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MEdical Handbook For Seafarers PDF
MEdical Handbook For Seafarers PDF
Leena Niemi
Medical Handbook
for Seafarers
Finnish Institute of
Occupational Health
Ministry of Social Affairs and Health
Ministry of Labour
Helsinki
Finnish Institute of Occupational Health (FIOH)
FIOH Bookstore
Topeliuksenkatu 41 a A
FI-00250 Helsinki, Finland
ISBN: 978-951-802-743-3
Gummerus Kirjapaino Oy, Jyväskylä 2007
Contents
I Emergency first aid ...............................................................................................7
1 First aid of vital functions ...............................................................................8
2 Foreign object in respiratory tract.................................................................14
3 Stopping major bleeding..............................................................................15
4 Shock............................................................................................................16
5 Classification of patients according to treatment requirement.......................19
W
hen a vessel is at sea, it is often difficult or even impossible to get a doctor on
board or to transport the ill or injured patient ashore. The success of the treat-
ment depends on the medical know-how and treatment facilities on board.
The captain of the ship is officially responsible for the treatment given on board. In
practice, the person in charge is the captain himself or a person appointed by him. In-
ternational and national regulations and instructions determine the crew’s level of medi-
cal training (e.g. STCW-95). In addition, the ship has a medical chest and the necessary
medical equipment.
The international Radio Medical system was developed to compensate for the lack
of well-trained medical staff on board. Via the service system of Radio Medical, a doctor
on shore can be consulted free of charge. Improved telecommunication systems have
facilitated direct contact between the crew and the shipping company’s occupational
health service or, for example, a designated health care facility.
It is crucial that the person in charge of treatment on board is capable of recognizing
the patient’s symptoms and of following the patient’s condition. Without these skills, de-
scribing the patient’s condition to Radio Medical’s doctor on land will not be successful.
The Radio Medical system has been used in seafaring already for a hundred years.
Video transmission, made possible by modern telecommunications technology, is not
expected to significantly change the basic situation of on-board treatment. All the treat-
ment given on board depends first and foremost on the know-how of the crew members.
The equipment on board and even the finest communication technology are only com-
plementary.
The objective of this manual, together with the possible medical consultation via
Radio Medical, is to help the person in charge of treatment on board to be able, on
the basis of the symptoms and findings, to choose the optimal treatment. Unlike earlier
manuals on medical treatment at sea, this book contains relatively little background and
theoretical information about illnesses, as such information is already available in many
medical handbooks and on the internet. There are also guide books on the dosage and
side-effects of drugs, thus this information is not repeated here.
The treatment instructions are in line with the contents of the ship’s medical chest.
The drugs are referred to by their official, i.e. generic names, so that the guide can be
used in all countries. The number/letter combination appearing after the drug (e.g. 6/D)
refers to the drug list at the end of the book. The list of drugs fulfils the demands laid
down by the EU Council Directive 92/29/EEC.
In the preparation of this book, an attempt has been made to take into account the
actual examination and treatment facilities on board ship. That is why the treatment pro-
cedures may differ from those carried out on land. The book is targeted at healthy, work-
ing-aged seafarers employed on ships. The treatment of children or elderly people is thus
not dealt with in this book.
The book can also be used when giving ship crews the required basic or advanced
training in drug administration.
The International Maritime Organisation’s (IMO) ‘Medical First Aid Guide for
Use in Accidents involving Dangerous Goods’ (MFAG) is not included in this book,
because it is already to be found on every ship. The same applies to the international
forms that are used when consulting a doctor via Radio Medical or by the satellite sys-
tem.
Because the book will probably be read on a chapter here and a chapter there basis,
depending on the patient and the situation at hand, certain points have been repeated
deliberately. It is essential that the ships’ crew can use it without having to read it from
beginning to end.
Expert consultants and commentators on the book have been Ari-Pekka Aarnio,
Ritva Borman, Eeva Ekholm, Harri Kankare, Kari Koskela, Leena Niemi, Sinikka Niemi,
Petri Nieminen, Erkki Nylamo, Tuula Oksanen, Katja Paakkola, Lassi Pakkala, Kari Riutta,
Heikki Saarni, Ulla-Maija Saarni, Heikki Suoyrjö and Erkki Säkö. They represent differ-
ent medical fields and have taught seafarers for a long time. The Health Division of the
Advisory Board for Maritime Affairs has offered their comments and has sponsored the
editing of the book.
I EMERGENCY
FIRST AID
1 First aid of vital functions
2 Foreign object in respiratory tract
3 Stopping major bleeding
4 Shock
5 Classification of patients according to
treatment requirement
I Emergency first aid
Emergency first aid is immediate first aid Emergency first aid procedures con-
with the aim of saving the patient’s life. The sist of the following: assessment of the
victim’s breathing and blood circulation situation and rescuing the victim from
are secured with emergency first aid. Emer- danger, securing breathing, securing cir-
gency first aid must be given without delay, culation, stopping bleeding and treatment
because the first few minutes are crucial of shock. When the situation has been
for the patient’s survival. Thus, emergency stabilized, the actual treatment and the
first aid must be started immediately at possible transportation of the patient to
the scene. The first aid procedures are the shore for further treatment can be started.
same in the case of an accident and an On arrival at the scene, a rapid evaluation
attack of illness. of what has happened must be made. If the
I Emergency first aid
dangerous situation continues, the patient Cardiac arrest means that the heart stops
must be rescued from it. The helper must pumping blood, the circulation stops and
at all times make sure that he/she is not the organs no longer receive the necessary
in danger him/herself (electric shock, gas, oxygen transported by blood. The patient
fire, etc.). suddenly loses consciousness. The pulse
First aid administration must be cannot be felt from the carotid artery.The
started immediately when it is safe to do respiratory movements are gasping, or
so. The patient’s own breathing is assessed the breathing stops altogether. The eyes
and mouth-to-mouth respiration started, if are glazed, the pupils are more or less
necessary. If the patient’s heart is not beat- dilated, the skin is pale and the lips turn
ing, cardiac massage is started. blue. The cause of a cardiac arrest can be,
A breathing patient is placed on his/ for instance, cardiac infarct, arrhythmia,
her back, and an unconscious patient on drowning, electrocution or anoxia of the
his/her side. It must be ensured that the heart caused by respiratory arrest.
lungs are getting oxygen, the respiratory
tract is open and the pulse can be felt. Determining the patient’s
External bleeding must be stopped. condition
When the patient is no longer in im- It is important to find out what has hap-
minent danger, he/she is examined more pened in order to get a picture of the loca-
carefully, his/her wounds are bound more tion and extent of the possible injuries. The
carefully, and fractures are supported. The patient is examined very carefully when an
patient is protected and settled as comfort- injury to the neck or head is suspected. If
ably as possible. Any necessary further the patient has an injury to the spinal cord,
medical treatment is initiated, and the moving his/her head may cause paralysis.
patient’s condition is monitored constantly, If the patient does not react to outside
and, if necessary, his/her transportation to stimuli, is not breathing, or the pulse can-
shore is arranged. not be felt, extra help must be called, and
resuscitation started immediately. If the
1 Resuscitation patient is unconscious, check whether his/
her respiratory tract is open and whether
Respiratory arrest may be caused by a for- he/she is breathing. Possible obstructions
eign object in the respiratory tract, drown- in the respiratory tract are removed (see
ing, poisoning, electric shock, paralysis, Chapter 2 Foreign object in respiratory
epiglottal inflammation, or injury blocking tract). If the patient starts to breathe after
the respiratory tract. When a patient is the respiratory tract is opened, and the
unconscious and lying on his/her back, pulse can be felt from the carotid artery,
the tongue presses against the pharynx, the patient is placed on his/her side (Figure
blocking the respiratory tract. By lifting 1). If the respiratory tract is opened, but
the jaw and tilting the head backwards the the patient is not breathing, resuscitation
respiratory tract can be opened. is started. Resuscitation is effective when
Even though the patient is not breath- the patient is lying on his/her back on a
ing, his/her heart still functions for a short firm, flat surface. If an unconscious patient
time, supplying oxygen to the brain and is suspected of having a neck injury, he/she
other parts of the body. Rapid resuscitation must be turned on his/her back extremely
may save the patient. carefully.
I Emergency first aid
Figure 1. An independently
breathing unconscious patient
placed on his side
10
I Emergency first aid
Figure 7. Mouth-to-mouth
respiration
11
I Emergency first aid
12
I Emergency first aid
Resuscitation drugs
The resuscitation drug found in the ship’s
pharmacy is adrenaline (8/A, 1mg/ml). A
dose of 1 ml is administered intramuscu-
larly. Adrenaline constricts the peripheral
circulation when the diastolic blood pres-
sure during cardiac massage rises and
coronary circulation improves. If the heart
starts to beat, adrenaline increases the
pumping strength of the heart.
13
I Emergency first aid
2 Foreign object in
respiratory tract
In adults, a foreign object gets caught in called Heimlich manoeuvre. Stand behind
the respiratory tract most often while eat- the patient (Figure 8). Make a fist with one
ing something tough, for example, a piece hand and place it on the patient’s upper
of meat. The risk for this is increased by abdomen, your forearm along the patient’s
talking while eating, a prosthesis of the lowest ribs, and with your other hand take
upper jaw (decreased feeling in palate), hold of your fist or wrist. Then pull force-
and drunkenness. Choking may resemble fully inward and upward with your hands,
a sudden attack of illness: the victim gasps and press the patient’s costal arches closer
for air, holds his/her throat and, sometimes, together with your forearms. In this way the
collapses to the floor. volume of the patient’s chest decreases and
its internal pressure rises. If one thrust does
not work, the procedure can be repeated
● An attack of illness that occurs
during a meal should primarily five times, if necessary.
be treated as an emergency caused If the abdominal thrusts do not work,
by a piece of food blocking the or the patient is much greater in size than
larynx. the helper, or the patient loses conscious-
ness, he/she is turned on his/her side on the
floor and hit sharply between the shoulder
Sometimes, even a very small foreign blades a few times.
object can cause a violent fit of coughing
lasting for a few minutes. The condition
of a patient who can cough is usually not
very serious, and it is usually sufficient to
bend the patient forward, pat him/her on
the back, and calm him/her down.
If the patient cannot talk, he/she is
asked if he/she is choking and told to
cough. If the patient’s condition deterio-
rates and he/she is not able to cough, help
must be called and first aid procedures
started quickly. First aid must be given
rapidly and effectively, because there is
not much time to lose. A foreign object
blocking the respiratory tract completely
can cause asphyxiation in a few minutes.
Position yourself behind the patient,
bend the patient’s upper body forward, and
sharply hit him/her five times between the
shoulder blades. If these blows do not help,
the foreign object can often be removed
by increasing the internal pressure of the Figure 8. Removing a foreign object with
chest with abdominal thrusts, i.e. the so- the Heimlich manoeuvre
14
I Emergency first aid
If the foreign object is still not expelled, object to go deeper past the left bronchus
and the patient is not breathing, cardio- and into the right bronchus. Thus, the left
pulmonary resuscitation is started (the lung starts to function and the patient is
rhythm of resuscitation 30 presses, 2 saved. After successful resuscitation, a
blows). Blowing air might make it possible doctor must always be consulted via Radio
to get some oxygen into the patient’s lungs Medical about possible further treatment.
past the foreign object, or cause the foreign
15
I Emergency first aid
4 Shock
Shock is a disturbance of the circulation Dehydration due to widespread burns,
that can originate from various causes. severe diarrhoea or vomiting may also
In a state of shock, the blood pressure is cause shock. A strong allergic reaction,
too low to maintain sufficient circulation, anaphylactic shock or sepsis may result in
resulting in severe oxygen deficiency. Of failure of the regulation mechanism of the
the vital organs, the kidneys require the blood vessels. This causes the blood ves-
highest level of blood pressure in order to sels to expand and the circulating amount
function properly (systolic blood pressure of blood can no longer maintain sufficient
at least 80 mmHg). The same level of blood pressure. Failure of the heart’s pumping
pressure is necessary for the pulse to be felt strength in connection with myocardial
from the radial artery. If the pulse cannot infarction may also lead to insufficient
be felt from the radial artery, the patient is blood pressure and shock.
in shock, or he/she will probably go into
shock. 2 Symptoms
1 Causes The body tries to compensate the fall in
blood pressure in many ways to ensure a
Shock has many causes. It can be caused sufficient blood supply to the vital organs,
by an insufficient amount of blood, due such as the heart and the brain. First, the
to, e.g. bleeding. Internal bleeding is usu- heart rate increases. Then, peripheral
ally not visible, and is therefore detected blood vessels start to contract, peripheral
only when the symptoms of shock appear. circulation decreases strongly, and the
Simple fractures (no open wound at the site skin, especially in the limbs, turns cold.
of fracture) may bleed substantially into the The sweat glands are activated, making
tissues (Table 2). the skin feel cold and clammy.
The amount of blood that the patient Low blood pressure is a sign that the
has lost can be estimated by following the disorder has already progressed quite far.
general state of circulation and the appear- The pulse can no longer be felt from the
ance of possible symptoms of shock (pulse, wrist (systolic blood pressure under 80
blood pressure, skin temperature). mmHg) and the circulation of the internal
16
I Emergency first aid
Bleeding shock
● Consult a doctor via Radio Medical
The treatment of bleeding shock is prima- for further treatment of bleeding
rily efficient first aid, securing basic vital shock.
functions and treating the causes of shock
(see Chapter 1 First aid of vital functions).
Make sure that the airways are open and Allergic shock
the patient is breathing. Stop the bleeding. A sudden allergic reaction can be caused
The circulation in the vital organs can be by an insect sting, food or a drug. Symp-
supported by placing the patient on his/her toms that may appear within minutes
back and raising his/her legs. can be dyspnoea, runny nose, bloodshot
17
I Emergency first aid
and itching eyes, rash, or even shock and After alleviating the most dangerous situ-
death. ation with adrenaline, hydrocortisone 2
The first symptoms of an allergic ml (5/C, 125 mg/ml) is administered
shock may be reddening and itching skin, intramuscularly. Treatment is continued
swelling of the tongue and the pharynx, with prednisolone (5/D) given daily in the
wheezing breathing, a feeling of pressure morning. On the first morning the dose of
in the chest, and difficulties in breathing. prednisolone (5/D) is eight 5 mg tablets,
The blood pressure can drop and cause all given at one time. The dose is reduced
weakness, vertigo and fainting. The throat, every other morning by 1–2 tablets, until
the larynx and the respiratory tract may the treatment is completed.
swell up, making breathing and swal- The patient should visit a doctor to
lowing difficult. Speech is often slow and try to determine the cause of the allergic
clumsy. The condition can rapidly become reaction, so that, by avoiding the aller-
life-threatening. gen, the reaction can be prevented from
The first aid in allergic shock is always recurring.
adrenaline (8/A, 1 mg/ml). The dose given
to an adult is 0.5–1.0 ml subcutaneously ● Consult a doctor via Radio Medical
or intramuscularly. If the symptoms are on further treatment of an allergic
severe or shock is developing, or has al- reaction.
ready developed, the adrenaline is injected
into the muscles of the tongue, where the
circulation is good despite shock, and the In mild disorders (hay fever, itching eyes,
drug is absorbed rapidly. Take hold of the nettle rash) without circulatory or respira-
tongue with a piece of cloth or paper, and tory symptoms, sufficient treatment usually
inject the drug directly into the tongue consists of cetirizine hydrochloride (5/B)
(Figure 9). The injection can be repeated one 10 mg tablet once or twice a day, or
after 10–20 minutes. prednisolone (5/D). To begin with, six 5
mg prednisolone tablets are given, all at
one time. The dose is reduced every other
day by 1–2 tablets, until the treatment is
completed.
The patient should visit a doctor to
try to determine the cause of the allergic
reaction, so that, by avoiding the aller-
gen, the reaction can be prevented from
recurring.
18
I Emergency first aid
5 Classification of patients
according to treatment
requirement
The classification of patients (triage) is car- Priority Category I. Patients whose breath-
ried out to identify severely injured patients ing and circulation have deteriorated or
who need immediate transportation and are deteriorating. An open respiratory
treatment. Triage is necessary when the tract is secured by placing the patient on
number of injured persons is so great that his/her side, clearing the mouth and the
all those in need of medical attention can- pharynx, or, if necessary, installing an
not be treated immediately. endotracheal tube (intubation). Imminent
Severely injured patients are divided or obvious shock is treated at the scene of
into four priority groups (those in category accident with intravenous infusion therapy
one have to be transported for further treat- (see Chapter 45 Intravenous (IV) infusion
ment first, Table 4): therapy). Fractured limbs of patients with
multiple injuries are splinted. Burns are
covered with sterile bandages. In case of
injuries to the face, an open respiratory
tract must be secured.
19
I Emergency first aid
Priority Category II. Patients whose con- treatment for a relatively long time. Patients
dition, in spite of severe injury, does not with injuries to the spinal cord, mild brain
deteriorate while waiting for transportation injuries, or simple fractures belong to this
or treatment. Unconscious patients or pa- category.
tients with chest injuries, but no breathing
difficulties, patients with injuries to the Priority Category IV. Patients whose inju-
abdominal area, and patients with mild ries are so severe that they are not thought
burns belong to this category. likely to survive. This category includes
patients with crush injuries to the head,
Priority Category III. After receiving first chest or body.
aid, these patients can wait for further
20
I Emergency first aid
II ACCIDENT
INJURIES AND
ACCIDENT INJURIES
THEIR TREATMENT
6 Skull injuries and cerebral haemorrhage
7 Injuries to the eye
8 Injuries to the abdominal area
9 Bone, joint and muscle injuries
10 Amputation
11 Burns and frost injuries
12 Heat-induced illnesses
13 Electrocution
14 Thermoregulation of organs and hypothermia
15 Near drowning
16 Poisoning
21
II Accident injuries and their treatment
22
II Accident injuries and their treatment
1 Concussion
In concussion, the period of unconscious- on the surface of the brain. This directly
ness after the injury is usually short, last- irritates the cerebral cortex and presses
ing only a few minutes, and there is often the structures under it. Increasing bleeding
related loss of memory. In the beginning, causes an increase in cerebral pressure.
the patient can be confused and he/she Cerebral membrane symptoms may
can have headache. Usually the symptoms occur quite rapidly after the injury: neck
worsen in an upright position, so it is much stiffness, headache, nausea and photo-
more comfortable for the patient to be ly- phobia. Usually the symptoms deteriorate
ing down. The patient often experiences continuously for a few days, and gradually
nausea or vomiting, and feels dizzy. There unilateral symptoms occur, for example,
can be neurological deficiency symptoms paralysis, difference in pupil dilation and
as well, but they usually disappear in a speaking difficulties. However, symptoms
few days. The symptoms are caused by that progress slowly and for a longer time,
damage to neural pathways that occurs in sometimes even for months, are more
connection with concussion, but these will common. Imaging of the head and surgery
subside with time. must be performed urgently.
23
II Accident injuries and their treatment
24
II Accident injuries and their treatment
25
II Accident injuries and their treatment
2 Radiation injuries
The light from a welding torch, ultraviolet
light, or strong sunlight may injure the
cornea. The symptoms are photophobia
and the feeling that there is something in
both eyes. The symptoms occur a few hours
after the exposure.
This condition is not dangerous even
Figure 13. Bleeding in the anterior cham-
if the symptoms are intense, and the patient ber of the eye and under the conjunctiva
will recover in a few days. If the symptoms
are unbearable, they can be relieved by ap-
plying anaesthetic drops to the eyes (oxy- 4 Bleeding into the
buprocain hydrochloride, 10/C), and drops anterior chamber
that constrict the blood vessels (tetrahydro-
zoline hydrochloride, 10/A). To prevent The most common eye injury caused by
inflammation, also chloramphenicol eye a blow is bleeding into the eye’s anterior
ointment (10/B) may be applied. chamber, where it may be seen as a dark
red patch (Figure 13). In a severe injury,
the whole anterior chamber may fill with
blood.
If there is blood in the anterior cham-
ber, the patient is ordered bed rest for a
26
II Accident injuries and their treatment
27
II Accident injuries and their treatment
28
II Accident injuries and their treatment
causing severe peritonitis, which usually tion. If there is even the slightest suspicion
leads to death if not treated. The degree of internal bleeding, intravenous infusion
of severity of the injury is difficult to as- is started at a standard flow rate (e.g. 20
sess, because internal bleeding is minor in drops/min, see Chapter 45 Intravenous
ruptures of the intestine and bladder. The (IV) infusion therapy). Thus, when shock
symptoms of peritonitis are exacerbating develops, the patient already has an open
pain, as well as tension and tenderness of blood vessel connection and the lost blood
the abdominal wall. The symptoms appear can be replaced.
gradually, so it is important to monitor the If the transfer is delayed, and it is sus-
situation carefully. pected that the patient is developing peri-
tonitis, antibiotic drug treatment should be
Injuries from sharp objects started. A non-vomiting patient is given, for
So-called sharp injuries are usually caused example, ciprofloxacin (7/C), two 250 mg
by a knife (e.g. a stiletto) stab, or a bullet. tablets three times a day. A more efficient
These are basically always penetrating antibiotic is cefuroxime (7/D) given as an
injuries, i.e. they penetrate the abdominal intramuscular injection. It is suitable also
cavity and damage internal organs. This for vomiting patients. The drug in the form
may result in bleeding of an internal organ of a dry substance ampoule is dissolved in
(liver, spleen), or in a penetration injury of 3 ml of sterile water, and then administered
a cavity organ (stomach, intestine, urinary intramuscularly. The dosage is three injec-
bladder). In addition, the direction of the tions in 24 hours.
stab may cause a penetration wound from
the thorax down through the diaphragm 4 Ruptured spleen and
and into the abdominal cavity, or on the liver, and other
contrary, through the abdominal cavity up abdominal injuries
into the chest cavity and even to the heart.
