.
• Compression Depth: Compress sternum to a depth of $5\text{ to }6\text{ cm}$ ($2\text{ to }2.4\text{ inches}$). Avoid excessive depth exceeding $6\text{ cm}$.
• Compression Rate: Maintain a cadence of $100\text{ to }120\text{ compressions per minute}$.
• Complete Recoil: Allow complete, uninhibited chest recoil after each downward stroke. Leaning on the chest reduces cardiac filling and organ perfusion.

Rescue Breaths & Ventilation

• Deliver 2 rescue breaths following every 30 compressions ($30:2$ compression-to-ventilation ratio).
• Seal an approved pocket mask with a one-way filter valve over the nose and mouth.
• Provide each breath smoothly over 1 second with sufficient volume to produce visible chest rise. Avoid rapid, forceful over-ventilation, which forces air into the stomach, triggering gastric inflation, regurgitation, and pulmonary aspiration.

Automated External Defibrillator (AED) Deployment

• Operation: Switch on the AED immediately upon arrival; follow the clear vocal and graphic prompts.
• Chest Preparation: Quickly wipe sweat or moisture from the casualty's bare chest.
• Pad Placement (Anterolateral Position):
  • Right Upper Pad: Apply directly below the right collarbone (clavicle), upper chest.
  • Left Lower Pad: Apply on the left mid-axillary line below the pectoral muscle, over the lower ribs.
• Shock Delivery & Steel Deck Safety:

  Important

  When the AED announces "Analyzing rhythm" or "Shock advised, stand clear", verify that no one is touching the casualty. An AED can normally be used on a wet or metal deck: quickly dry the bare chest so pads adhere correctly. Remove a casualty from immersion or immediate danger, but do not delay defibrillation merely to find an insulating mat or a dry deck. Follow AED prompts and resume compressions immediately after a shock or a no-shock decision.

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3. Severe External Bleeding Control: Hemorrhage Management

Uncontrolled hemorrhage after machinery entanglement, parting mooring wires, or heavy falls can cause fatal exsanguination within minutes.

Hemorrhage Control Steps

1. Direct Pressure: Apply firm, continuous manual pressure directly over the wound using sterile gauze pads or a clean cloth. Maintain pressure until bleeding is controlled; do not wait a fixed 10 minutes before escalating uncontrolled life-threatening bleeding.
2. Escalation: If life-threatening limb bleeding continues despite direct pressure, apply a tourniquet as soon as possible; do not delay for limb elevation.
3. Pressure Bandage: Wrap an elastic roller bandage or Israeli pressure bandage firmly over the dressing. Confirm distal pulses (radial or pedal) remain detectable; if the limb turns cold, blue, and pulseless, slightly ease pressure-bandage tension. This circulation check does not apply to a correctly tightened bleeding-control tourniquet.
4. Combat Application Tourniquet (CAT):
   • Deployed promptly for life-threatening limb bleeding not controlled by direct pressure, including catastrophic bleeding from traumatic amputations.
   • Position the CAT band $5\text{ to }7\text{ cm}$ ($2\text{ to }3\text{ inches}$) proximal to the injury site (between wound and heart). Never place a tourniquet directly over a joint (elbow or knee); place it immediately above the joint if the wound is adjacent.
   • Tighten the windlass rod until all bleeding stops and the distal pulse is absent. Lock the windlass in the retaining clip.
   • Time Marking: Record the exact time of application (e.g., T = 14:15) on the casualty's forehead or on the tourniquet time-strap with a permanent marker.

   Warning

   First aiders must not loosen or remove an applied bleeding-control tourniquet. Releasing it can restart life-threatening bleeding. Record the application time, monitor for continued bleeding and arrange urgent medical care. Leave loosening or removal to appropriately qualified healthcare professionals; follow TMAS instructions during the shipboard handover.

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4. Shock Management & Patient Positioning

Shock (systemic hypoperfusion) is an acute circulatory crisis where vital organs receive inadequate oxygenated blood, leading to cellular hypoxia and death.

Hypovolemic Shock: Signs & Symptoms

The most frequent type aboard ship is hypovolemic shock, caused by heavy blood loss, plasma loss in severe burns, or extreme dehydration:

• Skin: Pale, cold, clammy skin; profuse cold sweating (diaphoresis).
• Pulse: Rapid, weak, thready pulse ($> 100\text{ beats/min}$).
• Respiration: Rapid, shallow, labored breathing ($> 24\text{ breaths/min}$).
• Capillary Refill: Sluggish capillary refill time exceeding 2 seconds.
• Neurological: Thirst, weakness, restlessness, confusion, dizziness, and apprehension.