A stab directed at the pelvis or the buttock Rupture of the spleen
may penetrate into the abdominal cavity. A ruptured spleen is the most common
In such cases, the patient should be injury caused by a blunt blow to the ab-
transferred to land for surgical treatment as dominal area. Its symptom is pain in the left
soon as possible, because the probability side of the upper abdomen, under the cos-
of damage to the internal organs is great tal arch. The result of the rupture is usually
in all sharp injuries. When preparing the substantial internal bleeding, and its signs
transfer and during it, intravenous infusion are pallor, rapid pulse and low blood pres-
may be crucial for the patient’s survival. sure (shock). Without surgery, the bleeding
usually leads to death in a few hours. If a
3 Treatment rupture of the spleen is suspected, the pa-
tient must be transferred for surgical treat-
It is crucial to follow the patient’s condition ment immediately. While waiting for the
carefully and at short intervals, because as- transfer it is necessary to start intravenous
sessing the severity of the injury is difficult, infusion, which is increased if the blood
and even impossible, on board. Consulting pressure starts to fall. Sometimes a capsule
a doctor via Radio Medical is necessary. around the spleen can suppress bleeding.
First aid and resuscitation must be made Usually this ‘tamponing’ of bleeding is
available, as the possibility of internal temporary, and new substantial bleeding
bleeding is great in abdominal injuries. The can be expected in a day or two.
injured patient is placed in a resting posi-
29
II Accident injuries and their treatment
Rupture of the liver the pelvis and the lumbar vertebrae. The
A ruptured liver is less common, and a origin of the bleeding is very often deter-
rather strong blow is needed for it to oc- mined only during surgery.
cur. Sometimes the bleeding may be minor A blunt blow may also cause an intes-
and may subside by itself, but usually the tine or the urinary bladder to rupture, only
result of the rupture is bleeding that leads rarely does the stomach rupture. In this
to shock and death, as in a rupture of the case, intestinal fluid enters the abdominal
spleen. Pain and possible signs of external cavity, resulting in severe peritonitis. At
violence (contusions, bruises) are observed first a possible injury is difficult to assess,
on the upper mid-abdomen or in the area because bleeding is not always significant,
of the right costal arch. The treatment is and the symptoms of peritonitis appear
the same as in a ruptured spleen: intrave- gradually. The condition is very serious
nous infusion is started on board, and the and, if not treated, usually leads to death.
patient must be transferred for surgery as The symptoms are exacerbating pain, ten-
soon as possible. derness and tension of the abdominal wall,
the patient looks ill, the tongue is dry and
Other abdominal injuries the pulse is rapid. The condition requires
Other reasons for internal bleeding in the hospital treatment on land, but intravenous
abdominal cavity may be rupture of the infusion is of great help while waiting for
mesentery and its blood vessels, rupture the transfer. If peritonitis is suspected,
of the pancreas, or kidney contusion. Sub- antibiotic drug administration is started as
stantial internal bleeding in the abdominal described above.
cavity is often also related to fractures of
30
II Accident injuries and their treatment
31
II Accident injuries and their treatment
32
II Accident injuries and their treatment
33
II Accident injuries and their treatment
Dislocated shoulder (upper arm) Figure 18. Repositioning the upper arm
with a weight
The shoulder or upper arm is most often
dislocated in a fall on an extended arm. If
the shoulder has been dislocated before, If repositioning of the upper arm is not suc-
the ligaments are loosened, and disloca- cessful with a weight, repositioning may be
tion may occur as a result of even a minor aided by gently moving the arm back and
injury. forth, and pulling the top part of the upper
The patient feels pain in the shoulder arm away from the patient’s body.
and cannot move his/her arm. The pulse is After the joint is back in place, it is
felt from the wrist, and the tactile sensation necessary to use a sling for a couple of
and moving of the fingers are checked. This weeks. The upper arm must be examined
ensures that blood vessels and nerves are upon arrival ashore, and an X-ray must be
not damaged. If the pulse or the tactile taken to make sure that there is no frac-
sensation is abnormal, a doctor must be ture. If the repositioning is not successful,
consulted via Radio Medical. the upper arm is supported with a sling,
The upper arm should be repositioned and the patient is transferred for further
immediately after the injury. The patient is treatment.
placed on a bed on his/her stomach, and
the arm is allowed to hang down the side of Dislocation of a knee
the bed (Figure 18). If possible, a weight is Dislocation of a knee cap usually occurs
attached to the upper arm to pull the limb towards the outer side of the leg, the knee
downwards. If needed, more weight can be being slightly bent. A dislocated knee cap
added. The patient may be given a muscle usually returns to normal by itself immedi-
relaxant – a dose of diazepam (4/A, 5 mg/ ately. The symptoms are pain, swelling and
ml) as a 1–2 ml intramuscular injection. In inability to move the knee joint.
addition, pain medication may be given if If the knee cap does not reposition it-
needed, for example, diclofenac 25 mg/ml self, the knee is straightened very gradually.
(3/B) as a 3 ml intramuscular injection. At the same time, the knee cap is pushed
carefully with the palm of the hand towards
34
II Accident injuries and their treatment
the fore and inner side of the thigh. After Rapid first aid prevents the extension of
the knee cap is repositioned, the knee the injury and hastens recovery.
is supported. It is a good idea to place a The symptoms of muscle injuries
cold pack on the knee. The leg should be are local tenderness, painful movement,
elevated to decrease swelling. The patient haematoma and, sometimes, a lump or a
is transferred for further examinations and depression in the muscle.
treatment on arrival in port. First aid consists of cold, compres-
If the repositioning of the knee cap is sion and elevation of the limb. In addi-
not successful, the leg is supported in the tion, the injured limb is kept at rest. Cold
least painful position, and the patient is constricts the blood vessels and decreases
transported to hospital. bleeding. An ice pack, snow or anything
cold pressed against the injured area
3 Muscle injuries helps. Elevating the limb and compression
help to inhibit bleeding. The patient may
Muscle ruptures are usually related to press the injured area him/herself with the
sports. A muscle may rupture during exer- hand. The sooner that cold, compression
tion or as a result of a blunt blow directed and elevation are applied, the less bleed-
at the muscle. There is bleeding into the ing there is into the tissues, and the faster
tissue surrounding the ruptured muscle. the injured muscle heals.
10 Amputation
In an amputation injury, a limb or part of sible to press with the hands directly on
it is detached entirely as a result of ex- the wound or the bleeding artery above
ternal violence. Amputation injuries are the amputation. If this does not help, a
most common in the fingers and hands. tourniquet is applied to the stump. A sphyg-
Nowadays it is possible to replant an momanometer cuff, into which sufficient
amputated limb or part of it with the aid pressure is pumped (above systolic blood
of microsurgery. However, in an accident, pressure!) may be used. In an emergency,
the limb may be so severely damaged that any belt, strap or piece of cloth may be
replanting is not possible. used, as long as it is taut enough.
For the replanting to be as successful The stump of the limb is supported in
as possible, the amputated limb or its part an elevated position. A cold pack or ice
must be handled properly. In most cases, pack is placed on the base of the stump
the results of replantation surgery are good, to decrease bleeding by constricting the
if the injured person is transferred for treat- blood vessels.
ment immediately. If the bleeding is abundant, intrave-
nous fluid replacement (infusion therapy)
1 Stopping bleeding is started. Giving oxygen with a mask
improves the oxygen content of the re-
The bleeding must be stopped. If the stump maining blood.
of the limb bleeds substantially, it is pos-
35
II Accident injuries and their treatment
Classification of burns
Burns are classified according to their
extent and depth. When the extent of a
burn is determined, the so-called 9% rule
is used as an aid (Figure 19). An area the
size of the palm of the hand is 1% of the
superficial area of the skin. If more than
15% of the skin area has been burnt, there
is a risk of shock.
If only the outermost layer of the skin
is damaged, the skin turns red and the in-
jury heals in a few days leaving no scars.
Pain, redness and blisters are related to a
deeper injury. Healing takes two to three
weeks and may leave a minor scar.
Skin that is damaged through its entire
depth has a red leathery surface without
blisters. There is only slight pain or no pain
at all. Healing without surgical treatment is
Figure 19. Determining the extent of a
slow, and the injury leaves a scar.
burn with the help of the 9% rule
36
II Accident injuries and their treatment
37
II Accident injuries and their treatment
same way as an inflamed wound. The treat- area soon after warming, but they are signs
ment consists of an antibiotic, cefadroxil of only minor tissue damage. Small dark
(7/E), one 500 mg tablet twice a day, and blisters, on the other hand, are a sign of
cleaning the wound daily when chang- deep severe tissue damage.
ing the bandages (see Infected wound,
Chapter 47). Treatment
The injured area must be protected from
2 Frost injuries further damage and further exposure to
cold. The injured area must not be rubbed
When there is a threat of lowered tempera- with snow, and neither should the frozen
ture (hypothermia), the peripheral blood joint area be moved (no walking if the toes
circulation of the body is minimized, and are frostbitten).
the skin and extremities are exposed to The frostbitten area is warmed with
the surrounding cold. The hypothermic warm skin, for example, by placing the
patient may also have local frostbite, and injured body part into someone’s armpit.
a prolonged hypothermic condition speeds The fastest way to warm the injured part,
the development of frost injuries in the which also causes the least tissue damage,
limbs. On the contrary, there is rarely risk is to use 40–42ºC water in 20 minute peri-
of hypothermia in the case of a local frost ods, but this is painful. A less painful, but
injury. less efficient means, is to gradually raise
the temperature of the water.
Symptoms Pain medication may be used to al-
The symptoms of a local frostbite are tin- leviate pain. After warming, the injured
gling pain, numbness of the skin and its area is protected with sterile bandages.
wax-like or bluish, marble-like pallor, and Folded bandages are also placed between
poor mobility of the injured body part. the injured fingers or toes. It is good to
In superficial frostbite of a limb, the keep the limb in a slightly raised position.
skin is white and numb. Pain and clear For further treatment, follow the general
blisters, which may extend to the tips of principles of treating wounds.
the fingers or toes, appear on the injured
12 Heat-induced illnesses
Various symptoms may be caused by ex- evaporation of heat from the head, thus
cessive exposure to heat. enhancing the heat effect of the sun. The
symptoms are headache, nausea, vertigo
1 Sunstroke and irritability. Usually it suffices to move
the patient to a cool place to rest, with
Sunstroke is caused by exposure to ex- the head slightly elevated. A cool moist
ceptionally extensive heat radiation to pad on the forehead makes the patient
the head, for example, from sunlight. The feel better.
use of a protective helmet may prevent
38
II Accident injuries and their treatment
39
II Accident injuries and their treatment
13 Electrocution
40
II Accident injuries and their treatment
14 Thermoregulation of organs
and hypothermia
1 Thermoregulation In a crisis situation, for example, un-
of organs der water, the lowered body temperature
protects the brains from damage caused
The human being is warm-blooded and is by lack of oxygen. The cold causes the
able to sustain a stable body temperature, metabolism in the brain to slow down, and
despite temperature changes in the en- thus the need for oxygen decreases.
vironment. In normal conditions, heat is A person’s ability to resist cold de-
produced by metabolism, muscle exertion pends on the body’s surface area and mass,
and digestion. that is, the body structure. Tall persons
By contracting the skin’s dermal blood have a larger heat-releasing surface area
vessels, the body can decrease the evapo- than short persons. The subcutaneous fatty
ration of heat through the skin down to 1/5 layer of obese persons acts as insulation to
or 1/6 compared to normal conditions. The retain body heat. Good physical condition
body is able to decrease blood circulation increases the ability of the body to produce
in the limbs, which in turn decreases the and sustain heat by muscle exertion, while
area releasing heat, by guiding venous illness, and the poor physical condition
blood circulation inwards to the blood resulting from it, diminish this ability.
vessels near the arteries. Because the body
always tries to secure the oxygen level of 2 Hypothermia
the brains, the blood vessels in the head
do not contract even if it is very cold. If Hypothermia, or lowered body tempera-
unprotected, the head may release heat in ture, occurs when the body cannot suffi-
cold conditions, up to 40–95% of all the ciently increase its heat production in cold
heat produced by the body. conditions. The temperature of the internal
Figure 20. The development of symptoms of hypothermia as the body temperature falls
41
II Accident injuries and their treatment
organs gradually falls, and the body’s heat energy. The skin turns pale and cold all
balance is disturbed. over the body.
Hypothermia may develop either When the temperature of the inter-
rapidly or slowly. Hypothermia may nal organs falls from 35°C to 30°C, the
occur rapidly in water or in extremely functioning of the central nervous system
cold weather conditions without proper is disturbed. The patient is conscious, but
protective clothing. Wet clothes, or if the his/her judgement and initiative weaken
patient is injured, bloody clothes, increase as the body temperature falls. When the
the release of heat. Hypothermia, in turn, temperature of the internal organs is be-
increases bleeding and decreases the co- low 33°C, the level of consciousness is
agulation of blood. Increased release of markedly lowered and hallucinations are
heat is related to extensive burns. possible. The patient may feel very hot, and
Hypothermia develops slowly, for so may begin to take off his/her clothes,
instance, in a fatigue situation (fatigue hy- thus decreasing further the chances of
pothermia). It is caused by the combined survival.
effects of cold, fatigue and lack of energy. The temperature threshold between
The development of hypothermia may be minor and severe hypothermia is about
enhanced by some illnesses (e.g. diabetes), 33–32°C. When the temperature of the
medications (drug poisoning), age, inex- internal organs falls below 31°C, the hu-
perience in dealing with cold (abnormal man being becomes cold-blooded. This
climatic conditions) and malnutrition. means that the body is unable to return
The effects of cold on the body are the temperature back to normal.
the same regardless of whether the body As hypothermia progresses, the blood
temperature has fallen rapidly or slowly. A pressure, pulse and breathing begin to
person can be considered to be hypother- slow down rapidly. When the temperature
mic, if the temperature of his/her internal of the internal organs is below 32°C, ar-
organs is below 35°C. rhythmias of the heart’s atria and ventricles
are common. The blood pressure is no
The development of hypothermia longer measurable when the temperature
The symptoms that describe the level of of the internal organs is about 31°C. The
hypothermia are typical to the develop- pupils are dilated, and eye movements
ment of hypothermia, but the condition and reflexes disappear as the hypothermia
may also develop insidiously, without deepens.
the first symptoms, feeling in the skin, or The patient loses consciousness when
shivering (Figure 20). the temperature of the internal organs falls
When the body temperature starts below 30°C. The rigidity of the muscles in-
to fall, the pulse rises and blood pres- creases, muscle fibrillation having ended.
sure increases strongly, and the breathing The pulse and breathing continue to slow
becomes rapid. The basic metabolism down: the rate of breathing is 5–10 times/
may be 700% more active than in normal minute. Arrhythmias increase.
conditions. The body tries to raise its tem- The elasticity of the lungs and the
perature by muscle fibrillation, but this is functioning of the respiratory muscles
possible only when the temperature is at deteriorate as hypothermia progresses.
least 32°C, below which fibrillation ends The limbs are increasingly rigid and
permanently. The cooling of the muscles the patient no longer reacts to external
may cause extensive spasms in the lower stimuli. The basic metabolism gradually
abdomen, which use up more physical slows down to half its normal capacity.
42
II Accident injuries and their treatment
43
II Accident injuries and their treatment
be moved off the ground and protected A hypothermic patient is moved lying
from wind and cold. down, if possible. During the transfer, ac-
Further cooling down is prevented. tive warming must be avoided to prevent
If possible, 40°C fluid intravenously and the after-drop phenomenon. Resuscitation
extra oxygen with a mask are recom- attempts during the transportation are con-
mended and safe first aid measures. The traindicated. Further treatment is given in
limbs must not be rubbed, nor the patient accordance with the advice received via
actively warmed! Radio Medical.
15 Near drowning
44
II Accident injuries and their treatment
16 Poisoning
Poisoning on board may be related to 2 Exposure
work (e.g. carbon monoxide poisoning
in connection with a fire or exposure A substance that is dangerous to health
to the cargo), or is caused by one’s own may enter the body via
behaviour (e.g. alcohol or drugs). The lat- • respiration (gas, vapour or mist)
ter cases are more usual. In this section, • absorbance through the skin or mucous
the general treatment of poisoning cases membrane (liquids and partly gaseous
and the principles of dealing with some substances)
poisonous substances are described. A list • eating or drinking; oral route into the
of various harmful substances and treat- digestive system (powdery or liquid
ment procedures after exposure to these substances).
substances are given in the latest edition of
the MFAG book (Medical First Aid Guide The respiratory tract is the most usual path
for Use in Accidents Involving Dangerous by which a poisonous substance enters the
Goods, IMO). body. The hazard is often further increased
by the simultaneous absorption of the
1 Dangerous cargo same substance through the skin (solvents,
some central nervous system poisons).
Cargo is classified as dangerous, if expo- The swallowing of a poisonous substance
sure to it is harmful to health. Documents accidentally is rare. This usually happens
accompanying this type of cargo inform when an attempt has been made to suck
the ship crew of the nature of their cargo a dangerous liquid from one container to
already before loading. According to in- another with a tube.
ternational rules and regulations, the ship Accidental exposure through the
has to be equipped with the antidotes mouth is possible from dirty hands or
mentioned in the MFAG, and required by contaminated food supplies. In premises
the cargo. where dangerous substances are handled,
In addition to actual dangerous car- eating and smoking should be avoided,
goes, there may be other hazardous or even if there is no risk of fire.
harmful chemicals on board, for example,
fuels, lubricants, detergents, solvents, 3 Symptoms of poisoning
paints, disinfectants (e.g. chlorine), and and their appearance
the chemicals found in refrigeration equip-
ment. These may involve health risks in ir- The health effects of poisonous substances
regular conditions or if handled carelessly. may be local or general reactions. Irritation
It is life-threatening to visit or to work or even local corrosion (skin, eyes, mucous
without appropriate protective equip- membrane) may appear at the contact site.
ment in premises where, for example, the Gases have the same effect on the respi-
fermentation process of timber cargo has ratory tract. Allergic reactions or central
caused a lack of oxygen, or where gas nervous system effects are common.
emissions displace oxygen. The effect of a dangerous substance
may be immediate or delayed. Usually the
effect of a gaseous substance appears im-
mediately, whereas the effects of substances
45
II Accident injuries and their treatment
46
II Accident injuries and their treatment
Oral poisoning is treated with fine- breathing difficulties. Often also water-
grained medicinal charcoal (8/D) mixed ing or smarting eyes or nose are common
in water. The initial dose is 50 g taken all symptoms.
at once. Thereafter medicinal charcoal 25 The lack of oxygen, and carbon
g is given every 4 hours, until the patient monoxide poisoning causes malaise, head-
has recovered. Using charcoal tablets is ache and dizziness. Intense or prolonged
difficult, and they should not be used if exposure leads to unconsciousness and
powdery medicinal charcoal is available. convulsions.
The action of medicinal charcoal is based The basic guidelines are the same as
on its wide absorption surface, which in all poisoning cases: the rescuer’s own
binds poisonous substances several times protection is of prime importance before
its own weight. saving others. The exposed patients must
In general, medications that induce be transferred to fresh air as soon as pos-
the patient to vomit should not be used at sible. If necessary, the patients’ breathing
all in poisonings. may be aided by giving oxygen.
A drug which opens up the bronchi is
7 Hastening the often a useful aid in alleviating breathing
excretion of a difficulties. First, two sprays of salbutamol
poisonous substance (6/A) are given twice at 15 minute intervals,
and reversing its effect then two sprays 4–6 times a day. If chemi-
cal pneumonia is suspected, it is necessary
After absorption, poisonous substances to start cortisone medication (consult a
leave the body mainly through elimination doctor via Radio Medical). The patient’s
by the liver or through secretion into the condition is monitored carefully, until
urine via kidneys. The elimination of the it is certain that there will be no further
poison may be speeded up by increasing complications.
urinary excretion, by giving the patient flu-
ids to drink and a diuretic (furosemide, 1/C), 9 Swallowed poisonous
either one 40 mg tablet or a 2 ml intramus- substance
cular injection. In severe cases of poisoning,
it is justifiable to start intravenous fluid infu- Substances are corrosive if their pH is be-
sion therapy. Thus, if the patient’s condition low 2 (strong acids), or above 12 (strong
deteriorates, there is an already open blood alkalis, such as washing machine deter-
vessel connection through which to give gents). They cause immediate symptoms,
drugs and possible antidotes. for example, pain and burns in the area of
the mouth, pharynx and oesophagus. The
8 Inhaled substances and symptoms in the alimentary tract caused
what to do in gas by most swallowed substances are at first
poisoning minor and worsen only gradually.
The symptoms in the alimentary
Combustion gases, like carbon dioxide, tract (stomach pain, vomiting, diarrhoea)
carbon monoxide and nitrogen com- may be the first signs of any swallowed
pounds, are common causes of poisoning substance that is dangerous to health.
through the lungs. Several chemicals may Central nervous system symptoms, such
irritate and damage the respiratory tract as malaise, dizziness, confusion or un-
as they evaporate (e.g. chlorine). The ir- consciousness, may appear later. Heart
ritation symptoms of the respiratory tract and kidney symptoms are also possible
are coughing, secretion of mucus, and (arrhythmia, lowered urine excretion, for
47
II Accident injuries and their treatment
48
II Accident injuries and their treatment
and death related to alcohol intoxication overdoses, the use of medicinal charcoal
is often caused by depressed breathing is recommended even hours after the drug
induced by the drugs. has been taken.
Injuries related to drunkenness may
decrease the level of consciousness. In Carbon monoxide and
that case, it is difficult to distinguish which carbon dioxide
symptoms are caused by alcohol intoxica- Carbon monoxide is an ordinary gas which
tion and which by the injury. is formed in connection with burning.
It is odourless, colourless, tasteless and
Methanol and ethylene glycol lighter than air. The symptoms related to
Methanol, that is, methyl alcohol, disin- carbon monoxide poisoning are malaise,
tegrates in the body into more noxious headache, a feeling of weakness, and ar-
substances, causing, for example, dete- rhythmia. The symptoms result from the
rioration of eyesight, and in large doses, fact that carbon monoxide prevents the
permanent blindness. A dangerous dose transportation of oxygen by the blood,
is as small as 50–60 ml of pure methyl thus causing a lack of oxygen in the body.
alcohol! If methyl alcohol poisoning is High concentrations of carbon monoxide
suspected, the patient must be transported are soon followed by unconsciousness
to hospital as soon as possible. and death. First aid consists of preventing
Ethylene glycol, which is used to further exposure and moving the patient to
prevent corrosion and as an antifreeze, fresh air. Oxygen is given, if necessary.
may cause damage to the kidneys, if con- Carbon dioxide is formed in all burn-
sumed orally. A dangerous dose is 100 ing processes. It may also develop, for ex-
ml, and its effect appears a few days after ample, as a result of the slow fermentation
drinking it. process of a timber cargo. Carbon dioxide
In the case of both methanol and gas is heavier than air, and it therefore
ethylene glycol poisoning, it is necessary displaces the air in closed premises, for
to contact a care unit via Radio Medical. example, in the lower parts of the cargo
Drinking ordinary alcohol slows down the hold. Carbon dioxide poisoning is treated
disintegration of the poisonous alcohols in the same way as carbon monoxide
into more noxious products, and thus, it poisoning.
may be used as a first aid in methyl alcohol
and ethylene glycol poisoning. Hydrochloric acid
Splashes of diluted hydrochloric acid cor-
Drug poisoning rode the skin and the eyes, and undiluted
The most common drugs causing poisoning hydrochloric acid also irritates as a vapour.
are mood and sleeping medications affect- Like other acids, hydrochloric acid reacts
ing the central nervous system (CNS). Their strongly with alkalis, forming poisonous
overdoses result in fatigue and doziness. gases. First aid consists of rinsing with
Large overdoses additionally cause un- water, if the acid has been splashed on
consciousness or convulsions. Overdoses the skin or eyes.
of pain killers that affect the CNS may,
especially if taken together with alcohol, Sulphuric acid and nitric acid
cause breathing to stop. Large overdoses of If undiluted, sulphuric acid and nitric acid
ordinary pain killers and fever medications are very corrosive. Sulphuric acid evapo-
may cause intestinal bleeding a few days rates already at low temperatures, forming
after taking the drug. Similarly, paraceta- gases that irritate the eyes and respiratory
mol may damage the liver. In the case of tract. Nitric acid decomposes into nitric
49
II Accident injuries and their treatment
oxide which, at low levels of exposure, ir- Chlorine as a solution causes severe cor-
ritates the eyes and respiratory tract, and at rosion of the eyes, and irritation and burns
high levels of exposure, causes breathing on the skin.
difficulties as well. Delayed pneumonia If there is chlorine on the skin, it must
may result from exposure to nitric gas, and be rinsed and then treated like a burn. A
may appear even as late as a few weeks patient exposed to chlorine gas is given oxy-
after exposure. gen and medication that dilates the bronchi
(salbutamol, 0.2 mg/ spray, 6/A, 1–2 sprays
Hydrofluoric acid three times a day) if necessary.
Strong hydrofluoric acid evaporates easily,
and large amounts of it cause severe cor- Ammonia
rosion to the skin and mucous membrane. Ammonia gas is irritating at small concen-
Even small amounts are irritating. Splashes trations, but at very high concentrations, it
of strong hydrofluoric acid cause immedi- may cause the airways to swell up and be-
ate deep corrosion injuries, while less than come blocked in a few minutes. Liquid am-
20% acid causes local symptoms hours monia causes severe corrosion of the eyes
after the exposure has ended. and burns on the skin. The patient must
First aid consists of rinsing the acid be moved to fresh air. To overcome severe
off the skin as carefully as possible, and breathing difficulties, adrenaline (8/A) is
applying a thin layer of calcium gluconate given 1 mg/ml as a 0.5–1.0 ml intramus-
gel (see MFAG) to the injured area, until cular injection, or subcutaneously. In the
the pain is alleviated. If the injured area is case of less severe symptoms, medication
larger than the size of a palm, the patient to dilate the bronchi is given (salbutamol,
should be quickly transferred to hospital 6/A, 1–2 sprays three times a day).
for treatment on shore.
Cyanides and hydrogen cyanide
Phenol Both gaseous hydrogen cyanide and solid
Phenol vapours irritate the mucous mem- cyanides are extremely poisonous, and
brane, and a stronger than 5% solution absorb easily through the skin. Cyanide
is also corrosive. Phenol is also absorbed compounds rapidly cause apnoea and
through the skin, causing severe poisoning, convulsions. Small concentrations may
convulsions and symptoms of shock. Treat- cause symptoms such as rapid breathing,
ment consists of rinsing the injured area numbness of the limbs, headache and
carefully with water, and then washing with malaise. Cyanide solutions corrode the
polyethylene glycol solution (see MFAG). skin. The patient is given oxygen and is
placed in a resting position. If amyl nitrite
Chlorine ampoules are available (see MFAG), one
Chlorine gas has a typical pungent smell. ampoule is broken onto a gauze bandage,
At small concentrations, it irritates the which is then placed inside an oxygen
mucous membranes, thus contracting mask, through which the patient breathes
the bronchi. At very high concentrations, in the substance.
chlorine gas may cause sudden apnoea.
50
II Accident injuries and their treatment
THEIR TREATMENT
17 Headache, and pain in the head region
18 Vertigo
19 Alteration of consciousness and seizures
20 Eye problems and symptoms
21 Illnesses of the ear and the throat
22 Problems of the mouth and the teeth
23 Chest pain and cardiovascular diseases
24 Difficulty in breathing
25 Diseases of the airways
26 Vomiting, fever and diarrhoea
27 Constipation and haemorrhoids
28 Abdominal pain
29 Obstetrics and gynaecological disorders
30 Symptoms of the lower abdomen and acute
diseases of the urinary organs
31 Sexually transmitted diseases (STD)
32 Dry and itchy skin
33 Rash
34 Protective gloves and protective skin ointments
35 Joint and muscle pain
36 Mental disorders
37 Alcohol and drugs
38 Infectious and contagious diseases
39 Diabetes
51
III Symptoms and diseases and their treatment
52
III Symptoms and diseases and their treatment
who is allergic to acetylsalicylic acid can aura a one-sided headache begins, and the
be given only paracetamol (3/A). If nausea patient usually seeks bed rest. Migraine
makes dosing orally difficult, a nausea- is very often accompanied by nausea, at
inhibiting suppository can be given first times by vomiting, and occasionally even
(metoclopramide hydrochloride, 2/C). by diarrhoea. The patient is sensitive to
Strong painkillers that affect the light, sounds and smells.
central nervous system, such as morphine A migraine attack can last for as
(3/C) should normally not be used to treat long as three days, during which time the
headache. patient may be more or less in bed and
almost completely incapacitated. In most
3 Types of headache cases the patient him/herself recognizes
the headache as migraine.
Tension headache A milder onset of migraine can be
Tension headache is one of the most treated with painkillers. If nausea makes
common types of headache. The pain is dosing orally difficult, another option
continuous, constricting, pressing or felt as is to give the medication as a supposi-
a tight band across the forehead, but not tory together with a nausea-inhibiting
pounding. It can be accompanied by short suppository. In some migraine patients,
stabbing sensations and tender areas on the ergotamine suppositories help to alleviate
top of the head. No nausea or vomiting is severe attacks.
associated with the pain, nor any marked
sensitiveness to light. The pain is usually Headache caused by chemicals
relieved or vanishes altogether when the Many chemical and medical substances
patient exercises. The pain can last from a and stimulants can cause headache. Such
few minutes to several hours or even days. substances include:
A hot compress or massage usually aggra- • alcohol (hangover)
vates the situation, but a cold compress on • caffeine (withdrawal symptom)
the neck may relieve the symptoms. • substances containing nitro (1/A)
• monosodium glutamate (‘the Chinese
Migraine restaurant syndrome’)
A migraine attack can be preceded by • drugs, withdrawal symptoms (can-
tiredness, lethargy or even over-active- nabis)
ness, which may last from a few hours to • carbon monoxide
a couple of days. Many patients suffering • pain killers when used in high doses and
from migraine see sharp-edged zigzag for a long time.
images of light before or at the onset of an
attack. Such a preliminary feeling, a so- The most well-known is probably the
called aura, can also be felt as numbness hangover induced headache after mild al-
of the arm and/or hand, or the cheek, or as cohol poisoning, and the headache which
difficulties in speaking and finding words. results from suddenly giving up coffee after
A patient with migraine may even experi- normally drinking five cups a day. All these
ence temporary paralysis on one side, in headaches are circulatory, worsen with
which case it is difficult to differentiate movement, and are throbbing in nature.
between migraine and a transient cerebral They are often accompanied by nausea
haemorrhage. Usually some time after the and weakness.
53
III Symptoms and diseases and their treatment
54
III Symptoms and diseases and their treatment
18 Vertigo
Vertigo is a fairly common symptom in all The basic examination includes taking the
age groups, and may be related to many patient’s blood pressure, and examining
different illnesses. It is a functional disorder the eye movements and how the pupils
of the sense of balance. The sense of bal- react to light.
ance is based on information from three
basic systems: the vestibular organ of the 2 Treatment
inner ear, the proprioceptors of the striated
muscles of the neck and spine (positional A sudden spell of vertigo can be treated
sense), and the eyes. with 10 mg of metoclopramide hydro-
Vertigo means uncertainty in be- chloride (2/C) in the form of a 10 mg pill
ing able to stand, a falling sensation, or a or injection three times a day, or with a 20
feeling that the world is spinning around. mg suppository of the same. In the treat-
Sometimes it is clearly related to positional ment, and especially in the prevention of
changes or to a particular position. Turn- motion sickness, cyclizine hydrochloride
ing the head can cause vertigo, as can (4/C) is used. The treatment of position- and
suddenly rising from a bent-over position, movement-related vertigo is to avoid the
or from bed. Vertigo can be accompanied particular movement or position causing
by nausea and vomiting, and sometimes a the vertigo. Changes in position should be
ringing in the ears. In most cases vertigo made more slowly than before.
will stop on its own after a while. If the
vertigo does not end despite treatment, or 3 Causes of vertigo
is related to disruptions of consciousness
or headache, it may be a symptom of some Sea sickness
more serious condition. Sea sickness is the most common cause of
rotation vertigo. It is often accompanied
by nausea and vomiting. The cause is the
● Consult a doctor via Radio
Medical if continuous swinging and rocking motion
of a ship, resulting in a state of irritation of
• vertigo is related to disruptions of
the inner ear and sense of balance.
consciousness or headache
• vertigo continues despite medical Positional vertigo
treatment.
Positional vertigo manifests a few seconds
after a change of posture as a short attack
1 Examination of vertigo lasting less than a minute. The
patient has the symptoms in clear phases
Interviewing the patient helps in making from a few days to a week, and they have
the diagnosis. Motion sickness is related a tendency to recur.
to repeated back-and-forth motions. Ver- The treatment is to repeat the motion
tigo experienced when getting up from a causing the symptoms a few times. This
bent position or from lying down can be usually lessens the symptoms. Medical
explained by low blood pressure; the cer- treatment is seldom necessary.
ebral circulation is momentarily weakened
and causes a passing state of vertigo, even
a brief blackout.
55
III Symptoms and diseases and their treatment
Ménière’s disease
Ménière’s disease is caused by a defect in feeling of uncertainty when walking, or
the inner ear. Its symptoms include rather unsteadiness when moving one’s head.
severe vertigo and nausea usually lasting This is usually manifested when the line of
for hours. Hearing is weakened in the in- sight is directed to a different direction than
flicted ear, and tinnitus (ringing in the ear) the motion. Physiotherapy in the form of
is often experienced as well. massage of the neck and shoulder muscles
usually helps the patient.
Infection of the vestibular organ
Infection of the vestibular organ is a viral Ataxia
infection that may follow e.g. a respiratory Ataxia is a falling sensation or a rocking
infection. The symptoms are a sudden motion that usually originates in the brain.
spinning vertigo, nausea and vomiting. The most common cause is a disruption of
The condition passes on its own after a cerebral circulation. This results in a lack of
few days or weeks. oxygen in the brain, or a cerebral infarction
(stroke). Sometimes an epileptic seizure
Dizziness may manifest as vertigo. It is important to
The most common cause of vertigo is transfer the patient for further examination
tenseness in the muscles of the neck and so that the primary cause of the symptoms
shoulders. Vertigo is experienced as a can be found and treated.
19 Alteration of consciousness
and seizures
56
III Symptoms and diseases and their treatment
57
III Symptoms and diseases and their treatment
blood sugar level is suspected, as a too the seizure does not end within a few min-
high level of blood glucose is less harmful utes, the treatment can be repeated. If the
than a too low level. situation does not resolve itself, a doctor
If the patient responds to pain and should be consulted via Radio Medical.
attempts to open his/her eyes in a normal
way, the unconsciousness may be psycho- 4 Causes of loss of
logical in origin. No treatment is needed, consciousness
but 5 mg of diazepam (4/A) as an intramus-
cular injection is recommended. The most common causes of sudden dis-
Headache and vomiting, neurological ruptions of consciousness are
symptoms, disturbances in equilibrium, • sudden fainting
and functional disorders of the limbs, • decreased blood glucose levels
associated with symptoms of disruption • a fit of epilepsy
of consciousness indicate a severe dis- • psychological factors
turbance of the central nervous system. • a cerebral circulation disorder
Consulting a doctor through Radio Medi- • unconsciousness caused by an injury
cal is recommended. • poisoning.
The patient should be kept at rest.
As first aid for nausea, metoclopramide Sudden fainting
hydrochloride can be given as a sup- Fainting is the most common form of dis-
pository or an intramuscular injection, or ruption of consciousness. It is caused by
prochlorperazine as a suppository. Even a lack of oxygen in the cerebral cortex,
if the patient is in pain, morphine should which may be due to, e.g. distress or be-
not be given, as it can interfere with the ing upset, strong stress, staying up late, a
patient’s breathing. In case of seizures, hangover, or e.g. the sight of blood. Some-
5–10 mg of diazepam (4/A) can be given times fainting can be related to urinating,
intravenously or intramuscularly, but also defecating, or a fit of coughing.
diazepam can have an adverse affect on
breathing. Unconsciousness due to
low blood glucose level
Unconsciousness caused by a low level of
● A patient with symptoms of cerebral
palsy should be moved to shore for blood glucose is almost always connected
further treatment as soon as possible. with diabetes that requires insulin treat-
ment. Fluctuations in blood glucose levels
do not cause unconsciousness in healthy
If the unconsciousness is accompanied by individuals. Before losing consciousness,
seizures, the patient’s movements should the patient is often disoriented, sweaty,
not be restrained. Instead, the patient restless and shaky, and his/her skin is cold
should be placed in a safe location, and and clammy to the touch. When the blood
he/she should be protected from falling glucose level falls, the patient may have sei-
or hurting him/herself. It is of no use to try zures. The blood glucose should always be
to place something between the patient’s measured from an unconscious patient.
teeth. The patient can be given diazepam
(4/A) either as an injection into the vein (2 Hysteria
ml slowly; can cause respiratory arrest!) or Unconsciousness resulting from psycho-
as an intramuscular injection. The treat- logical causes is often very dramatic and
ment will not affect the on-going seizure, complex, and can be associated with
but may prevent onset of the next one. If fussing and seizures. Such an episode
58
III Symptoms and diseases and their treatment
usually takes place when other people haemorrhage include severe headache
are present. Commonly it is also ‘soft’, and nausea. The neck is typically very stiff.
which means that the patient falls, as by Unconsciousness occurs often. Usually the
accident, on top of a bed or other soft symptoms of paralysis are minor, but the
surface. The type of attack has usually patient feels unwell and often vomits. The
been learned from the person’s immediate patient should be transferred for further
social environment, e.g. a friend who suf- treatment immediately!
fers from epilepsy. During the attack, the
patient reacts to pain and opens his/her 5 Seizures
eyes in a normal way. For instance, an
attempt to intubate immediately ‘cures’ If the patient has seizures, care should be
the patient. Any possible further treatment taken that he/she does not hurt himself.
should be psychological in nature. Seizures can be caused by misuse of al-
cohol, drugs, a brain tumour, encephalitis,
Unconsciousness due to cerebral a disruption in cerebral circulation, or a
circulation disorders congenital defect in the brain. As soon as
Unconsciousness that is related to cer- the immediate situation has been resolved,
ebral circulation disorders and cerebral the patient should always be transferred to
haemorrhage is a sign of a serious condi- a doctor for further examination.
tion. It is usually connected with cerebral An epileptic seizure can begin with
thrombosis (stroke) or some other serious a presaging feeling (aura). When the
neurological syndrome. The patient should seizure starts, loss of consciousness is
always be transferred for further neurologi- instantaneous and all muscles are tensed
cal examination. in a tonic spasm. At the same time, air is
A disruption of the cerebral circula- often expelled from the lungs, resulting
tion usually causes disturbances in equi- in a screaming utterance. Breathing stops
librium. There may be functional disorders and the patient turns blue. This phase
in the limbs on both sides, in addition to usually lasts for a few seconds. After this
unconsciousness. Cerebral haemorrhage the twitching phase begins: the patient’s
can in the beginning cause seizures, muscles twitch back and forth, foam often
unconsciousness, headache and vomit- comes from the mouth and it may be red in
ing. The symptoms may diminish on their colour if the patient bites his/her tongue or
own, but the paralysis may be permanent. cheek. Urine and, sometimes, faeces can
Consulting a doctor via Radio Medical is be released. During the seizure the patient
recommended. A patient with symptoms of does not react to pain. After this, the patient
paralysis should be transported for further slowly returns to consciousness. This takes
treatment as soon as possible. a few minutes.
Cerebral haemorrhage can be initi- In the case of status epilepticus, the
ated by strong exertion (intercourse, lift- seizures follow one after the other with no
ing or pushing a heavy burden). In such returning to consciousness between them.
cases the wall of a blood vessel in the This is always a life-threatening condition,
brain ruptures and causes a sudden onset and the patient must be transferred for fur-
of symptoms. The symptoms of cerebral ther treatment as soon as possible.
59
III Symptoms and diseases and their treatment
60
III Symptoms and diseases and their treatment
a day. For the night the same medication 5 Redness and itching
can be applied as an ointment. The treat- of the eye
ment is continued for 2 to 3 days after the
symptoms have vanished. One-sided redness, itching and a change in
Itching together with swelling and the ability to see with the affected eye may
redness of the conjunctiva are typical be caused by an acute rise in intraocular
symptoms of an allergic infection of the pressure, infection of the iris, or a wound
conjunctiva. The eyes are usually free on the surface of the cornea. Because the
of any discharge. The symptoms can be cause may also be a serious eye disease,
relieved with eye drops that constrict the consulting a doctor through Radio Medical
blood vessels (tetrahydrozoline hydrochlo- is recommended.
ride, 10/A). However, these are not suitable
for long-term use. The allergic symptoms Acute rise in intraocular pressure
of the eyes can also be relieved by admin- A sudden rise in intraocular pressure is
istering 10 mg of cetirizine hydrochloride related to severe pain in the eye and blood-
(5/B) once a day. shot eyes. The cornea of the eye becomes
clouded causing the vision in that eye to
4 Red eyes weaken. The pupil is dilatated and does
not contract in light. The patient is often
Unusual redness of the conjunctiva can nauseous and vomiting.
be caused by dilated blood vessels. If the As first aid, eye drops containing pilo-
eyes are bloodshot, but there are no other carpine hydrochloride (10/D) are adminis-
marked symptoms of the eyes, it is most tered every 10 minutes to make the pupil
likely that irritation is the cause of the contract. Medication for pain and nausea
dilation of the blood vessels. For instance, can be given if necessary. The patient is
tobacco smoke or a dusty environment instructed to see an ophthalmologist for
may be the reason for bloodshot eyes. No further examination and treatment as soon
treatment is required, but the symptoms as possible. Consulting a doctor through
can be temporarily relieved with eye drops Radio Medical is recommended.
that constrict the blood vessels (e.g. tet-
rahydrozoline hydrochloride, 10/A). Sudden infection of the iris
By rubbing the eye, or during a fit The symptoms of a sudden infection of
of coughing, or even without any obvi- the iris are one-sided redness, dull pain
ous reason, one of the fine blood vessels in the eye area, pain in the eye itself,
beneath the conjunctiva can rupture, fuzzy vision and sensitivity to light. Bright
causing haemorrhage. A clear, evenly red, light increases the pain. The pupil of the
asymptomatic pool of blood can be seen inflicted eye may be smaller.
on the conjunctiva. This one-sided pool of If untreated, infection of the iris will
blood will vanish on its own and requires lead to severe eye complications. The pa-
no treatment. The blood will be absorbed tient should be referred to an ophthalmolo-
within one or two weeks. gist for further examination and treatment
when ashore. Conculting a doctor through
Radio Medical is recommended.
61
III Symptoms and diseases and their treatment
62
III Symptoms and diseases and their treatment
63
III Symptoms and diseases and their treatment
When the infection is in the middle In frontal sinusitis, the forehead is locally
ear, the tympanic membrane appears red- sore and sensitive to touch.
dish, dull and swollen when inspected If the mucous membrane in the nose
with an ear lamp. On the other hand, if is swollen, it can be eased with a nasal
the auditory canal is discharging, reddish solution (xylometazoline, 6/D): one squirt
and swollen, it is a case of an infection of into the nostrils four times a day, but this
the auditory canal. treatment should not be continued for
The treatment for infection of the more than 10 days. If the symptoms are
auditory canal is ear drops containing severe and the spray does not help within a
flumethasone-clioquinol (11/A). If the couple of days, antibiotic treatment should
condition is prolonged, and changes can be started: doxycycline (7/B), a 150 mg
be seen on the tympanic membrane of the tablet is given once a day for 7–10 days.
afflicted ear, treatment with an antibiotic
drug should be started. A 150 mg tablet of 8 Nosebleed
doxycycline is given once a day for 7 to
10 days. Pain-relieving ear drops (11/B) are The most common causes of nosebleed are
poured into the auditory canal to ease the injury, infection, or rupturing of the blood
pain: 8 drops are dropped into the auditory vessels in the mucosa of the nose (e.g. due
canal every 4 hours while the patient is ly- to picking the nose). Most often the bleed-
ing on his side. Orally administered pain ing originates from the upper front part of
medication helps to ease the symptoms. the nasal canal. The wound can often be
Pain in the ear region can also be seen when looking into the nose (an ear
caused by an illness that is not related lamp is useful for this purpose).
to the ear in itself. One-sided pain in the First aid consists of bending the pa-
throat can radiate to the ear. The jaw joint tient forward, which prevents the blood
is located immediately in front of the ear. from flowing into the throat. Constant
Pain in the joint can be perceived as a pressure is applied to the side of the bleed-
problem in the ear. Infections of the sali- ing nostril. A cold pack on the neck can
vary glands can cause pain in the ear area also help by constricting the blood vessels
as well (e.g. in mumps). in the nose. This in turn helps to stop the
Problems with the teeth and tension bleeding.
in the neck and shoulders can also be ex- Constant pressure on the nostril for 15
perienced as pain in the ear region. to 20 minutes is usually sufficient to stop
the bleeding.