Shock Treatment & Positioning

                                  THE SHOCK POSITION
                         (Modified Trendelenburg: Legs Elevated)

                        Head and Torso Flat on Deck
                          .--------------------.
                         /                      \     Legs Elevated
                        |    O          +-------+      20 to 30 cm
                        |   /|\         |       |      (8 to 12 in)
                        |   / \         |       |        .-------.
                     ===================+       +=======/         \==== Deck

• The Shock Position:
  • Lay the casualty flat on their back (supine).
  • Elevate the lower limbs $20\text{ to }30\text{ cm}$ ($8\text{ to }12\text{ inches}$) above heart level to assist venous return to the heart and brain.
  • Contraindications: Do NOT elevate legs if pelvic fracture, spinal injury, head injury, or chest trauma is suspected. In chest injuries with breathlessness, place the casualty in a comfortable semi-reclined sitting posture.
• Maintain Body Temperature: Shield the casualty from cold winds with dry woolen blankets or a Thermal Protective Aid (TPA). Avoid direct radiant heaters or hot water bottles, which dilate peripheral skin vessels and aggravate core shock.
• Zero Oral Fluids: Do NOT administer food or drinks, even if the casualty complains of severe thirst. Moisten dry lips with a damp cloth. Oral intake causes vomiting and delays emergency surgery requiring general anesthesia.

The Recovery Position

For an unconscious breathing casualty with no spinal trauma:

1. Kneel beside casualty; place nearest arm at a right angle with elbow bent, palm up.
2. Bring far arm across chest, placing back of hand against near cheek.
3. Grasp far leg above knee, pull upward to bend leg, and roll casualty toward you onto their side.
4. Tilt head gently back to keep airway open, mouth pointing downward so vomitus or secretions drain clear.
5. Bend upper knee at a $90^\circ$ angle to stabilize the body, preventing rolling onto face or back.

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5. Burns, Scalds & Hazardous Chemical Decontamination

Shipboard personnel encounter severe burn hazards from superheated steam, hot fuel oil lines, exhaust piping, galley fryers, and chemical cargoes.

+-----------------------------------------------------------------------------------------+
|                               BURN DEPTH CLASSIFICATION                                 |
+-----------------------------------------------------------------------------------------+
|  [ Superficial (1st Degree) ]      --> Epidermis only; red, dry, painful, no blisters.  |
|  [ Partial Thickness (2nd Degree)] --> Epidermis + dermis; red, weeping, blisters, pain.|
|  [ Full Thickness (3rd Degree) ]   --> Transdermal; white/charred, leathery, painless.  |
+-----------------------------------------------------------------------------------------+

Thermal Burns & Scalds Protocol

1. Immediate Cooling: Cool the affected area immediately under clean, cold, gently running potable water for at least $10\text{ to }20\text{ minutes}$, or until burning pain subsides. Rapid cooling arrests deep thermal penetration and limits tissue damage.
2. Clothing & Jewelry Removal: Gently remove watches, rings, belts, and constrictive clothing before swelling begins.

   Warning

   Never pull away burnt clothing stuck to charred skin! Carefully cut around adhering fabric remnants with shears.

3. Dressing Application: Cover the cooled burn with a sterile, non-adherent dressing, or lay clean plastic cling film loosely along the burned area. Cling film relieves air-contact pain, prevents fluid loss, and acts as a bacterial barrier.
4. Strict Prohibitions:
   • Never pop or break blisters; intact skin protects against lethal maritime wound infections.
   • Never apply butter, grease, cooking oil, toothpaste, or unprescribed ointments; grease traps heat and invites infection.
   • Never use ice or ice-cold slush on extensive burns; severe cold induces vasoconstriction and fatal hypothermia.

Chemical Burns & Eye Contamination

Under the IMDG Code and the Medical First Aid Guide (MFAG):

• Continuous Flushing: Irrigate the contaminated skin or eyes under an emergency safety shower or eye-wash station with copious clean water for at least 20 minutes.
• Remove Contaminated Clothing: Strip off chemical-soaked boiler suits and boots while under continuous water irrigation.
• Eye Splashes: Hold eyelids wide apart; flush from inner eye corner outwards for at least 20 minutes.
• MFAG Consultation: Use the MFAG emergency-action flow chart and treatment tables. Identify the chemical from cargo documents and its SDS, and give that information to TMAS.