7 Pain in the region of If the bleeding does not stop, a cotton
the cheek bones wad dampened with nasal solution (6/D)
can be placed inside the nostril. It is kept
A feeling of pressure and congestion in the there for 5 minutes and then removed. If
cheek-bone region can be caused by a bad the bleeding has stopped, a cotton wad
cold or by maxillary sinusitis. It is often soaked in bacitracin ointment (9/D) can be
impossible to tell the difference between placed in the nostril for one or two days.
the two without laboratory tests. If the bleeding does not stop despite
The symptoms of maxillary sinusitis the above procedures, the cause can be
are a runny or blocked nose, cough, local a wound further back in the nose canal
pain or soreness of the cheek, nasalization or in the nasopharynx. There may be a
of the voice, tiredness, headache, sensa- great deal of blood in the nasopharynx.
tion of pressure around the cheek bones, Consulting a doctor via Radio Medical is
and the flowing of mucus into the throat. recommended.
64
III Symptoms and diseases and their treatment
65
III Symptoms and diseases and their treatment
exposed, pain medication may be neces- symptoms are foul breath and bleeding of
sary because of the stabbing pain. The the gums in connection with brushing. A
nature of futher treatment given by a dentist prolonged infection leads to decay of the
depends on the severity of the damage. attachment apparatus, loosening of the
teeth, and finally their detachment. The
5 Infected gum prevention and treatment of this infection
on board includes careful brushing of the
If the teeth are not brushed regularly, tartar teeth and cleaning of the spaces between
collects on the surface of the teeth and the teeth with a tooth pick or tooth floss.
may cause an infection of the gums. The Further treatment is done by a dentist.
66
III Symptoms and diseases and their treatment
67
III Symptoms and diseases and their treatment
68
III Symptoms and diseases and their treatment
If repeated blood pressure measure- striated swelling under the skin, usually
ments, carried out unhurriedly in a peace- on one leg. There is local redness on the
ful environment, show a systolic pressure skin, and the patient’s temperature may be
of > 150 mmHg and a diastolic pressure slightly elevated. Phlebitis is most often
of > 90 mmHg, the patient may need harmless, and sufficient treatment is a
antihypertensive medication and should painkiller. In addition, a cold compress can
be referred for further care. However, the be applied to ease the symptoms.
first step is to pay attention to both dietary
intake and life-style. The patient should eat Deep venous thrombosis
less salt, lose weight, exercise, stop smok- An occlusion, caused by a blood clot, may
ing and drink less alcohol. Also stress can develop in the deep veins of the calves.
raise blood pressure. Predisposing factors are, for example, the
The patient may suffer from a hyper- sedentary position of a leg when in a plaster
tensive crisis or severe elevation of blood cast, a long bed rest e.g. after an operation,
pressure when the diastolic pressure a long trip in an aeroplane, and smoking.
repeatedly exceeds 120 mmHg, and if The symptoms of deep venous throm-
he/she also has headache, convulsions, bosis include unilateral pain and swelling
stroke symptoms or symptoms of conges- which develops during several hours or
tive heart failure. In addition, the patient days, difficulty in walking, and soreness
may be confused and drowsy. A hyperten- of the calf when pressed gently. Usu-
sive crisis can progress rapidly and may be ally the affected calf is warmer than the
fatal. Radio Medical should be consulted healthy one. Superficial veins may be
about the treatment aboard ship, and the markedly visible, and the whole limb
patient must be transported to a hospital may be flushed. The higher the thrombosis
as soon as possible. reaches, the more swollen the limb is. The
most severe consequence of a deep venous
Low blood pressure thrombosis is pulmonary embolism, which
Low blood pressure or hypotension as is often life-threatening.
a single finding is harmless in a healthy First aid includes elevating the leg
person and requires no medical attention. and resting it. Give three acetylsalicylic
If there are additional problems, such as acid tablets (3 x 100 mg, 1/B) if the patient
chest pain or an allergic reaction, the is not allergic to this drug. It is forbidden
condition may lead to shock. In that case, to massage the leg. Consult a doctor via
urgent medical attention is required. Radio Medical. A patient suspected of
suffering from deep venous thrombosis
Diseases of the venous circulation always requires examination by a doctor
Superficial varicose veins can be seen as and treatment in a hospital.
dilated and tortuous veins on the calves
and thighs. Varicose veins are treated with Pulmonary embolism
surgical stockings and bandages. Elevating Sometimes blood clots are detached from
the limb eases the symptoms temporarily. the deep venous thrombosis. The clots
Surgery is the treatment of choice for most are transported by the blood stream to the
patients. heart and lungs where they block pulmo-
nary vessels.
Superficial venous inflammation The symptoms of pulmonary em-
Superficial venous inflammation, phle- bolism are sudden or rapidly worsening
bitis, is usually related to varicose veins. shortness of breath, chest pain, tachycar-
Phlebitis can be felt as tender, warm and dia, low blood pressure, cold, clammy and
69
III Symptoms and diseases and their treatment
24 Difficulty in breathing
70
III Symptoms and diseases and their treatment
abdominal thrusts, the so-called Heimlich the breathing difficulty and the required
manoeuvre. If this fails, try to remove the treatment can vary significantly. Therefore,
foreign object with the fingers (see Chapter consulting a doctor via Radio Medical is
2 Foreign object in respiratory tract). often necessary.
Pulmonary auscultation should be per-
2 Breathing difficulties formed, because a condition that has devel-
within minutes oped within hours usually does not require
immediate care. Special attention should be
Anaphylactic or allergic reaction paid to the breath sounds during inhalation
Narrowed airways may result from an and exhalation. The sounds of breathing
allergic reaction, which is always treated should be similar in both lungs. If they
with 0.5–1.0 ml of adrenaline (1 mg/ml, differ, there is something wrong. If breath
8/A) administered subcutaneously. If shock sounds cannot be heard at all from one of
is developing, adrenaline can be injected the lungs, this is a sign of an inflammation
directly into the tongue to hasten absorp- or a collapsed lung (pneumothorax).
tion (see Chapter 4 Shock). After this, 2 A difference in the breath sounds
ml of hydrocortisone (125 mg/ml, 5/C) between the left and right lung is always
is administered either intramuscularly or a sign of an abnormality. A doctor should
intravenously. be consulted via Radio Medical.
Possible chest pain can be identified
Asthma attack by gently pressing and tapping the chest
Difficulty in breathing may be caused by area. Chest pain may explain symptoms
an asthma attack. The patient’s breathing such as difficulty in breathing, e.g. due to
becomes wheezing as he/she breathes out a fractured rib.
and, in a severe attack, he/she can speak
only with difficulty. First, have the patient Pneumonia or inflammation
inhale salbutamol aerosol (0.2 mg/spray, 6/ of the pleural sack
A) 1–3 sprays. Second, administer 125 mg The signs and symptoms usually include
of hydrocortisone (125 mg/ml, 5/C) intra- fever, cough, increased secretion of
muscularly at 4-hour intervals, if necessary. phlegm, and one-sided chest pain. The
Third, if the condition does not improve, condition is treated with an antibiotic,
give 0.5 mg of adrenaline (1 mg/ml, 8/A) phenoxymethylpenicillin (660 mg / tablet,
subcutaneously. Finally, consult a doctor 7/A), at a dose of one tablet three times a
via Radio Medical. day. The patient who is allergic to penicillin
can be given doxycycline (7/B), one 150
3 Breathing difficulties mg tablet daily, for 10 days. In addition,
developed within hours medication can be given to ease pain and
fever. Consult a doctor via Radio Medical
Slowly developing difficulty in breathing if pneumonia is suspected.
can be caused by an inflammation or a
collapsed lung. Cardiovascular causes Spontaneous pneumothorax
are, for example, heart attack and conges- Pneumothorax can occur spontaneously
tive heart failure. Hyperventilation, i.e., without an identifiable reason. However, it
unnaturally fast and deep breathing, is a is often caused by a trauma, for example, a
common manifestation of psychic disor- fractured rib. The broken bone can injure a
ders, like panic attacks. Hyperventilation lung and allow air to escape into the pleu-
can also resemble a condition in which ral sack. As a result, the lung collapses.
the body lacks oxygen. Thus the cause of
71
III Symptoms and diseases and their treatment
72
III Symptoms and diseases and their treatment
73
III Symptoms and diseases and their treatment
74
III Symptoms and diseases and their treatment
75
III Symptoms and diseases and their treatment
76
III Symptoms and diseases and their treatment
continued for four days after the symptoms vomiting, which is a typical sign of food poi-
have disappeared. soning. Other symptoms include nausea, fa-
The patient’s condition must be moni- tigue and general malaise. The sudden onset
tored carefully. Preventing dehydration is of the disease and strong symptoms includ-
essential in the treatment of diarrhoea. If ing CNS symptoms make food poisoning a
diarrhoea persists or the symptoms are se- particularly serious event if, for example, the
vere, consult a doctor via Radio Medical. entire crew responsible for controlling the
Part of the microbes which cause ship fall ill at the same time.
diarrhoea may remain in the body. The
patient may be symptom-free, but can still Salmonella
spread the disease. That is why people who Diarrhoea can be caused by salmonella
handle unpacked food products must be bacteria as they grow on the inner surface
sent for laboratory tests after an episode of the intestines. Faeces are also contami-
of diarrhoea. nated with salmonella bacteria and if the
patient ignores personal hand hygiene,
4 Illnesses causing other people are in danger of infection.
diarrhoea The clinical picture ranges from
symptom-free disease carrying to poison-
Viral diarrhoea ing with a wide range of symptoms. Com-
It is typical to viral diarrhoea that people mon symptoms are diarrhoea, vomiting
fall ill one by one on successive days, as and possibly fever. The time between
the infection spreads from one person to becoming infected and the appearance
another. The incubation time, i.e. the time of symptoms (incubation time) is 12−24
from infection to the appearance of symp- hours. The symptoms disappear in 2−5
toms, of viral diarrhoea is usually 1−2 days. days. Even if the symptoms usually disap-
The symptoms include sudden, intense pear spontaneously within a few days, the
vomiting, watery diarrhoea, and possibly patient may remain a disease carrier for a
fever. The infection is over in 1−2 days. long time. In other words, the patient may
Viruses can spread via droplets spread a contagious disease even if he/she
without contaminated food or water. Vi- is symptom-free. Therefore, the patient
ral infections spread easily aboard ship, should give a stool sample to verify the
because people live close to each other. absence of the disease at the latest when
Widespread diarrhoea epidemics may oc- he/she returns home. This is particularly
cur particularly on a passenger ship where important if the patient has handled un-
the infection spreads among the passengers packed food products.
and the crew.
Shigella
Food poisoning Shigella is a bacterial inflammation of
The so-called yellow staphylococcus the intestines. It is transmitted via food or
bacteria thrives in heat-processed and water contaminated by faeces. Salads are
salted foods, like smoked fish and ham. common sources of the infectious agents
As the bacteria grow, they secrete toxins when travelling abroad. Shigella bacteria
which cannot be removed by cooking or produce toxins in the intestines, causing
heating. severe bloody diarrhoea and fever. Intes-
Symptoms appear ½−8 hours after tinal cramps and pain are also typical.
the meal, and usually disappear in about However, vomiting is not a usual symptom.
24 hours. The toxins have a direct effect on The incubation period is 1−4 days.
the central nervous system (CNS) causing
77
III Symptoms and diseases and their treatment
Causes 2 Haemorrhoids
The most common causes of constipa- Haemorrhoids (or piles) are abnormally
tion are lack of exercise and inadequate enlarged veins in the walls of the rectum
fibre and fluid intake. Also medications and anus. Internal haemorrhoids are situ-
or organic changes, such as tumours, can ated on the bowel side of the sphincter
sometimes cause constipation. muscle and appear only when straining to
defecate. External haemorrhoids are found
Treatment in the region of the sphincter muscles and
In temporary constipation, medication can can normally be seen protruding from the
be used to stimulate bowel movements. The anus as purple bulges.
patient is given one to three 5 mg tablets
of bisacodyl (2/D) in the evening, enabling Symptoms
the patient to defecate in the morning. A The symptoms are a feeling of pressure
sodium citrate enema (2/E) can also be around the anus, itching and hygiene
given by inserting one tubeful as deep as problems. Pain is typical to clotted haem-
possible into the rectum. The patient will orrhoids. The most common symptom is
then defecate in 5–15 minutes. bleeding, which is noticeable during and
78
III Symptoms and diseases and their treatment
after defecating. The bright red blood stains symptoms, prednisolone cinchocaine hy-
can smear underwear or toilet paper after drochloride cream or suppositories (2/G)
defecating. can be used three times a day until the
condition improves. Treating constipa-
Treatment tion and flatulence is part of treating and
Asymptomatic haemorrhoids do not re- preventing haemorrhoids. Widespread
quire treatment. Good personal hygiene and symptomatic haemorrhoids can be
is nevertheless needed in the treatment removed surgically.
of symptomatic ones. To alleviate the
28 Abdominal pain
Most abdominal pains are harmless or, food poisoning or a viral disease should
at least, do not require immediate medi- also be considered. In addition, excessive
cal attention. They can be treated aboard use of alcohol may cause vomiting. Pyloric
ship with the available medication. How- stenosis, that is, occlusion in the lower
ever, some acute abdominal problems are orifice of the stomach, may also cause
potentially life-threatening and require vomiting. This situation may be caused by
immediate surgery or other treatment in a tumour or scarring due to chronic ulcera-
hospital. tion. The condition is quite rare and causes
It is difficult to estimate the severity vomiting which does not cease until the
of the situation when the symptoms begin. occlusion is surgically removed.
Intense pain caused by intestinal cramps Dehydration is avoided by giving the
due to sudden diarrhoea may be harmless, patient small amounts of fluid at a time.
whereas mild pain may be symptomatic Solid food is given when the condition has
of a severe problem, such as appendicitis. improved (see also Chapter 26 Vomiting,
Observing the progression of the condi- fever and diarrhoea > Nausea and vomiting
tion is therefore important. The cause of > Treatment).
pain can usually be determined within The reason for diarrhoea is usu-
24 hours. The severity of the condition as ally unsuitable food, food poisoning, or
well as the possible need for further care a harmless viral inflammation of the gas-
on shore can then be estimated. It is often trointestinal tract, gastroenteritis. Mild di-
necessary to consult a doctor via Radio arrhoea requires no medication or special
Medical. drinks as treatment. If diarrhoea is intense
or continuous despite treatment efforts,
1 Signs and symptoms consult a doctor via Radio Medical. The
condition can cause dehydration which
Vomiting is a common sign of both mild may require administration of intravenous
and severe abdominal illnesses. The sever- fluids and hospitalization. Diarrhoea may
ity of the condition can be determined on also be caused by a tropical disease, in
the basis of the intensity of vomiting, the which case the situation may be danger-
amount and quality of vomit and, above ous. (See Chapter 26 Vomiting, fever and
all, other possible symptoms. Sea sickness diarrhoea > Diarrhoea > Treatment.)
is usually recognizable. The possibility of
79
III Symptoms and diseases and their treatment
80
III Symptoms and diseases and their treatment
required than mentioned above. A healthy right side is often tender and the stomach
adult can cope with 1−2 extra litres of muscles are tense. The pain typically radi-
fluid. However, infusing extra fluids may be ates to the right side of the lower abdomen
life-threatening if the patient suffers from when the left side is gently pressed.
congestive heart failure or heart attack. If the symptoms are vague or mild,
and the patient has no fever or loss of
5 Most common reasons appetite, his general condition should be
for acute abdominal monitored. Even if the pain is mild but
pain persists, a doctor should be consulted via
Radio Medical. If the patient has appen-
Appendicitis dicitis, he should be operated on within
Inflammation of the appendix begins 24−48 hours. If the patient is going to
with a vague aching sensation around undergo surgery within the next 12 hours,
the navel. During the following hours the do not serve him food or much to drink.
pain moves to the right side of the lower Antibiotic medication can be started if the
abdomen (Figure 22). Trembling, coughing patient’s condition worsens or if hospitali-
and moving aggravate the pain. Lack of zation is delayed. Ciprofloxacin (7/C) can
appetite and vomiting are common. The be administered, two 250 mg tablets three
patient is often constipated as well. In ap- times a day if the patient is not vomiting. A
pendicitis, the stools may be loose at first, more efficient medicine, suitable also for
but intense diarrhoea is nevertheless an a vomiting patient, is cefuroxime (7/D),
indication of some other illness (usually which is administered in 750 mg intramus-
a viral infection). The patient may have a cular injections three times a day.
slight rise in temperature (37.5−38.0°C), If the patient is not operated on time,
but high fever is not typical. If the patient and the possible antibiotic does not have
has a high fever, the cause is most probably the desired effect, the appendix may rup-
not appendicitis. It is typical for the patient ture. Fortunately, the rupture is usually
to walk leaning forward to avoid sudden followed by a local abscess which restricts
movements, or to lie still with the knees the inflammation. However, sometimes
bent. When palpating the abdomen, the the rupture may lead to a life-threatening
inflammation of the peritoneum.
81
III Symptoms and diseases and their treatment
first inflammation is the most dangerous often radiates to the back and may cause
and 10% of all patients with pancreatitis difficulty in breathing. Vomiting may occur.
require intensive hospital care. There is no Unsuitable food may induce pain, but often
efficient medication for pancreatitis, and there is no clear connection with a meal.
it cannot be cured by surgery. During a severe bilious attack, the patient
The main symptom is a severe belt- may become restless, trying to find the
like pain and soreness in the middle of the most comfortable position. The pain often
upper abdomen (Figure 23). Vomiting is a eases by itself in 2−3 hours.
common symptom. If the inflammation is When palpating under the rib cage,
severe, the patient may have a swollen, the patient experiences pain. The body
tender abdomen and general malaise. As temperature is usually normal. Usually,
the condition proceeds, shock develops a painkiller given as a suppository helps
(low blood pressure, rapid pulse, cold and to ease the pain. The condition often im-
clammy skin) and urine secretion ceases. proves rapidly, and no immediate further
The patient may become disorientated due care is needed. Surgery may be required
to the inflammation and not because of later on.
alcohol. In this case, sufficient intravenous
fluid therapy (4 litres or more in 24 hours) Inflammation of the gall bladder
is the correct treatment rather than seda- Inflammation of the gall bladder (cholecys-
tive medication (as in alcohol withdrawal titis) is related to gall stones and is often the
delirium). If pancreatitis is suspected, the first sign. In cholecystitis, the pain persists
patient should be hospitalized. and the patient develops fever. When
palpating the upper abdomen, the pain is
Attack of gall stones more severe than in a bilious attack. When
A bilious attack is caused by gall stones pressing under the right side of the rib cage,
(precipitations of bile) which block the the pain grows even worse. Cholecystitis is
bile ducts. Often the patient is aware of typical in older women, but usually more
having gall stones and knows the reason severe in men.
for his/her symptoms (Figure 24). The most If cholecystitis is suspected, and the
common symptom is a severe pain on the patient’s eyeballs and skin turn yellow
right side under the rib cage. The pain (first seen in the eyeballs), he/she is most
Figure 23. The site of the Figure 24. The site of the pain
pain in pancreatitis and its radiation to the back in
a bilious attack
82
III Symptoms and diseases and their treatment
Intestinal obstruction
Intestinal obstruction is usually caused
by adhesions due to previous abdominal
surgery, but it can also be caused by an
incarcerated hernia, or even a poorly
digested piece of food high in fibre, e.g. a
piece of orange.
At first, the patient suffers from in-
termittent, undulating abdominal pain,
increasing vomiting and constipation
(even intestinal gases cannot be expelled).
Continuous pain may be symptomatic of
intestinal necrosis and perforation. Other Figure 25. An incarcerated hernia and
serious symptoms include fever and palpa- pushing it inside
tion tenderness of the abdomen which is
visibly swollen. The patient’s general con-
dition gradually deteriorates and he/she be- An incarcerated hernia should be
comes dehydrated and looks ill. The patient pushed back into the abdominal cavity
has a dry, coated tongue, increased heart while the patient is lying on his/her back.
rate, low blood pressure and decreased Put your hand around the hernia and
urinary secretion. squeeze and push back at the same time.
Dehydration cannot be compensated The manoeuvre should be done firmly
by drinking, because the intestines cannot but carefully (Figure 25). If this fails, the
process fluids. Therefore, intravenous fluid patient should be operated on as soon as
replacement therapy should be started possible.
while waiting for a transfer to hospital.
Intestinal obstruction may ease off by Gastric ulcer
itself in two to three days without surgery. The patient may be aware of having a
However, hospital care and monitoring are gastric ulcer, but the condition may also
always necessary. appear suddenly without warning (the
same applies to a bleeding gastric ulcer).
Hernia incarceration The patient develops sudden and severe
In hernia incarceration, the hernia becomes pain in the upper abdomen as an ulcera-
swollen and the tissue cannot be pushed tion forms in the stomach or duodenum,
back into its place. Hernia incarceration is allowing the strongly irritating gastric acid
typical in inguinal (groin), femoral (under and other stomach contents to leak into
the groin) and umbilical hernias. The her- the abdominal cavity. The pain may ease
nia becomes sore. If there is intestine inside momentarily, but the condition becomes
the hernia (as is often the case), intestinal worse again in a few hours as peritonitis
obstruction and perforation may result. In develops. At the same time, the patient
older persons, and especially in women, becomes dehydrated, looks ill and lies
hernia incarceration may cause only ab- still, perhaps with knees bent. Breathing is
dominal ache and vomiting, without any superficial and rapid, the tongue is dry and
symptoms around the hernia itself. coated, the pulse is rapid, blood pressure
83
III Symptoms and diseases and their treatment
84
III Symptoms and diseases and their treatment
because of the adverse effects they have on complications of an early (possibly un-
the fetus (see Chapter 42 The drugs in the known) or ectopic pregnancy or threatened
ship’s pharmacy and their use). miscarriage. Irregular vaginal bleeding
may include spotting of small amounts of
1 Menstrual bleeding blood between periods – often seen on
toilet tissue after wiping – or heavy periods
The usual cause of vaginal bleeding is during which a pad is soaked with blood
menstruation (the monthly period). Most in one hour. Any vaginal bleeding lasting
women have menstrual cycles of 28 days. for weeks at one time is also considered
However, a woman can be healthy and irregular.
normal and have only 3 or 4 cycles a year. Vaginal bleeding with fever, abdomi-
Despite such variation, this could never- nal pain, or unusual mucus or any vaginal
theless be also a sign of serious underlying discharge may indicate an infection.
problems. Ovulation occurs about 14–16 Bed rest is recommended if the
days before a woman’s period (not 14 bleeding is heavy. It is useful for the
days after the start of her period). During doctor to know the dates of the patient’s
the second half of the cycle the ovum, if normal menstrual cycles and the times of
not fertilized, leaves the uterus with the abnormal bleeding, as well as how many
uteral mucous membrane, constituting napkins or tampons are needed per day.
menstruation. Consulting Radio Medical may be nec-
Menopause, the end of the menstrual essary. A woman with vaginal bleeding
flow, occurs between the ages of 40 and should visit a gynaecologist when she
60 years and takes place over a period of 6 returns to shore.
months to three years. At menopause, the
menstrual cycle usually goes through many 3 Vaginal discharge
changes. A common experience is loss of
large amounts of blood during menstrua- All women have some vaginal discharge.
tion, and the passage of large clots. Hot Healthy vaginal discharge is clear or white
flashes or flushes, changes in sleep pattern, and does not smell unpleasant. It may
headache or migraine, etc., are common change at puberty, pregnancy and meno-
signs accompanying menopause. pause, and there is a cyclical pattern to its
thickness. There should be no blood in the
2 Vaginal bleeding discharge between periods, and no bleed-
ing in connection with intercourse.
Any vaginal bleeding that is not normal Infections in the vagina and external
menstrual bleeding is abnormal, and may genital organs are very common. Infections
be a sign of a problem in the vagina, uterus are most often caused by yeast pathogens.
(womb) or ovaries. Inserting a tampon into The symptoms of a yeast infection include
the vagina can confirm that the source of itching of the external genital organs, clot-
bleeding is the vagina/cervix/uterus, not ted vaginal discharge, swelling and burn-
the rectum or urinary bladder. ing of the vaginal mucous membranes,
Vaginal bleeding can have a number and even small ulcers. The patient often
of causes, such as hormone imbalance complains of pain when urinating. The
(most common), injury to the vagina or infection is treated by placing a vagitorium
vulva, sexual abuse, infection, sexually of miconazole (15/A) deep into the vagina
transmitted diseases, polyps and fibroids for 3–5 nights.
in the uterus, gynaecological cancer, and
85
III Symptoms and diseases and their treatment
86
III Symptoms and diseases and their treatment
tion of an ectopic pregnancy, and it may via Radio Medical as soon as possible.
also occur without any preceding symp- Immediate hospitalization is usually not
toms. Sometimes the patient is unaware of necessary if the patient is not bleeding
being pregnant. heavily, if the bleeding does not continue
The bleeding may be so heavy that too long, and if the bleeding is not ac-
the patient goes into shock. As first aid, companied by severe pain.
she should be given fluid intravenously
on board ship to save her life, and then 9 Childbirth
hospitalized as soon as possible.
The normal duration of pregnancy is
8 Problems during approximately 40 weeks, but a woman
pregnancy may also go into labour suddenly and
prematurely. If you suspect that the patient
Bleeding is about to go into labour, arrange her
In the last stages of pregnancy, clear, bloody transportation ashore as soon as possible.
vaginal discharge may signal the rupture Consulting a doctor via Radio Medical is
of the placenta or the premature detach- also recommended.
ment of the placenta. Consulting a doctor Childbirth is preceded by contrac-
via Radio Medical is recommended. The tions of the womb, during which the
patient should be hospitalized for further womb becomes hard and feels painful.
treatment as soon as possible. The contractions help to open the orifice
of the uterus to allow the baby to be born.
Pre-eclampsia At first, the contractions come irregularly,
Pre-eclampsia usually develops during the but when the woman goes into labour,
third trimester of pregnancy. The expectant painful contractions occur every few
mother often complains of headache; she minutes, at regular intervals.
may see bright spots, be nauseous and If the patient is showing signs of
vomiting, and suffer from abdominal pain. going into labour, consult a doctor via
If the pre-eclampsia progresses, the patient Radio Medical at once. Consider the saf-
may have spasms. The patient’s blood pres- est course of action: should the patient
sure is high, and tests reveal a leakage of be evacuated, or should a doctor or nurse
protein into the urine. Medical examination be brought aboard ship, for example, by
should be started by taking the patient’s helicopter? It is wise to maintain radio
blood pressure and testing for protein in contact during the entire childbirth for
her urine. continuous instructions.
As first aid, the patient should be
moved into a quiet, dark room. If she is Preparing for childbirth
feeling dizzy and shaky, she may be given When preparing for childbirth, you need
one 5 mg tablet of diazepam (4/A). If she • clean sheets
has spasms, she should be given diazepam • sterile gloves
in the form of an injection. The patient • bandages
should be transported ashore for further • suction to clean the newborn baby’s
treatement as soon as possible. airways
• sterile scissors and a clamp
Miscarriage • warm water
Bloody vaginal discharge during pregnancy • towels or soft cloth to wrap the baby
may signal a miscarriage. If a possible in.
miscarriage is suspected, consult a doctor
87
III Symptoms and diseases and their treatment
If the baby has to be delivered on board may start pushing actively. She should turn
ship, three persons should help the expec on her back and push during every con-
tant mother. One is mainly responsible traction, as if she were defecating.
for the delivery, and one gives assistance.
The third person is responsible for the During every contraction, the expectant
maintenance of the necessary instruments, mother
and is in contact with a doctor via Radio • takes a deep breath
Medical. • pushes while holding her breath
• exhales deeply.
The first stage of labour
In the first stage of labour, the orifice of the This should be repeated until the contrac-
uterus opens. Normally, this takes 8–10 tion is over. During the contraction, a small
hours, but can also occur much more rap- amount of blood, mucus or faeces may
idly. The contractions grow stronger and emerge. The anal region should be wiped
come more regularly as labour progresses. clean with water and a disposable towel,
The contractions come every five minutes from the vagina towards the anus. The
or more frequently, and they last 15–30 washing water should be changed often.
seconds. The membranes usually rupture Change your gloves and the sheet as well,
at the end of the first stage of labour, releas- if it is stained.
ing the amniotic fluid. In normal childbirth, an assistant is
Once the amniotic fluid has been not always needed. However, when the
released, the expectant mother should baby’s head emerges, it is useful to have
empty her bladder and stay in bed. She an assistant to support the perineum to
should be made as comfortable as pos- keep it from being torn. This is done by
sible, and covered with a blanket to keep slowing down the emerging head with
her warm. Both sides of the bed should be one hand, while at the same time pulling
kept free for the actual childbirth. A doubly down the perineum along the head with
folded extra sheet may be placed on the the other hand.
lower end of the bed. Once the baby’s face has turned to
After the amniotic fluid has been either side, you should ask the mother to
released, the contractions often grow push, while at the same time gently pulling
stronger and come more regularly. The the baby’s head in an outward and down-
expectant mother may start to feel a need ward direction. This helps the emergence
to push. However, she should not start of the upper shoulder. The lower shoulder
pushing actively before the baby’s head should emerge when you pull slightly
can be seen. The need to push can be upwards (Figures 26–28). If the shoulders
eased if the expectant mother turns on do not emerge easily, the mother’s thighs
her side and concentrates on her breath- and knees should be firmly bent. Some-
ing. During each contraction, she should times the baby is born by breech delivery,
breathe shallowly and quickly (shallow which means that the baby’s buttocks or
panting). When she feels the need to push, feet are the first to emerge. In such cases,
she should not push, but should breathe it is important to avoid touching the baby
deeply in and out. at least until the navel has emerged.
The newborn baby should be careful-
The second stage of labour ly dried and kept warm, because an infant’s
The expulsive stage of labour usually lasts thermoregulation is not fully developed,
from 30 minutes to an hour. When the and the lowering of body temperature
baby’s head appears, the expectant mother can be dangerous. If the infant has trouble
88
III Symptoms and diseases and their treatment
89
III Symptoms and diseases and their treatment
in a plastic bag before use. A used napkin amounts to about 300 ml. If the amount of
should be put in a plastic bag and weighed blood exceeds 1000 ml, the mother should
again. The total amount of blood loss is be given fluid intravenously to replace the
the difference in the respective weights. blood she has lost. After the delivery, the
In normal childbirth, the total bleeding mother should also take a shower.
Symptoms of the lower abdomen may should therefore always be asked if she is
result from diseases of the urinary organs menstruating. Sugar is secreted into the
or the genitals. Intestinal disorders and, urine only in the case of inadequately
for example, hernia, may also cause the treated diabetes.
symptoms. See also Chapter 28 Abdomi- The presence of leukocytes (white
nal pain and Chapter 29 Obstetrics and blood cells) in urine is a sign of bacterial
gynaecological disorders. infection, and the patient should be treated
The need to urinate even when only with an antibiotic. Ciprofloxacin (7/C) one
a small amount of urine is passed suggests 250 mg tablet once a day, or one cefadroxil
bladder or urinary tract irritation in both (7/E) 500 mg tablet twice a day should be
men and women. In women, the reason is given for 5–10 days. The patient should rest
often cystitis and, in men, prostatitis (infec- if he/she has a fever or is feeling weak.
tion of the prostate) or prostatic hyperplasia To ease cramp-like pain, diclofenac
(enlargement of the prostate). If the infec- (3/B) can be given: one 50 mg tablet three
tion of the urinary organs gets worse, the times a day, or one to two 100 mg supposi-
patient may have fever and pain in the tories a day (not suitable for patients who
lower abdomen, along with the need to uri- are hypersensitive to acetylsalicylic acid).
nate more often. Cramp-like pain may be Paracetamol (3/A), one to two 500 mg
a sign of a urolith (urinary stone) in which tablets three times a day, should be given
case the pain can be very severe. to patients hypersensitive to salicylate.
A urine sample – to test for protein, A serious illness, for example a tu-
sugar, blood and leukocytes with a test mour, is rarely the cause of symptoms in
strip – should always be taken from a the urinary organs. Infections of the urinary
patient with symptoms of the lower abdo- organs can also turn into symptomless,
men. Blood in the urine can be a sign of latent, progressing illnesses. Therefore,
kidney stones, protein a sign of nephritis even after the symptoms have disappeared,
(infection of the kidneys), and leukocytes the patient should always be re-examined
(white blood cells) a sign of urinary tract by a doctor, to make sure that he/she has
infection. Blood in the urine of women recovered fully.
may be due to menstrual flow. A woman
90
III Symptoms and diseases and their treatment
1 Blood in the urine the severe pain and he/she may twist and
turn, trying to find a position where the
Blood is usually not secreted into urine. pain would lessen.
Only very rarely is there so much blood When the patient is examined, pal-
that the urine appears reddish. Minor pation tenderness is detected on the back
haematuria (a small amount of blood in the at the site of the kidneys. There is usually
urine) can be detected only with special little blood in the urine, which can be
urine test strips. Minor haematuria can detected with test strips. The urine rarely
occur in connection with a urolith (urine looks bloody.
stone) or a urinary tract infection. Tumours The pain should be treated with suf-
of the bladder or urinary tract, and tuber- ficient pain medication. Drinking a lot of
culosis (rare) can also cause haematuria liquids is neither necessary nor recom-
(blood in the urine). If there are no other mended when the patient is in pain. When
symptoms, the haematuria is usually not the pain has stopped, drinking can speed
immediately life-threatening, and there is urine flow and thus help to remove the
no need for immediate treatment. How- urolith from the body. The urine should
ever, a thorough urologic examination on be strained through a sieve to confirm
shore is necessary to clarify the reason for the diagnosis. The urolith is usually small,
the haematuria. rough and dark like a grain of gravel. There
The urinary tract may suffer damage is no hurry to get the patient on shore if the
in an accident. Also a fall or a kick on the pain stops, but he/she should be examined
back can cause contusion of the kidneys. by a doctor some time later.
An accident can also cause a more severe
renal rupture which needs immediate 3 Urinary tract infection
surgery. A hit on the crotch may cause
injury to the urethra. In severe injuries it A urinary tract infection is usually caused
can rupture completely, causing bleeding by bacteria in the urine. A burning or
in the urinary tract. If the urine flow is smarting sensation in the lower abdomen,
normal, there is no need for immediate together with the need to urinate more
attention. Inability to urinate is a symptom often than usually, are common symptoms
of a severe urinary tract injury, and the of bladder infection. If the patient also has
patient needs medical attention on shore. fever and back ache, the entire urinary
Do not attempt to catheterize, as it can system, including the kidneys, is infected.
cause more damage. Urinary tract infection is more common
in women than in men. In older men,
2 Urolith prostatic hyperplasia (enlargement of the
prostate) and problems in the urine flow
A urolith (urinary stone) is composed of can cause urinary tract infection.
urinary compounds formed in the renal A urinary tract infection can be de-
pelvis. It travels along the ureter and causes tected with test strips. During an infection
pain when it gets stuck. The pain starts there is often a little blood in the urine.
quite suddenly. At first it is wave-like and The basic treatment is drinking a lot of
then usually becomes unbearable. The water to increase urine flow and irrigation
pain is located mostly in the loins on one of the urinary tract. In addition, antibiotic
side. The pain often radiates to the back medication is needed. The possibility of a
and to the lower abdomen or groin region. sexually transmitted disease (STD) might
The patient is sweaty and restless due to also be considered.
91
III Symptoms and diseases and their treatment
92
III Symptoms and diseases and their treatment
31 Sexually transmitted
diseases (STD)
As many diseases spread in sexual con- able to new infections. If a person has a
tact, it is better not to talk about venereal STD, he/she is much more easily infected
diseases (syphilis, gonorrhoea, etc.), but with another one. Thus, it is likely that a
rather about sexually transmitted diseases. person is not infected with only one STD. A
The definition is not entirely unambiguous, person can also become infected or infect
because most of these diseases can spread someone else with several diseases during
in other ways as well. On the other hand, one single act of intercourse.
some infectious diseases, for example,
hepatitis B, can spread also in sexual
● If a person is infected with one
contact (see Chapter 38 Infectious and sexually transmitted disease, it
contagious diseases). Thus, the symptoms is possible that he/she is infected
of sexually transmitted diseases may vary with several sexually transmitted
greatly. diseases at the same time.
1 Symptoms 2 Treatment
Depending on the disease, the symptoms Even if left untreated, sexually transmitted
of sexually transmitted diseases develop diseases do not quickly cause serious dam-
within a few days or weeks from the time of age and inability to work. Thus, they should
the contagion. In men, the first symptoms not normally be treated at all on board ship.
may include urethral discharge, especially It is worth remembering that one type of
in the morning before urinating, the need medication treats only one type of disease,
to urinate often, and swelling of the ure- so the other STDs that the patient may have
thral orifice. In women, the symptoms are may be left untreated. The treatment may
often less abundant, and may include vagi- also give the patient a false sense of security,
nal discharge, the need to urinate often, and a feeling that all sexually transmitted
and a burning sensation when urinating. diseases have been taken care of. The pa-
The inguinal glands may become swollen. tient should undergo a medical examination
Later, when the infection spreads to a larger immediately after docking. The purpose of
area, the symptoms are a combination of the examination is to ascertain what kinds
infections in various organs (salpingo- of STDs the patient may be infected with,
oophoritis, orchitis). The disease is often and to make certain that all the diseases are
diagnosed by the later symptoms, and it properly treated at the same time.
is therefore possible for an asymptomatic If you suspect that the patient may
person to have an infectious disease for be infected with a STD, inform the patient
a long time, and to be infectious without at once. The patient should refrain from
knowing it (e.g. HIV). sexual intercourse until his/her condition
A sexually transmitted disease damag- has been reliably diagnosed and treated.
es the mucous membranes of the genitalia
and thus makes the patient more vulner-
93
III Symptoms and diseases and their treatment
94
III Symptoms and diseases and their treatment
• caressing the anal region with the orchitis in men. In women, it may lead to
mouth infections in the fallopian tubes, and even
• sharing contaminated sex toys with peritonitis.
partners.
Chlamydia
95
III Symptoms and diseases and their treatment
advance in the body. Two years after the syndrome) develops in years, possibly dec-
infection, the disease is no longer conta- ades, after the primary infection. The active
gious. It may, however, be transferred from AIDS phase varies from a few months to
the mother to the fetus, causing develop- several years. The most common causes
mental anomalies and malformations. At of death are various infectious diseases
this stage of the disease, the presence of and tumours.
syphilis in the body can only be diagnosed The HIV infection spreads via blood
with tests for antibodies. throughout the body if the virus gets into
About 10–15 years after the infection, the circulatory system. Casual sexual
the syphilis has spread throughout the contacts involve a particularly high risk
body. The patient has extreme difficulty of infection. The risk of exposure is further
walking because of muscular hypotomia increased if semen, blood, urine or a large
of the lower extremities. Syphilis causes amount of saliva comes into contact with
megalomania and dementia, and may the mucous membranes of the mouth, the
lead to sudden death from aneurysm and anus, the vagina, or skin wounds.
rupturing of the aorta. It is possible to be infected with HIV
without having had sex with an infected
Condyloma person. In central Africa, the infection may
Condyloma is a growth on the mucous spread, for example, via contaminated
membranes, caused by the human papil- medical instruments. People who use
loma virus. In men it is found on the penis intravenous drugs are at risk of getting the
(Figure 31); in women it is found on the la- virus from used injection needles. There is
bia or in the region of the anus. Condyloma always a possibility of infection from used
is a fleshy, soft growth, sometimes with a needles, so nurses should be careful not to
cauliflower-like appearance. The infec- get pricked when handling them.
tion spreads during intercourse. Checking
and, if necessary, treating the partner is It is worth remembering that you cannot
necessary. There is a connection between get AIDS from
condyloma and cervical cancer. • objects (with the exception of contami-
nated sex toys)
HIV/AIDS • air
This is an incurable disease caused by the • toilets
human immunodeficiency virus (HIV). The • bath water
disease causes the collapse of the immune • clothes
system, exposing the patient to various in- • shaking hands, touching, talking, etc.
fections, which ultimately lead to death.
The symptoms develop within one By the time when the first symptoms ap-
to eight weeks from the infection. They pear, HIV antibodies are not yet detected,
resemble the symptoms of a common viral but they are detected before the symptoms
infection and include fever, headache and disappear. If the blood tests are not positive
nausea. The patient’s glands are swollen. (antibodies are not present) 3–6 months
These first symptoms disappear in a few after the exposure, it is obvious that the
weeks, after which the disease may be person is not infected.
asymptomatic for 10 years or more. After The HI virus spreads mostly through
the asymptomatic stage, the symptoms in- blood and excretions. The disease does not
clude swollen glands, fever, and diarrhoea. spread in the course of normal work life or
The actual AIDS (auto-immune deficiency communication. Testing for HIV antibodies
96
III Symptoms and diseases and their treatment
Figure 30. A crater-like painless lesion Figure 31. Condyloma on the penis
caused by syphilis
97
III Symptoms and diseases and their treatment
Air-permeable, light lotion used often is ness and itching (so called atopic skin),
better than a heavy, greasy ointment used scabies, allergic reaction or, rarely, some
rarely. internal illness (e.g., cirrhosis of the liver
or renal disease).
2 Itchy skin If the treatment for dry skin mentioned
above is not sufficient, special moistur-
Itchy skin is merely a symptom, not an izing ointments, such as basic ointments
actual skin disease. If the skin colour is containing carbamid, can be used. Itch-
normal, the reason for the itching is usually ing can also be controlled with internal
dryness of the skin. Scratching may cause antihistamine medication, for example,
drying and lichenification (thickening and by giving cetirizine hydrochloride (5/B),
roughening of the skin), which makes the one 10 mg tablet once a day. If external
skin itch even more, leading to a vicious factors such as rough clothing, sweating,
circle. Sometimes, the reason for the itch- or certain foods cause the itching, they
ing may be a hereditary tendency to dry- should be avoided.
33 Rash
1 Examination
The patient is asked about the onset of the crew until a risk of infection has been
the rash and about its possible external ruled out. A doctor should be consulted
causes: What was the patient doing when via Radio Medical.
the rash appeared, and did his/her skin
come into contact with any substances? Assessing the rash
Avoiding the irritants may help to prevent Rashes are grouped into superficial and
further rashes. deep rashes according to their appearance.
Symmetrical symptoms on the right In a superficial rash, the outer layers of the
and left side may indicate that the rash is skin are irritated. The outer layer may be
triggered from the inside, for example, by thick, lichenous or even cracked, but the
a food allergy. A unilateral rash is often deeper skin layers are healthy. In the case
caused by an external skin irritant. of a superficial rash, treatments applied on
the skin are effective.
Risk of infection In a deep rash, the infection has
If a rash is watery, or if vesicles or pustules spread to the deeper skin layers and the
are present, it should be treated as infec- skin has thickened completely. In this
tious. In the prevention of a infectious case, oral medication is needed in addi-
rash, cleanliness is important, especially tion to local treatment. The rash takes at
in public facilities like washrooms. Soap least a month to heal completely, and the
and towels are not to be shared. A rash treatment should always be continued to
that has spread all over the body may be completion even if the skin appears less
caused by an infection. The patient should red and almost normal after only a few
not be in contact with other members of days of treatment.