Electrical Burns

• Disconnect and isolate the electrical circuit breaker before touching the casualty.
• Inspect the casualty for both a small entrance wound and an explosive exit wound.
• Be prepared for immediate CPR and AED defibrillation, as electric shocks frequently cause ventricular fibrillation.

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6. Fractures, Dislocations & Musculoskeletal Splinting

Falls on deck, slipping down engine room ladders, and mooring accidents frequently produce fractures and dislocations.

Signs of Fractures

• Deformity: Abnormal angulation, rotation, or shortening of the injured limb.
• Crepitus: Grating or bone-grinding sensation/sound felt or heard when broken ends move.
• Severe Localized Pain: Intense tenderness localized directly over the bone fracture line.
• Swelling & Bruising: Rapid tissue edema and purple ecchymosis.
• Loss of Function: Total inability to move or bear weight on the injured limb.

Splinting Principles

1. Immobilize Joint Above & Below: A splint must immobilize the joint immediately proximal (above) and distal (below) the fracture to prevent bone fragment movement and arterial/nerve laceration. For a forearm fracture, immobilize both wrist and elbow joints.
2. Check Distal Circulation, Sensation & Movement (CSM): Test distal pulse (radial or pedal), capillary refill, and toe/finger sensation before and after applying splints or bandages. If pulse is lost, immediately ease the bandage.
3. Triangular Bandages & Slings:
   • Broad Arm Sling: Supports the forearm horizontally across the chest for forearm, wrist, and hand injuries.
   • Elevation Sling: Supports the forearm and hand in a raised position, with fingers resting on the opposite shoulder, helping control bleeding and reduce swelling.
4. Spinal Trauma Precautions: Suspect spinal injury after a significant fall or head strike and minimise neck and trunk movement. Avoid unnecessary transfer; move for immediate danger or lifesaving care, or under a trained rescue plan. If rolling is needed to open the airway, use helpers to keep the body aligned. Select spinal support with medical guidance.

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7. Shipboard Casualty Handling, Transport & Telemedical Support

Moving casualties through tight merchant ship compartments requires specialized rescue equipment and coordinated procedures.

                  NEIL ROBERTSON STRETCHER APPLICATION

     +-----------------------------------------------------------+
     |   [ Padded Head & Neck Restraint / Bamboo Slats ]         |
     |   [ Chest & Thorax Wrap with Heavy Webbing Straps ]       |
     |   [ Groin Strops & Independent Leg Encasing Flaps ]       |
     |   [ Sturdy Outer Lifting Bridle & Hoisting Ring ]         |
     +-----------------------------------------------------------+
       * Wraps and secures the casualty; select injury-appropriate support.
       * Check hatch clearance and use a casualty-rated lifting arrangement.

Stretcher Types & Extraction

• Neil Robertson Stretcher:
  • A commonly used maritime confined-space rescue stretcher, made of flexible longitudinal wooden or bamboo slats sewn into heavy canvas.
  • Wraps snugly around the casualty's head, torso, and legs with buckled straps and groin strops, securing the patient firmly like a cocoon.
  • Used for vertical or horizontal recovery through restricted accesses. Check clearance with the secured casualty, obtain medical advice on any spinal support, and use the specified lifting points and a system approved for lifting casualties; ordinary cargo-lifting gear is not automatically suitable.
• Stokes Basket Stretcher: Rigid tubular steel frame with wire mesh or plastic shell; used for helicopter winch rescues and ship-to-ship transfers.
• Manual Carries: Two-handed seat carry, four-handed seat carry, and Fireman's Lift or shoulder drag in smoke-filled spaces.

Regulatory Guidance & Telemedical Assistance (TMAS)

• Ship's Medicine Chest: Maintained in accordance with DG Shipping scales and the WHO International Medical Guide for Ships. Contains prescription antibiotics, analgesics, IV fluids, and splints.
• Medical First Aid Guide (MFAG): Supplement to the IMDG Code providing emergency treatment tables for chemical spills.
• Telemedical Maritime Assistance Services (TMAS / CIRM):
  • Global 24/7 radio and satellite medical consultations connecting the vessel with shore doctors (e.g., CIRM in Rome, national TMAS centers).
  • Ratings assist officers by recording accurate vital signs: Blood Pressure ($BP$), Pulse Rate ($PR$), Respiratory Rate ($RR$), temperature, and AVPU score.
  • TMAS physicians advise on diagnosis and treatment, including prescription medicines administered by authorized, trained personnel, and coordinate medical evacuation with Maritime Rescue Coordination Centres (MRCC).