98
III Symptoms and diseases and their treatment
A rash and the patient’s disease (Figure 32). The main symptom is
general symptoms itching.
If the skin disease is related to general
symptoms, such as fever or nausea, also Contact eczema is caused by an external
internal medication is needed. Before factor that irritates the skin and brings
starting the medication, a doctor should about the clinical picture of eczema. Too
be consulted via Radio Medical. strong or too frequent exposure to this
If a sudden rash has spread over a external factor damages the skin. The most
wide area of the body and is accompanied common external factors causing eczema
by the first symptoms of shock, breathing are detergents, solvents like acetone and
difficulties, blurred speech, stiffness of the turpentine, plastics, adhesives, mineral
tongue, or swollen lips, the patient should oils, lubricants and cutting fluids. The en-
immediately be given 1 ml of adrenaline (1 gine room crew’s irritation eczema may be
mg/ml, 8/A) intramuscularly (see Chapter caused by some of the handled substances,
4 Shock). A doctor should be consulted or by substances used for cleaning the
via Radio Medical. After the consultation, hands (Figure 33). In this case, a substance
instructions are follewed and, if necessary, that is too strong damages the skin immedi-
antibiotic or cortisone treatment is started. ately. On the other hand, it may take weeks
Antibiotics are taken orally and continued or even months for a milder substance to
until the patient is better or can be trans- cause eczema.
ferred for treatment on shore. A rash can also be due to an allergy.
Allergies are chronic and affect the entire
2 Treatment skin, not only the places where the rash
first appeared. With repeated exposure to
The basic treatment for rashes is shown in the allergen, in time less and less of it is
Table 5. If in doubt, always consult a doctor needed to cause symptoms. Common al-
via Radio Medical. lergens are rubber and rubber chemicals,
dual component resins and adhesives. If
3 Different types of rash metal on the skin causes an allergic rash,
this is usually caused by the nickel in the
Eczema is the most common type of rash metal (Figure 34).
that occurs on board ship. The other types The basic treatment for eczema is a
of rash described here are important be- local treatment according to the symptoms
cause many jobs on board ship may cause (see Table 5). All irritating and exacerbat-
them. Some of the rashes discussed here ing factors should be avoided. Protection
are caused by bacteria or viruses and can should be used if the irritant can not be
be infectious. avoided. Sometimes it is necessary to
change jobs, sometimes even occupa-
Eczema tions.
Eczema is a non-contagious superficial in-
flammation of the skin. The name eczema Impetigo
does not tell the cause of the disease, but Impetigo is a superficial, very contagious
rather it describes the clinical picture of skin infection caused by bacteria. It is
the condition. Eczema can be caused by characterized by red eczema which has a
internal or external factors, and is charac- light yellow crust and is occasionally wet.
terized by redness, swelling, burning, ooz- The fluid is filled with bacteria.
ing, blistering, scaling and lichenification Treatment consists of cleaning the
of the skin, depending on the stage of the crust from the skin with water, for example,
99
III Symptoms and diseases and their treatment
101
III Symptoms and diseases and their treatment
102
III Symptoms and diseases and their treatment
Figure 36.
Erysipelas in the
lower limb
Figure 37.
Generalized
widespread eczema
103
III Symptoms and diseases and their treatment
104
III Symptoms and diseases and their treatment
missing a spot, but not on the hair or face. After scabies has been treated, the itching
The cream is left to act for 8–15 hours. Dur- can typically continue for several days,
ing the treatment the patient’s hands are not depending on the condition of the skin. The
washed, but are covered with cotton gloves itching can be alleviated by antihistamine
during the entire time. If, for some reason, tablets and, for example, by hydrocortisone
the hands must be washed, the cream is cream. Do not repeat the scabies treat-
reapplied immediately after the wash. After ment until two weeks have passed from
the treatment the skin is washed and the the previous one.
clothes are changed again.
Mole – Skin neoplasm, nevus
During the scabies treatment: Moles (nevi) are the most common neo-
• all family members are treated at the plasm (tumour) of the skin. They are brown
same time in colour and round or oval in shape, and
• instructions are followed carefully are darkened by sunlight. About one ne-
• the bed linen is aired outside for two vus in a million can turn into a malignant
hours tumour, melanoma. 50% of melanomas
• the clothes are washed appear at the site of a nevus.
• any remaining itching is treated accord- It should be suspected that a nevus is
ing to the symptoms. turning malignant if its colour becomes un-
even or black, its edges irregular, if it starts
to itch, or if it gets red around the edges. A
mole like this should be removed soon.
105
III Symptoms and diseases and their treatment
106
III Symptoms and diseases and their treatment
107
III Symptoms and diseases and their treatment
numbness in the forearm and fingers, and pain caused by lumbago is relieved much
occasionally, muscle weakness and loss faster than sciatic pain.
of feeling. Consulting a doctor via Radio
Medical is necessary, especially if the Lumbago or sciatica?
symptoms are severe and of rapid onset. The treatment of lumbago is not total bed
rest. It is, however, best to avoid straining
3 Back pain the back for two or three days, and after
that to gradually return to normal strain as
Sudden back pain soon as possible. A suitable pain medica-
Acute lumbago is a suddenly appearing tion is, for example, one 50 mg tablet of
pain in the lower back, which often limits diclofenac (3/B) two to three times a day
back movements considerably. The pain for three or four days. Those allergic to sali-
does not radiate to the lower limbs. cylate, may be treated with one or two 500
In sciatica, the pain radiates from the mg tablets of paracetamol (3/A) three times
lower back to the lower limbs. The condi- a day. If the muscle tension is severe, it can
tion may be severe and require immediate be relieved with a 5 mg tablet of diazepam
treatment, if the symptoms include faecal (4/A) two or three times a day. Warning:
or urinary incontinence, urinary retention causes drowsiness! Therefore anyone be-
and/or numbness around the anus and but- ing treated with diazepam should not be
tocks, or weakness and paralysis in one or carrying out tasks which require alertness
both of the lower limbs. and accuracy. A good physical and mus-
cular condition help prevent the symptoms
from recurring.
● Consult a doctor via Radio
Medical, if Sciatica takes longer to heal than
lumbago, but complete bedrest is not
• the backache is severe and is not
necessary. Lifting heavy burdens and sit-
relieved in a resting position
ting for long periods should be avoided
• the sensation of the skin around the for some weeks. Pain medication is given
anus weakens
symptomatically when necessary.
• bladder and intestinal functions
change. Chronic back pain
Prolonged, chronic lumbago may be
caused by conflict between the physical
Sciatica is usually caused by a ruptured condition of the back and the require-
disk in the low back or pelvic region, when ments of work. Restricted movements,
a part of the vertebral disk bulges into the degeneration, alterations in posture, and
spinal cord canal. Pressure or irritation in muscle weakness may occur in the spine.
the nerve root causes the pain to radiate Tension in the muscles of the pelvic region
to the lower limbs. This mechanism is not or in the lower limbs may make the back
present in lumbago, and explains why the susceptible to chronic pain. The spine
LUMBAGO SCIATICA
• localized back pain • pain radiating to lower limbs
• rapid onset • numbness or loss of sensation in lower limbs
• stiff back • possible weakness in the lower limbs
108
III Symptoms and diseases and their treatment
36 Mental disorders
1 Symptoms
The most common, minor symptoms of Sometimes the symptoms may de-
a mental disorder are, for example, anxi- velop gradually and increase slowly within
ety, social phobias, obsessive-compulsive weeks or months. In this case, immediate
symptoms, and depression. If the symp- treatment on board is not justified, and the
toms include loss of functional capacity patient should be advised to seek treatment
and loss of sense of reality, hallucinations, on shore.
and the patient’s unawareness of his/her In assessing the severity of the mental
illness, the condition is more severe and is disorder, it is important to find out whether
called a psychosis. This requires immedi- the patient is aware of his/her illness.
ate treatment on shore. The possibility of
violent behaviour and an increased risk of
● Always consult a doctor via Radio
suicide must be taken into account when Medical about mental disorders!
the transfer to shore is arranged.
109
III Symptoms and diseases and their treatment
110
III Symptoms and diseases and their treatment
111
III Symptoms and diseases and their treatment
112
III Symptoms and diseases and their treatment
113
III Symptoms and diseases and their treatment
114
III Symptoms and diseases and their treatment
115
III Symptoms and diseases and their treatment
LSD different used as such visual and disorientation, mental disor- psycho-
coloured small auditory shivering, ders, suicide logical
tablets or clear mixed in a hallucinations fearfulness
fluid liquid chromosome
sense of being increased abnormalities
absorbed in outside one’s secretion of
paper own body saliva some of the
reactions re-
increased uncertain cur even after
confidence, movements discontinuing
cheerfulness LSD use
overall picture
depression, of a mental
panic disorder
Opiates tablets large doses euphoria intoxicated rapidly physical
Morphine injected into disorientation, appearance developed and
Heroin heroin also as muscle or vein fatigue but no addiction psycho-
liquid or white alcohol smell logical
powder sometimes contracted AIDS and
sniffed up the pupils needle marks hepatitis
nose transmitted
loss of withdrawal by dirty
appetite symptoms needles
116
III Symptoms and diseases and their treatment
nosebleed AIDS,
jaundice
mental
disorders,
death
Ampheta- different sized injected into agitation, restlessness addiction physical
mines tablets muscle or vein anxiety and psy-
dilated pupilsbrain chological
capsules sniffed up the fears, haemor-
nose hallucinations sweating,high rhages
white powder pulse rate
swallowed insomnia, loss effects similar
liquid of appetite needle marks to cocaine
shaking,
disorientation
117
III Symptoms and diseases and their treatment
118
III Symptoms and diseases and their treatment
the patient must wear a disposable mask and disinfected thoroughly with a fluid
(according to the instructions received via containing 40–60% ethanol.
Radio Medical).
The patient must not use public
● A disposable mask should be worn
toilets, and the toilet used by the patient when mouth-to-mouth respiration is
must be disinfected with chlorinated deter- given.
gents. The dishes and cutlery used by the
● Always wear gloves when you touch
patient must be disposable, and disposed the patient!
of directly after use. The used bed clothes,
towels, etc. must be handled with gloves
and machine-washed separately in the Any care giver who suspects having been
hottest possible water. Stained surfaces infected by the patient must report this, e.g.
in the cabin must be disinfected with a to the shipping company’s occupational
chlorinated detergent. health service. They will start further in-
vestigation of whether an infection could
4 Avoiding risk of be possible, and take care of the juridical
infection when details, such as possible compensation for
treating a patient an occupational accident in connection
with the treatment.
Blood and body fluids are possible sources All disposable instruments used in
of infection, and handling them always treating the patient must be placed in an
involves an increased risk of infection, for undamaged, waterproof container and dis-
example, hepatitis, HIV and AIDS. The risk posed of according to instructions concern-
of infection from the patient to the care ing hazardous waste. Other instruments
giver is especially high if the care giver’s must be carefully washed and disinfected
skin is pricked by a needle or sharp instru- for future use. Contaminated, secretion-
ment used in the treatment. Anyone treat- stained tables and rooms must be cleaned
ing a patient must bear in mind the possible immediately after the treatment with a
risk of infection from the patient, and safety chlorinated disinfectant (2% chloramine
precautions must always be taken. or 0.25% liquid sodium hypochloride) or
a disinfectant containing phenol. Finally,
it is advisable to wipe the surfaces with
● Blood and body fluids are always
possible sources of infection, so a liquid containing 40% ethanol. Gloves
PROTECT YOURSELF! must be worn during the disinfection. It is
important to remember that used gloves
● Sharp instruments used in the
treatment of the patient must be may be a source of infection.
handled with care.
5 Communicable diseases
Instruments and clothes contaminated by Malaria
the patient’s secretion or body fluids must Malaria is caused by a single-cell parasite
always be handled with gloves, and packed transmitted to human beings by mosquito
away carefully so that they are not a risk to bite. The incubation period is 10 to 15
anyone else handling them. Contaminated days, but the symptoms may start several
surfaces must be disinfected. Anyone treat- months, even years after returning from
ing the patient must wear gloves. If the care a journey. The first symptom is fits of
giver’s hands are stained during the treat- repeated chills (ague), lasting 15 minutes
ment, they must be washed immediately to an hour. These are followed by fever,
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III Symptoms and diseases and their treatment
which lasts 1 to 4 hours and may rise up to • Always use a mosquito net over your
40–41°C. Sweating after the bout of fever bed. Insect repellent spray may also be
leads to the fever dropping. The symptoms sprayed on the mosquito net and on
recur regularly. If untreated, malaria may clothing to increase the effectiveness
persist for decades as recurring bouts of of the protection.
fever.
Hepatitis A
● Even slight fever during, or even Hepatitis A is a viral infection which
long after a journey in a tropical spreads by faeces-contaminated food or
country may be a sign of malaria! water. It is common in central Europe,
and even more widespread in countries of
Other typical symptoms of malaria are poor hygiene. Some foods, such as oysters,
diarrhoea, pulmonary problems and grow in contaminated waters and the virus
problems of the central nervous system, accumulates in them.
such as disorientation and lowered level The incubation period may vary from
of consciousness. Sometimes the clinical two weeks to two months. The clinical pic-
picture of malaria is more atypical and ture may resemble stomach flu with fever,
resembles influenza. nausea, vomiting and muscle aches. The
The resistance of malaria to the effects symptoms may also be similar to a sudden
of different medications constantly varies. inflammation of the liver: yellow skin and
This is why different regions have different especially yellow whites of the eyes, dark,
recommendations for preventive medi- ‘coffee- coloured’, urine and grey faeces.
cation. The World Health Organisation There is no medication for a viral in-
(WHO) annually publishes recommenda- fection. That is why the best treatment for
tions for preventive health care, which vary hepatitis A is rest and long-term abstinence
depending on the geographic area. Preven- from alcohol consumption.
tion of malaria on board ship should follow The most effective preventive measure
these yearly updated instructions. is a vaccine which gives 10-year protection
In addition to preventive medication, against hepatitis A: an injection of gam-
it is important to take other preventive maglobuline (usually 2 ml) intramuscularly
measures, which are often even more offers protection for about two months; it
efficient than the actual medication. The is not as effective as the vaccine.
aim of these measures is to avoid mosquito
bites, and thus, infection. Hepatitis B
The instructions below should always Hepatitis B is a viral infection transmitted,
be followed in regions where there is a risk for example, via blood, body fluids and
of malarial infection: sexual intercourse. It also spreads through
• Always wear long-sleeved shirts/ shared needles, and during childbirth from
blouses and long trousers outdoors mother to child.
between sunset and sunrise, especially The incubation period is 2–6 months.
in the countryside and on the outskirts The illness may be asymptomatic in over
of towns. half of infected adults. A part of those
• Use insect repellent on exposed skin infected become chronically infected
areas. carriers, and have either no symptoms or
• Before going to sleep, destroy mos- develop chronic hepatitis.
quitoes by spraying insecticide in The symptoms of hepatitis B are
the sleeping quarters and inside the similar to those of hepatitis A. Treatment
mosquito net. is symptomatic; there is no specific treat-
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III Symptoms and diseases and their treatment
ment. The illness increases the risk of liver taken a vaccination against yellow fever
cancer later in life. in his home country before departure. All
The most important preventive meas- kinds of injections should be avoided in
ure is to minimize exposure to the disease. the developing countries because of the
Any contact with body fluids and blood high risk of HIV or hepatitis infection from
must be avoided, as the disease is trans- a contaminated needle.
mitted through them. There is a vaccine
for hepatitis B, which offers 5–10 year’s Diphtheria
protection after three vaccinations. Diphtheria is a bacterial disease, which
develops a widespread, festering, viscous
Other forms of hepatitis yellow lining in the pharynx, nasal cavity
Hepatitis C is a disease similar to hepatitis and larynx. The bacteria produce a toxin,
B. It is also transmitted in a similar way, which may cause a variety of symptoms in
e.g. through shared needles. Also other the heart, kidneys and nervous system.
forms of hepatitis, such as D and E exist. Diphtheria may spread as droplet
There is no vaccine to protect against these infection, by kissing the infected person,
diseases! or by sharing cutlery.
Vaccination is the best way to avoid
Yellow fever the infection. If it has been over 10 years
Yellow fever is a viral infection. Its origins since the last vaccination, a booster vac-
are in Africa but it has also spread to cination is needed before travelling to
Central and South America. The virus is regions with a risk of infection. Diphtheria
transmitted by mosquitoes, first to mon- can be cured with penicillin.
keys, and then to humans. In towns it is
transmitted from human to human. The Salmonellosis
risk is highest in the jungle. In addition See Chapter 26 Vomiting, fever and diar-
to the vaccine against yellow fever, insect rhoea > Illnesses causing diarrhoea.
repellent is the most effective protection
against the disease. Cholera
The incubation period is two to five See Chapter 26 Vomiting, fever and diar-
days. The first symptoms are fever and rhoea > Illnesses causing diarrhoea.
redness of the face. The clinical picture
includes liver and kidney dysfunction and Tuberculosis
vomiting. The disease is life-threatening See Chapter 25 Diseases of the airways.
– mortality is as high as 10%. A vaccine
offers complete protection for 10 years. SARS
It is always possible that a country See Chapter 25 Diseases of the airways.
in a region currently infected with yellow
fever requires a valid vaccination of any- AIDS/ HIV
one travelling in the country. Thus, anyone See Chapter 31 Sexually transmitted dis-
travelling to these regions should have eases.
121
III Symptoms and diseases and their treatment
39 Diabetes
122
III Symptoms and diseases and their treatment
123
III Symptoms and diseases and their treatment
in Table 7. If it is not known whether the low blood sugar level. The body endures
condition is due to too low or too high a high sugar concentration considerably
blood sugar, it must be treated as a too better than a low one.
Table 7. Differences in the symptoms and signs of insulin shock and ketoacidosis
Cold, moist, sweaty skin, pale face Externally visible Dry, warm skin, often redness in
symptoms the face, heavy breathing, fruity
odour in the breath (acetone)
124
III Symptoms and diseases and their treatment
TREATMENT PROCEDURES
IV TREATMENT
PROCEDURES
40 Securing the airways, intubation
41 Measuring the blood sugar
42 The drugs in the ship’s pharmacy and their use
43 Drug injections
44 Drug treatment of the eyes
45 Intravenous (IV) infusion therapy
46 Measuring blood pressure
47 Wounds
48 Retention of urine and catherization of urinary
bladder
49 Positioning, moving, and evacuating a patient
50 Cleaning hands and instruments
125
IV Treatment procedures
One of the most important and urgent upwards so that the head tilts slightly
treatment procedures for a critically ill backwards, and the lower jaw (dental
or injured patient is ensuring his/her level) is positioned in front of the up-
breathing. The body’s oxygen intake must per jaw.
be guaranteed, and a possible lack of • Check to see whether the patient is
oxygen has to be treated as efficiently as breathing, by feeling the movement of
possible. The airways have to be opened the air with the back of your hand and
and any obstruction removed. Breathing observing breathing movements.
must be secured with a pharyngeal tube • Make sure that there are no foreign
or by intubation, if necessary. If a patient is objects in the mouth or pharynx and,
breathing weakly, his/her breathing is en- when necessary, clear the mouth me-
hanced by giving extra oxygen with a face chanically with your fingers or with
mask. When the patient is not breathing suction.
independently, the ventilation of the lungs • Insert the pharyngeal tube to keep the
has to be aided with mouth-to-mouth res- airway open.
piration, or with a breathing bag attached • Secure the ventilation of the lungs
to a face mask or intubation tube. via the pharyngeal tube by mouth-
to mouth respiration or by using a
● Ensure the patient’s oxygen supply mask and a breathing bag when the
patient’s own breathing is weak or
• by opening the airways
undetectable. The rate of blowing is
– turn the patient on his/her side the same as the resuscitator’s own
– clear the airways with suction respiration rate (about 12–16 times a
or by removing any obstruction minute).
from the mouth and pharynx
with your fingers When breathing is assisted either mouth-
• by giving extra oxygen to a patient to-mouth or with a breathing bag, the
who is breathing independently success of the air flow has to be monitored
• by blowing air into a non-breathing all the time by watching the movement of
patient, mouth-to-mouth or the patient’s chest. If the chest is not rising
with a breathing bag connected to although air is being blown in, then the air
a face mask or an intubation tube.
may be going into the stomach. Blowing
must not be continued in the same way,
until the position of the patient’s head
1 Securing the airways has been corrected. After correcting the
with a pharyngeal position of the head, the blowing must be
tube repeated, and it must be checked that the
chest really rises during the blowing. When
Open airways are secured with a pharyn- air is blown into the patient’s stomach, it
geal tube in the following way: may induce vomiting and, as the patient
is lying down, the contents of the stomach
• Lay the patient down on his/her will go into the lungs. The pharyngeal tube
back and lift the patient’s lower jaw does not prevent this. The result is severe
126
IV Treatment procedures
lung irritation that may even lead to life- • Breathing bag. Make sure that the
threatening pneumonia. breathing bag can be attached tightly
to the endotracheal tube!
2 Intubation • Pharyngeal tube.
If the patient does not start breathing on Performing the intubation (Figures 41–46).
his/her own, or requires more efficient Before beginning the intubation, make
long-term assistance, a breathing tube is sure that there is enough room behind the
inserted into the trachea (intubation). This patient’s head. Calm yourself and proceed
is to make sure that the patient’s airways as follows:
definitely stay open and the breathing as- • Take a good position (kneeling behind
sistance is efficient. In addition, intubation the patient’s head and facing the pa-
prevents any stomach contents from going tient).
into the lungs. • Put something under the patient’s head
to lift it (e.g. a pillow or a thick book)
Performing the intubation and tilt the head backwards (Figure
Prepare the following equipment: 41).
• Laryngoscope. Check first that the lamp • Hold the laryngoscope in your left hand
is working (Figure 40). and insert it into the patient’s mouth,
• Endotracheal tube (size corresponds to slightly slanted from the right towards
the width of the patient’s little finger). the midline, or straight to the midline
Adult sizes are 7, 8 or 9. (Figure 42). The purpose of inserting the
• Tape for attaching the tube. laryngoscope from the right side of the
• 10 ml syringe. mouth is to move the tongue towards
the left side to enhance visibility into
the pharynx.
127
IV Treatment procedures
IV Treatment procedures
128
IV Treatment procedures
129
IV Treatment procedures
130
IV Treatment procedures
Normal fasting blood sugar measured from absorbent paper towel or tissue, the test
a drop of blood taken from the fingertip, strip kit, and a watch (Figure 47). The blood
is considered to be between 3.5 and 5.5 sugar is measured as follows:
mmol/l (the person has fasted 6–8 hours • Wear protective gloves.
prior to the test). • Take the test strip from the container
In instant tests, the blood sugar is de- and close the container immediately.
termined from a drop of blood with a test • Clean the tip of the patient’s middle
strip (e.g. Glucotest). A healthy person finger with a cleansing swab and let
does not secrete sugar into his/her urine. the fingertip dry.
Consequently, measuring the amount of • Take a firm grip of the fingertip and
sugar in urine does not help in determining prick a hole with an injection needle
the blood sugar level of a healthy person. or a lancet on the side of the fingertip
If a person has diabetes, his blood sugar about 5 mm from the edge of the nail
level rises and sugar starts to secrete into (Figure 48). The hole has to be big
his/her urine. However, even in a diabetic enough for a drop of blood to come
patient the amount of sugar in urine does out by itself. The fingertip should not
not indicate the current blood sugar level be squeezed.
of the patient’s blood. It merely tells that • Wipe off the first drop of blood and let
the blood sugar level has at some point a new drop form.
been too high and has crossed the person’s • Touch the drop of blood with the
individual renal threshold, at which point indicator head of the test strip so that
sugar starts to secrete into the urine. In the the whole indicator area is wet (Figure
case of diabetic patients, the secretion of 49).
sugar into the urine is a sign of a poorly • Follow the instructions and time guide-
managed disease. When diabetes is treated lines of the test strip kit carefully when
well, no sugar is secreted into the urine. handling the strip.
Every test strip kit meant for measur- • After waiting for the colour reaction for
ing blood sugar contains precise instruc- exactly the length of time stated in the
tions. They must be read carefully before instructions, compare the colour with
measuring, because different manufactur- the test colours on the container (Figure
ers’ instructions give different handling 50). The patient’s blood sugar level is
methods and times. The instructions given determined by comparing the colour of
here are mostly suggestions. The instruc- the test strip with the colour squares on
tions concerning the test strips that are used the side of the container.
dictate the actual steps of the procedure.
In case of an emergency, the patient’s skin
can be left uncleaned. However, the fin-
● Follow the instructions for using the
test strips carefully. gertip must always be dry. Always and in
all situations avoid skin contact with the
patient’s blood.
The equipment needed for measuring
blood sugar: an injection needle or lancet,
131
IV Treatment procedures
IV Treatment procedures
132
IV Treatment procedures
133
IV Treatment procedures
Triangle drugs and alcohol should itching and reddening of the treated skin
not be taken simultaneously. When used area, which become worse as the treatment
IV Treatment
together they have a depressive effect on procedures
is prolonged.
the central nervous system. Their com- The allergic reaction caused by drugs
bined effect can be totally unpredictable, used internally may appear in many differ-
ranging from depression to an episode of ent forms, ranging from symmetrical rash to
aggressiveness. Alcohol and a tranquilliz- fever, skin and lip swelling, elevated pulse,
ing drug enhance each other’s effect and breathing difficulties and anaphylactic
may together lead to an unexpected lapse shock. A similar reaction can be caused
in judgment and perception. by any other ingested substance as well
The effect of a triangle drug may last (food, drink).
a considerably long time. For example,
diazepam taken in the evening can still
● Suspect an allergic reaction if,
have an effect the following morning. during medical treatment, the
There are no contraindications to us- patient develops a symmetrical
ing triangle drugs if the patient is unable rash or suffers from breathing
to work because of his/her illness or injury. difficulties which become worse as
the treatment continues.
For example, diazepam (4/A) causes fatigue
and relieves anxiety but, at the same time,
eases muscle tension and spasms. When The treatment for a sudden allergic re-
treating a painful muscle cramp, lumbago action with severe symptoms is always
for instance, diazepam and a painkiller is an adrenaline injection (1 mg/ml, 8/A)
a good combination. given intramuscularly or intravenously
It must be borne in mind that all drugs (see below). The dose for a normal-sized
may cause fatigue. The illness itself can adult is one ampoule (1 mg) of adrenaline
also cause tiredness. These factors must be (1 ml). Only after this proceed to other
taken into account when assessing a sick treatments.
person’s ability to work.
● The primary treatment for a sudden
3 The harmful effects allergic reaction with severe
of drugs symptoms is always an adrenaline
injection.
All drugs can have harmful effects. The
beneficial and harmful effects of triangle If the patient is able to communicate and
drugs often go hand in hand. Tranquillizing is still breathing with relative ease, the
and causing tiredness are beneficial effects adrenaline injection can be administered
of a drug for a restless person, but they are intramuscularly. An intravenous injection is
harmful for persons working in positions recommended when the situation is really
requiring precision and alertness. serious, the patient’s breathing is shallow,
Some drugs irritate the stomach (e.g. and he/she is pale and nauseous. Instead
painkillers and fever medicines) and some of spending time trying to find a vein, the
cause diarrhoea (e.g. anti-inflammatory injection can be given into the tongue
analgesics and antibiotics). because it has good blood circulation, and
One common harmful side effect of a the drug is effectively absorbed. You can
drug is an allergic reaction. When a drug is get a good grip on the tongue by holding it
used locally (e.g. creams for treating rash, with a piece of paper or cloth. The dose can
analgesic cream) the allergy appears as be administered again in 10–20 minutes, in
case the first injection did not help.
134
IV Treatment procedures
43 Drug injections
An injected drug takes effect more quickly
than an orally given drug, and the dosage ● When giving an injection you need:
is more accurate. This method of medica- • the drug
tion can also be used when the patient’s
• suitable-sized syringe and two
condition does not allow other medication needles
methods.
• cleansing swabs for cleaning the
injection bottle and the skin.
1 Preparatory
procedures
When the equipment is ready, proceed in
Drugs are packed either in glass ampoules, the following way:
the neck of which needs to be broken in • Make sure that the drug bottle contains
order to use the drug, or in injection bottles the correct drug preparation, and that
from which the drug is drawn with a syringe the concentration of the drug (mg/ml)
and a needle through a rubber cork. is correct!
135
IV Treatment procedures
• Check the date on the package to see common site for an injection is the outside
that the last date for using the drug has of the upper arm. A fold of skin is taken
not expired. IV Treatment
between the procedures
thumb and the index finger,
• Check how large a dose of the drug and the skin is pierced at a 45 degree
is required. angle, so that the needle tip goes in to the
• Take a syringe and attach a needle correct depth (subcutaneous tissue). Check
to it. that the needle has not pierced a blood ves-
• Injection bottle: sel. This can be done by either detaching
– Carefully clean the rubber cork of the syringe from the needle or pulling the
the injection bottle with a cleansing syringe piston outwards. If blood does not
swab. come out, the needle is at the right depth
– Draw the same amount of air into the and the drug injection can be slowly given.
syringe as drug will be taken from the After this, the needle is carefully pulled out
injection bottle. and, when necessary, the site of injection is
– Push the needle through the rubber pressed for a short time with a pad in order
cork. Inject the air into the bottle. to keep the drug from dripping out.
– Draw the correct amount of drug into
the syringe. Intramuscular injection
– Remove any air that may have en- A drug is absorbed much more quickly
tered the syringe when drawing the if it is given intramuscularly rather than
drug in and replace the needle by a subcutaneously. The most common site
new, clean, dry one. for the injection is the outside of the out-
• Drug ampoule: ermost quarter of the buttock or the thigh
– Move the drug from the ampoule muscle on the outside of the thigh. The
neck to the bottom of the ampoule sciatic nerve runs closest to the midline of
by gently tapping it. the buttock and it is necessary to be very
– Wipe the neck of the ampoule and careful not to damage it. When giving the
break it. injection, the muscle has to be as relaxed
– Draw the amount of drug needed as possible in order for the injection to be
into the syringe with a needle. painless.
– Remove any air that may have The syringe is held like a pen, and is
entered the syringe when drawing the thrust perpendicularly into the skin and
drug in. through it into the muscle. Check to see
• Clean the area of the patient’s skin that the tip of the needle has not struck a
where the injection is to be given with blood vessel (see above). Then inject the
an alcohol swab. drug slowly into the muscle. The needle
• Give the injection. is pulled out and, when necessary, the
injection site is pressed for a short time
2 Giving the injection with a pad.
136
IV Treatment procedures
in intravenous fluid replacement therapy: on the vein with a pad for about five
• Clean the injection site with an alcohol minutes to control bleeding.
swab. • When necessary, put an ordinary
• Place a tourniquet on the forearm or wound plaster (band-aid) on the injec-
upper arm to slow down venous blood tion site.
flow and thus distend the veins.
• Push the needle of the drug-contain- 3 Handling the
ing syringe through the skin into the equipment after
vein. Ensure that the needle has struck injecting the drug
the vein by pulling the syringe piston
outwards; if the needle is in the vein, Used needles and syringes must not be
blood flows into the syringe. thrown into an ordinary rubbish bin. They
• Open the tourniquet. must be collected in a glass or plastic jar or
• Inject the drug slowly into the vein, tak- bottle reserved for the purpose, and taken
ing care to keep the needle steady. Mov- off the ship according to the instructions of
ing the needle easily causes it to come the shipping company. Used cleaning pads
out of the vein and the injection fails. are handled like normal waste.
• After giving the drug, first pull the
needle out of the vein and then press
The eyes are most often treated locally with 1 Eye drops
eye drops or ointments to the palpebral
fissure (under the lower eyelid). The drops Eye drops are given in the following way:
have a fast but usually short-lasting effect. • The person giving the drops washes
The drug is released more slowly from eye his/her hands.
ointments and is not diluted by the tear • Check that the drug to be used is the
fluid as easily as eye drops. correct one. The date of the opening
Eye medications or drug packages
are personal. An opened eye drug remains
usable for one month when stored as
instructed. The date of the opening of the
package should always be marked on the
package so that the time period during
which the drug is usable is known.
Eye drugs are administered into a
clean eye. If there is any discharge in the
eye lashes or eyelids, the eye is cleaned
before medication either by washing with
water or saline solution, or by gently wip-
ing it clean. Figure 51. Eye drops are dropped into the
opened lower eyelid
137
IV Treatment procedures
138
IV Treatment procedures
139
IV Treatment procedures
140
IV Treatment procedures
141
IV Treatment procedures
while a standard flow rate is 15–20 The infusion does not work. What
drops/min. is the problem?
• Monitor the infusion constantly, IV Treatment
and procedures
If the fluid does not seem to flow from
record the amount of fluid given and the tubing into the patient, the reason
the infusion rate on the patient’s fol- may be:
low-up form. • The roller clamp is closed – open the
roller clamp.
● Consult a doctor via Radio Medical • A bend in the tubing prevents the flow
about the infusion rate and total of fluid – straighten the bend.
amount of fluid.
• The infusion bottle or bag is set too
low, and thus the infusion pressure is
If the infusion is continued after the first too weak – move the infusion bottle
bottle or bag is empty, make sure that or bag higher.
when changing the bottle or bag, the drip • The catheter is not in the vein but, for
chamber of the IV set is half full and the example, under the skin – insert the
tubing is full of fluid, so that no air gets into catheter at a new site, usually above
the patient’s circulation. the previous insertion site.
There is a plug on top of the catheter • A blood clot has blocked the needle
into which the tip of a syringe fits. Through – rinse the catheter by injecting sterile
this, it is possible to administer medications 0.9% saline through it, or insert a new
directly into the vein, if necessary. catheter at a different site.
142
IV Treatment procedures
143
IV Treatment procedures
47 Wounds
A wound is a skin injury which may also A scratch or abrasion results from, for ex-
involve damage to deeper tissues. ample, a graze or a fall. When capillaries
are broken, blood trickles from the wound.
1 Different types Treat the wound by cleaning it properly
of wounds with water and an antiseptic, and then
cover it with a clean dressing.
Healing of a wound depends on the type, An incised wound is caused by a
size, location and cleanness of the wound, sharp, cutting object such as a knife. The
and how quickly it is treated. edges of the wound are clean. The wound
penetrates to the subcutaneous tissue and
144
IV Treatment procedures
bleeding may be profuse. Nerves and risk of infection is very high, so antibiotic
tendons may also be damaged. Close the treatment is usually necessary, in addition
wound, depending on its size, either with to cleaning and dressing the wound. A bite
skin strips or stitches. Cover it with a sterile, wound should not be closed with stitches,
absorbent dressing. Consult Radio Medical because of the risk of infection.
if you suspect nerve or tendon injuries.
A puncture wound is caused by a 2 Treatment of wounds
stab with a sharp object, and is often very
dangerous. Visible bleeding may be minor, Stopping bleeding
but deep in the body there can be internal Stop minor bleeding by dressing the
bleeding, and even severe tissue and organ wound, and use stitches, if necessary. Ma-
damage. The risk of infection is high. If a jor external bleeding must be controlled
puncture wound penetrates a lung, the as soon as possible, since arterial bleed-
lung may collapse. Thus, it is important to ing can cause the patient to lose a large
move the patient to shore for further treat- amount of blood in a short time.
ment as soon as possible. Always use protective gloves when
In a shot wound, the entry wound is treating wounds. This way you will not
usually small, but the exit wound is large introduce any additional infectants into
and ragged. Visible damage may be small, the patient; at the same time you protect
but internal damage caused by a bullet is yourself from possible diseases transmitted
nevertheless often severe. Do not close by blood (e.g. hepatitis and HIV).
puncture or shot wounds with stitches,
since it is impossible to evaluate the depth
● Always use protective gloves when
of the wound and possible internal dam- treating wounds! Infection risk!
age on board.
Especially puncture and shot wounds
can be life-threatening, regardless of their Raise the bleeding limb above the patient’s
appearance. heart level. The wound area should not be
touched, unless this is necessary because
of profuse bleeding. If the blood comes
● Consult a doctor via Radio Medical!
out in spurts, the wound can be pressed
directly with thumb, fist or palm. Place a
A contused wound is usually caused by a clean dressing over the wound, and on top
blunt object. The tissue around the edges of of it, e.g. a roll of bandage as a pressure
the wound is bruised and the edges of the bandage, and then bind the wound snugly
wound are ragged. The wound may bleed with an elastic bandage. Monitor the status
profusely, and risk of infection is high. of the patient to make sure that the bleeding
If the wound is in a limb, it is im- stops. The bandage should not be so tight
perative to check that the limb functions that the fingers or toes start to tingle or turn
normally, the fingers and toes move, cold and bluish. An injured upper limb can
and their sense of touch is not impaired. be supported in an elevated position with a
Determine whether the circulation func- triangular bandage (Figure 60).
tions normally by feeling the pulse at the A tourniquet should generally not be
extremities of the limb. If the wounds are used. It is an extreme treatment method,
in the head, remember the possibility of a and should be used only in cases when a
fractured skull. limb is amputated or crushed in several
A bite wound usually results from a places, and there is no other way to stop
bite by an animal or a human being. The the bleeding.
145
IV Treatment procedures
Cleaning a wound
Incised wounds caused by sharp objects do
not usually require any special cleaning, Figure 60. The upper limb can be
so they can be closed immediately. If there effectively supported with a triangular
is dirt or debris (e.g. sand) in the wound, bandage
it must be removed first before other treat-
ment is given.
A particularly dirty wound should first
be washed properly in running water. A the blood flow back to the heart and thus
less dirty wound can be cleaned by rins- reduces bleeding and swelling of the in-
ing with sterile antiseptic solution, which jured area, and eases pain.
is injected into the wound with a syringe If the wound is clean and does not
and injection needle. The dirty area around bleed through the dressings, the dressings
the wound can be cleaned with soap and can be left on for even a week. The dress-
water. However, do not let the soap get into ings should not be allowed to get wet. If the
the wound itself. dressings nevertheless get wet, they should
be changed immediately for dry ones. You
Dressing a wound can leave the lowermost non-adherent pad
After cleaning, place a gauze dressing over unchanged and change only the dressings
the wound. Place a non-adherent pad next over it. It is easier to remove dressings if
to the wound to make it easier to change they are moistened before removal.
the dressing. Never put cotton wool di- If there is substantial secretion from
rectly onto a wound, since it is difficult to the wound, and especially if the secretion
remove later. Place sterile gauze dressings increases or the wound area becomes
over the initial dressing or pad and secure sore or reddened, the dressings should
them with tape or bandage. If the wound be opened daily to clean the wound (see
bleeds, the bleeding can be reduced by Cleaning a wound).
moistening the lowermost dressings with
blood-vessel-contracting nasal solution Closing wounds
(6/D). Bleeding can also be stopped with A wound heals more quickly and the
a pressure bandage: place an unopened growth of scar tissue is reduced, if the
gauze roll over the lowermost gauze dress- edges of the wound are brought together.
ings and press it against the wound by If the edges of the wound are relatively
wrapping an elastic bandage around it. clean and cannot be kept together with a
The injured area should be kept in an dressing, try to close the wound with skin
elevated position, because this facilitates strips or with stitches.
146
IV Treatment procedures
Usually a wound should be closed as Carefully remove any hair around the
soon as possible, within six hours of the wound to allow the skin strips to attach bet-
incident at the latest. If it is done later, the ter. Do not, however, touch the edges of the
edges of the wound must be treated first. wound. Clean the edges with chlorhexidine
In such a case the wound should be closed solution and allow them to dry.
by a doctor. Attach one end of the skin strip to one
side of the wound. Draw the edge of the
Closing a wound with hair wound towards the other edge with the
Wounds on the scalp can be closed using strip; at the same time, support the other
the patient’s own hair (Figures 61 and 62). edge with the fingers. When the edges of
Place a thread (suture thread, ordinary the wound touch each other, attach the
sewing thread is also suitable) in the other end of the strip to the skin on the
wound parallel to it. Take some hairs from opposite side of the wound.
both sides of the wound and pull them The edges of the wound should
transversely across the wound to draw touch each other lightly. Avoid unneces-
the edges of the wound together. Next, tie sary tightening. The length of skin strip
the hairs tightly together with the thread should be about 2–3 cm on either side of
placed in the wound, so that the hairs from the wound.
opposite sides of the wound stay fastened The stability of the skin strips can
together and, at the same time, keep the be ensured by placing an additional strip
edges of the wound together. If necessary, across the ends of the strips. Keep the
repeat this at several points of the wound wound dry as long as the strips are kept
to close it along its full length. Leave the on, usually for 7–10 days.
bindings on for about 10 days.
Closing a wound with stitches
Closing a wound with skin strips Sometimes the methods described above
In hairless skin areas, a wound can be are not enough, and the wound must be
closed with skin strips (Figure 63). closed with stitches (sutures).
Figures 61 and 62. A head wound can Figure 63. A wound can be closed with
be closed with the help of the patient’s skin strips
own hair
147
IV Treatment procedures
148
IV Treatment procedures
twice a day. Continue the local treatment the heart, caused by the swelling and
of the wound and the antibiotic medication inflammation of lymph vessels. When the
until the situation has subsided. Usually a infection reaches the lymph nodes, they
10-day antibiotic treatment is sufficient. In become enlarged and tender. Lymphangitis
uncertain situations it may be advisable to is not life-threatening (it is not blood poi-
consult a doctor via Radio Medical. soning!) but it requires a course of antibiot-
Lymphangitis (inflammation of lymph ics. Give the patient one 500 mg capsule
nodes and vessels) often originates from of cefadroxil (7/E) twice a day for 10 days.
infected wounds. A visible symptom is a Also take care of the local treatment of the
red, tender streak from the wound towards wound that caused the infection.
149
IV Treatment procedures
IV Treatment procedures
Figure 65. Anaesthe-
tize both edges of the
wound
150
IV Treatment procedures
151
IV Treatment procedures
2 Performing
The length of the male urethra is 15–20 catheterization
cm from the bladder to the tip of the penis.
The female urethra follows the front wall of Male urinary catheterization
the vagina and is much shorter, only about Cover the patient’s stomach and legs with
4–6 cm. Female catheters are shorter than a clean cloth leaving the penis clearly vis-
male catheters. Female urinary catheteri- ible. Place the patient in a supine position
zation can also be performed using male with legs straight. Calm him and tell him
catheters, but not vice versa. that the procedure will be unpleasant.
Take hold of the penis with a sterile
cloth and retract the foreskin to its maximal
limit. Cleanse the opening of the urethra
thoroughly using cleansing cream and
Urinary bladder sponges. Anaesthetize the urethra with
local anaesthetic gel.
Pubic bone
Use tweezers to hold the catheter
Prostrate gland about 5 cm from its tip. While lifting the
Urethra penis upwards with your other hand,
Rectum slowly and gently insert the catheter into
the bladder through the urethra until urine
Testicle
flows into the tube (anatomy of male ure-
thra, Figure 71). An assistant, if available,
holds the other end of the catheter.
Figure 71. Anatomy of male urethra
152
IV Treatment procedures
Let the urine drain into the urinal cleansing cream and sponges. Cleansing
and measure the amount. The flow can be is performed by wiping backward using a
stimulated by gently pressing the stomach new sponge each time. Anaesthetize the
above the pubic bone. When the urine flow opening of the urethra with local anaes-
stops, remove the catheter. thetic gel.
Use tweezers to hold the catheter
Female urinary catheterization about 5 cm from its tip. Slowly and gently
The procedure for female urinary catheteri- pushing in the direction of the patient’s
zation is the same as for the male cath- chin, insert the catheter into the bladder
eterization. Place the patient in a supine, through the urethra until urine flows into
frog-legged position. Cover her stomach the tube.
and legs with a clean cloth. Let the urine drain into the urinal
Spread the labia so that the opening and measure the amount. The flow can be
of the urethra, situated above the vaginal stimulated by gently pressing the stomach
orifice, can be clearly seen. Cleanse the above the pubic bone. When the urine
opening of the urethra thoroughly with flow stops, remove the catheter.
49 Positioning, moving,
and evacuating a patient
In the case of accident and sudden illness, Supporting the legs
the aim is to prevent the patient’s condition An injured limb can be supported in many
from worsening by positioning the patient ways. The idea is to prevent movement in
correctly. A conscious patient can choose the injured part or the whole limb. The
the most comfortable position him/herself. support and bandages must not adversely
When unconscious, the patient needs to be affect the patient’s overall condition. The
positioned correctly to keep the respiratory support should be padded, and too tight
tract open. The correct position depends on bandages should be avoided.
the condition of the patient (Table 8). An inflatable air splint is a quick and
easy way to support a limb. Triangular
1 Supporting the bandages are very useful for supporting an
patient’s neck or legs upper limb. The arm rests on top of one tri-
before moving from angular bandage, while the other bandage
the site of the accident supports the arm against the chest. An arm
sling is also a good first aid support for a
Supporting the neck shoulder dislocation as well as for fractures
If there is even the slightest possibility that of the collarbone, shoulder and arm.
the patient has a cervical spine fracture,
a neck support is put in place carefully
without moving the head.
153
IV Treatment procedures
2 Moving a sick or
injured person
IV Treatment procedures
If there is a possibility of imminent danger,
such as fire, explosion, or poisoning, in
the immediate vicinity, the patient needs
to be moved immediately to a safe place.
Anyone helping the patient also needs
to consider his/her own safety, as there
might be a risk of electric shock, poison-
ing, etc.
The patient is given first aid in safe
surroundings. Only then are plans made
for moving the patient to a place such as
the ship’s infirmary or sick bay for further
treatment, or to land. The patient needs to
be prepared for the transfer (e.g. the neck
and limbs need to be supported), and the
best route and means for the transfer are
decided upon. The best way to move a
patient depends on the patient’s condition,
the type of injury, and the route. Figure 72. The
The patient must be monitored during patient is well
the transfer to prevent his/her condition strapped into the
from worsening. Before moving the patient, stretcher when
his/her basic vital functions (i.e. breathing being moved
154
IV Treatment procedures
and blood circulation) must be secured. from the other consulates. The contact
The patient is kept warm using blankets. information of the national consulates
If a stretcher is used for moving the can be obtained from the local telephone
patient, he/she must be strapped in so directory, hotels, or the evacuation au-
well that the injuries (e.g. fractures) are thorities.
not made worse by the movement of the The Internet contains a lot of infor-
stretcher. The stretcher is carried horizon- mation about travel safety, passports and
tally. If this is not possible, the patient must visas. There is also detailed information
be supported extra carefully to be moved about the current situation and the level
vertically (Figure 72). of health care of the countries. Especially
the US pages are up-to-date, and offer
3 Evacuation a great deal of information (http://travel.
state.gov).
According to international law, if a sick or The consulates offer advice and help
injured person needs to be evacuated to in organizing the treatment, as well as
land for further treatment, it is the shipping other help. If necessary, they will also
company’s responsibility to make sure that give help in contacting the shipping or
the patient gets proper treatment there. insurance company, or the family of the
Evacuation is performed according to injured person. However, they do not pay
the instructions of the shipping company. the hospital costs or any other expenses,
Practical implementation of the evacuation e.g. the services of an interpreter.
is negotiated and decided upon mainly Both domestic and foreign insurance
with the coast guard or harbour authorities companies annually publish various bul-
of the evacuation country. letins and lists of the different physicians
If the shipping company has its own and treatment facilities they have approved
agent in the harbour of the evacuation in the various countries. Insurance com-
country, he/she will help to organize the panies have a 24-hour telephone service.
evacuation, to find a treatment facility, and Many private emergency enterprises
to get the patient back to the home country. provide worldwide medical services and
If the company does not have an agent of its the patient’s evacuation back to the home
own, it might have, for example, financial country.
connections at the evacuation harbour.
Therefore it is always worth asking advice
● Before evacuating a patient, contact
from the shipping company. one of the following to organize the
The level of treatment varies markedly evacuation and to choose a suitable
in different countries as well as within treatment facility (Note: Instructions
a country. The quality of treatment may of the shipping company):
vary greatly also in one treatment facility • harbour authorities
at different times. If the evacuation occurs
• coast guard
outside the so-called developed countries,
it may be difficult to find a facility with • shipping company agent
proper treatment services, where the sick • national embassy or consulate
or injured person could be safely left. • insurance company.
The national embassies, consulates,
and honorary consulates can be consulted
about choosing the treatment facility. If a A report should accompany the evacuated
national contact is not represented in the patient. The report should include as accu-
evacuation country, help can be asked rate information as possible about the situ-
155
IV Treatment procedures
156
IV Treatment procedures
3 Cleaning of 4 Handling
instruments and contaminated
disinfection dressings and textiles
All non-disposable instruments such as Always wear sterile gloves when handling
scissors, needle holders and tweezers need contaminated dressings and textiles. Place
to be rinsed with cold water first and then the textiles in a plastic bag and close it
washed with warm water and soap (dish- tightly. The manner of their disposal should
washing liquid) using a brush until all the be agreed upon with the occupational
visible dirt is removed. Then sterilize the health service of the shipping company,
instruments by boiling them in water for 10 because there is always a risk of infection
minutes. Lift them out of the water without with materials contaminated e.g. with
touching them with the bare hands. Put the excretions. There are special instructions
instruments into a covered steel container for the disposal of contaminated materials.
used for storing instruments. The instru- Taking off contaminated gloves should also
ments should always be clean and sterile be done with care.
so that they are ready to be used whenever
needed. 5 Cleaning treatment
Respiration masks and respiratory tables and rooms
valves are washed in cool soapy water,
after which they are dried. Then wipe the Treatment rooms need to be cleaned well
masks and valves with a cloth soaked in after use, especially if there is blood or
plenty of liquid disinfectant. After this, let excretion on the treatment table or floor.
them dry again and place them in the con- Wash the excretion from treatment tables
tainer, ready for use the next time. and dirty surfaces with soap and water, and
For everyone’s own safety, it is impor- then wipe the surfaces with a cloth soaked
tant to remember to use sterile gloves when in plenty of liquid disinfectant. It is also
cleaning instruments and work tables. If possible to use chlorhexidine solution or,
the instruments are kept unwrapped in a for example, 40–60% alcohol.
steel container, it is good to rinse them, for
example, with liquid disinfectant just be-
fore use. In an emergency, strong alcoholic
solution is also acceptable.
157
SELF-PROTECTION
V SELF-PROTECTION
51 Self-protection and prevention of infections
52 Vaccinations for seafarers
53 Death on board
V Self-protection
160
V Self-protection
161
V Self-protection
53 Death on board
An injured or sick person will be treated
until death can be confirmed. Even if a If the time of death is unknown, it can be
patient cannot be saved, everything pos- estimated on the basis of the so-called
sible should be done to alleviate his/her secondary signs of death:
last moments. • Body temperature decreases by about
one degree an hour at room tempera-
Death can be confirmed on the basis of ture.
the following signs: • Blotches (skin colour turning to bruise-
• Pupils are permanently enlarged and like purple) appear on the body parts
do not react to light. facing downward in less than half an
• Spontaneous breathing has stopped hour from the moment of death (livor
and cannot be restarted by giving re- mortis). Within 6 hours of death the
suscitation. blotches can be removed completely
• There is no heartbeat and resuscitation by pressing.
has not been successful.
162
V Self-protection
• Rigor mortis, stiffness, first becomes ered: If the person is found dead, when
evident in the jaw within 2–4 hours. It was the last time he/she was seen alive?
spreads down to the legs in 6–8 hours, Who was the last person to see him/her
and disappears in the same order alive? Who found the deceased person?
within a couple of days. Are there any signs indicating the cause
• The first sign of putrefaction appears as of death (e.g. violence or accident) on the
a greenish colour on the lower abdo- body or at the scene?
men within a couple of days. If the deceased is found on board, the
surroundings should be kept unchanged.
When a patient dies, the time of death, If that is not possible, information about
as well as all the signs of death, are re- the events and the situation should be
corded. The signs include no breathing, recorded in detail. If there are any abnor-
no heartbeat, no blood pressure, size of malities in the surroundings or the scene,
pupils, no reaction to light, blotches and the deceased and the surrounding area
the possibility of removing them by press- should be photographed.
ing, and rigor mortis. The ship’s captain informs the authori-
For later investigation of the cause of ties about the death, and they give instruc-
death, the following information is gath- tions on how to proceed.
163
ADVICE AND INSTRUCTIONS
VI ADVICE AND
INSTRUCTIONS
54 Radio Medical
55 Confidentiality and seafarers’ health care
VI Advice and instructions
54 Radio Medical
166
VI Advice and instructions
• Ask for instructions for further treat- • always when there are respiratory
ment. problems or abnormal breathing
• Keep record of the instructions given • fever has lasted for over 2–3 days
by the doctor. • the temperature from the armpit is
• Carry out the instructions given by the over 39.5˚C
doctor. • all cases of stomach or chest pain
• Record the treatment given. • when administering medication
• Monitor the patient’s condition. which is marked “only on doctor’s
• Consult the doctor again if necessary. orders”
• Call a doctor to the ship, for example, • fractures and larger bruises and cuts.
by helicopter.
• Evacuate the patient from the ship as
● If you are at all unsure about
soon as possible. what you should do, consult a
doctor through Radio Medical!
3 When is consultation
via Radio Medical 4 Consulting Radio
necessary? Medical in practice
The ships’ modern communication equip- The importance of the advice given by
ment enables consulting a doctor through Radio Medical and the benefit gained from
Radio Medical whether you are sailing in it depend above all on the fact that there is
home waters or far away in foreign seas. a person on board with basic knowledge
A doctor should be consulted in all cases of medicine. He/she must be able to de-
of illness or injury. Even when the person scribe the symptoms in detail, so that the
responsible for treatment on board ship doctor understands them correctly. Basic
believes that his/her knowledge and skills readiness and know-how must be available
are sufficient, it is still often advisable to on the ship so that the doctor’s advice and
ask for a professional opinion (a so-called instructions can be carried out.
second opinion) to support his/her own
decisions and actions. Clear messages
Most minor complaints and injuries Even with modern equipment there is still
can be treated safely and rather well with- considerable disturbance in radio commu-
out consulting a doctor. However, always nication today. It is therefore important that
remember that even minor symptoms can all the information given from the ship to
sometimes be a sign of a more serious the doctor and all the advice and instruc-
condition. Monitoring the patient’s health tions given by the doctor are heard and
and condition after initial treatment is understood clearly and unambiguously.
always necessary. When reporting medical informa-
It is impossible to give a complete list tion it must be remembered that the
of situations when consulting a doctor is confidentiality of radio communication
necessary. For example, in the following is often inadequate e.g. marine VHF (very
cases, consultation through Radio Medical high frequency) radio calls. Therefore,
should be at least seriously considered: the name of the patient, identity code, or
• all mental health disturbances other personal information should not be
• all disturbances of consciousness mentioned without a compelling reason
• always when heart rate and blood in a communication medium that can be
pressure are abnormal monitored by outsiders.
167
VI Advice and instructions
55 Confidentiality and
seafarers’ health care
The data security regulations concerning carry out his/her statutory duties. Only a
the confidentiality of seafarers’ health person appointed by the shipping company
care are in accordance with those of any has access to medical records, no one else.
other form of public health care. Seafaring All confidentiality regulations also apply
regulations and guidelines might, however, to this person.
complicate the already complex data secu- Seafarers need a special health cer-
rity and confidentiality regulations. tificate when a contract of employment is
drawn up. This may include a comprehen-
1 Maritime employer’s sive, detailed description of prior health,
obligation to obtain which is verified by the seafarer’s signature.
information If an employee has failed to report an in-
jury or illness when signing the contract of
The maritime employer must be aware employment, the maritime employer may
of the seafarer’s health and any potential not be obligated to cover, for example,
changes in it. Without this information, treatment costs.
the maritime employer will not be able to
168
VI Advice and instructions
169
STRUCTURE AND FUNCTIONS OF THE
HUMAN BODY, EXAMINATION AND
RECORDING THE INFORMATION
FUNCTIONS OF THE
HUMAN BODY,
EXAMINATION
AND RECORDING
THE INFORMATION
56 Structure and functions of the human body
57 Examining the patient
VII Structure and functions of the human body,
172
examination and recording the information
Skull
Cervical spine
Clavicle
Scapula
Breastbone (sternum)
Humerus
Ribs
Spinal column
Elbow bone (ulna)
Radius
Pelvis
Sacrum
Wrist (carpus)
Kneecap (patella)
Shinbone (tibia)
Fibula
Ankle (tarsus)
Pulmonary artery
Aorta
Heart
Liver Lungs
Spleen
Kidney
Intestines
173
VII Structure and functions of the human body,
tricular fibrillation, and the patient dies resistance in the arteries. Systolic blood
without effective resuscitation. pressure refers to the pressure in the arte-
The arteries transport oxygen-rich rial system when the heart is contracting.
blood to the tissues. The arteries, which Diastolic blood pressure, on the other
originate from the aorta branch further hand, is the pressure in the arteries when
into smaller arteries, and finally into very the heart is at rest. An electrocardiograph
small vessels called capillaries. The passing is a device used to measure the electrical
of nutrients, oxygen and carbon dioxide activity of the heart. Damage to the heart
from blood into the tissues, and vice versa, muscle after a cardiac infarction, for ex-
takes place in the capillaries. When the ample, is displayed as an abnormality in
capillaries join together again, they form the electrocardiogram (ECG).
veins that transport the blood back to the
heart. Blood pressure is caused by the flow Blood
The body of an adult contains about 5 litres
of blood. It consists of plasma and blood
cells: red blood cells, white blood cells
Superior Aorta and platelets. There are more red blood
vena cava Pulmonary cells than any other types of blood cells.
artery
Blood cells are formed mainly in the bone
marrow. The life span of white blood cells
Left (except lymphocytes) and platelets is only
atrium a few days; the life span of red blood cells
Right
atrium Left is a few months. Losing a large volume of
ventricle blood, as a result of, e.g. haemorrhage,
may cause circulatory shock.
Red blood cells contain haemoglobin.
Inferior It is a protein which transports oxygen from
vena cava Right
ventricle the lungs to the tissues, and carbon dioxide
from the tissues back to the lungs, from
where it is removed by exhaling. Normally,
Figure 75. The heart
there are 135–170 g/l of haemoglobin in
the blood of men, and 115–160 g/l in the
Superior vena cava blood of women.
Aorta White blood cells help the body
to resist bacterial and viral infections.
They are formed in the bone marrow,
Pulmonary artery
but some of them mature and specialize
in lymphatic tissue. The volume of white
Coronary blood cells in blood normally increases
arteries during infections. Some white blood cells
are capable of moving also in the tissues,
and perform various functions. Thus,
the pus at the site of a local infection is
formed by white blood cells, the bacteria
causing the infection and the damage in
Inferior vena cava the tissue.
Platelets are the smallest type of blood
Figure 76. The heart and coronary arteries cells and originate in bone marrow. They
174
examination and recording the information
have a central role in the clotting of blood to the lung. The space between these two
and in stopping haemorrhage. layers is known as the pleural cavity which
Plasma, the liquid part of the blood, contains a small amount of fluid enabling
contains large amounts of proteins which the smooth sliding of the pleural mem-
carry nutrients and hormones to the tis- branes during the movement of the lungs.
sues. Plasma also contains antibodies and The negative pressure in the pleural cavity
is involved in the clotting process. prevents the lungs from collapsing.
Breathing occurs mainly by move-
3 Lymphatic tissue and ments of the diaphragm and the intercostal
the lymphatic system muscles. At rest, the respiration rate is
12–16 times per minute. About 500 ml
Lymphatic tissue is part of the body’s de- of air is inspired or expired at a time. The
fence system and is found, for example, rate, frequency and intensity of breathing
in the spleen and lymph nodes. There are increase during exertion, as well as during
lymphatic vessels in almost all organs of the course of various diseases.
the body. They all lead to small groups of After passing through the bronchi into
lymph nodes. These groups of lymph nodes the smaller bronchioles, the oxygen of the
are situated in the abdominal cavity, the inhaled air reaches the alveoli where the
thoracic cavity, under the chin, in the neck, gas exchange occurs. The oxygen is ab-
in the crook of the arm, the groin, and in sorbed through the thin wall of the alveoli
the armpits. The nodes become tender and is taken up by the red blood cells. The
and swollen during local inflammations carbon dioxide in the blood, on the other
or infections, and they can then be felt by hand, moves through the membrane into
pressing with the fingers, for example, the the alveoli and is removed from the body
nodes under the chin during pharyngitis. through expiration.
175
VII Structure and functions of the human body,
176
examination and recording the information
177
VII Structure and functions of the human body,
Uterus Cerebrum
Bladder Cerebellum
Pubic bone Medulla
Urethra oblongata
Vagina
Rectum
Spinal cord
Ovaries
Fallopian tubes
Figure 83. Nervous system
Uterus
Vagina
8 Nervous system
Figures 80 and 81. Female reproductive The nervous system consists of the central
system nervous system (CNS), i.e., the brain and
the spinal cord, and the peripheral nerves
that radiate from it (Figure 83). The brain
Bladder is protected by the skull. It comprises the
Pubic bone cerebrum, the cerebellum and the medulla
Prostate oblongata. The brain is surrounded by me-
ninges, between which there is a protec-
Urethra
tive layer of cerebrospinal fluid. The same
Rectum
meninges protect the spinal cord.
Testicle The brain comprises a complex
network of nerves, which control nearly
Figure 82. Male reproductive system all bodily functions and senses either
directly or through neurotransmitters. The
cerebrum, or the main part of the brain,
The male internal genitals consist is responsible for motor functions and
of two testicles, two epididymides, the thought processes. Each organ and sense
seminiferous tubules and the prostate has a corresponding area on the cortex,
(Figure 82). Sperm is produced in the tes- from where its functions are controlled.
ticles, from where, during ejaculation, it The cerebellum takes part in coordi-
is transported via the epidymides, through nating movement and balance. The medul-
the prostate into the urethra and out of the la oblongata is responsible for respiration.
body. The semen largely consists of secre- The spinal cord transmits nerve impulses
tions from the prostate. from the body to the brain and vice versa.
Reflexes are transmitted directly through
the spinal cord and are therefore fast and
involuntary.
178
examination and recording the information
The peripheral nerves consist of send an impulse through the optic nerve
several parallel nerve cell branches. The to the visual centre in the brain, where the
nerves transmit information from differ- visual sensation is formed.
ent organs to the central nervous system The eyes are very cooperative. Ef-
and back. The sciatic nerve starts from the ficiently functioning oblique muscles are
spinal cord and runs through the buttocks needed to focus the eyes at the same point
to the back of the thigh, all the way to the and to form a three-dimensional picture.
ankle. It is the longest nerve in the body. Squinting and double vision are usually
Irritation of the sciatic nerve causes radiat- signs of poor cooperation between the
ing pain in the lower extremities. oblique muscles. Possible causes include
a serious illness or an injury.
9 The eye
The eye is a ball about 2.5 cm in diameter, Middle Organ of
ear chamber Ossicles equilibrium
surrounded by the white sclera. The trans-
(Semicircular
parent cornea is situated in the anterior part canals)
of the eye (Figure 84). The iris lies behind
Vestibulocochlear
it. The pupil is a round opening in the iris nerves
that allows light to pass through it. Its size
changes according to the amount of light Cochlea
present: the pupil contracts in the light and
expands in the dark. The lens is situated Outer
ear External Ear Eustachian canal
behind the iris and becomes thicker or drum
auditory
thinner depending on whether the person canal
wants to focus on near or far objects. With
Figure 85. Anatomy of the ear
age, the lens loses its elasticity, and the
ability to focus on all distances decreases.
In this case, eyesight can be improved by 10 The ear
using glasses.
The area between the cornea, the The outer ear consists of the external ear
iris and the pupil is called the anterior (auricle) and the external auditory canal
chamber, which is full of clear watery fluid. (Figure 85). The external auditory canal
Behind the lens lies the vitreous chamber secretes wax to protect the canal. It ends
filled with a gelatinous substance, vitreous at the ear drum, which is skin-coloured,
humour. Behind it, on top of the choroid light-reflecting and bright when examined
layer, lies the retina, the photosensitive part with an ear lamp. The sound entering the
of the eye. The sense cells react to light and ear passes from the ear drum through to
the ossicles in the middle ear and into the
Anterior chamber Vitreous humour inner ear, where the sound waves cause
the auditory nerve cells to vibrate. These
cells transmit nerve impulses via the audi-
Retina tory nerve to the brain, where the sound is
Cornea
registered and interpreted. The middle ear
Optic
Lens nerve is filled with air and is connected to the
outside air by the eustachian canal, which
Iris opens into the nasopharynx.
Figure 84. Anatomy of the eye
179
VII Structure and functions of the human body,
180
examination and recording the information
181
VII Structure and functions of the human body,
• Do other persons on board have similar appendicitis. Previous diseases might re-
symptoms? appear, and knowing about them helps to
• Is the patient on medication – what, determine the appropriate treatment. Such
why, strength, dosage, when last diseases might be attacks of gallstones or
taken? kidney stones, for instance, as they are
• Alcohol – when last taken; is the pa- often similar to earlier episodes. These
tient intoxicated? possibilities should be discussed with the
• Allergies to medication – to what; re- patient. If there is a history of a disease,
actions to the medicine: rash, itching, such as coronary disease or diabetes,
anxiety, shock? these might worsen on board and cause
• Fever, shivering, fluctuating tempera- symptoms.
ture – what is the patient’s tempera- If the patient is injured, it is impor-
ture? tant to investigate the mechanism of the
• Self-treatment – how has the patient injury and how much time has passed
tried to treat the illness; medicine before seeking treatment. An injury in the
taken, other treatment? abdominal area caused by a blunt instru-
ment might not show symptoms for hours,
Medical history can be charted further with during which shock can develop due to a
the following questions: leakage from a ruptured spleen or kidney.
• When and how did the symptoms The strength of the cause of the injury
begin? should be determined. The height of a fall
• How have the symptoms changed, and or the force of a blow can give some idea
what are they like now? of how severe the damage is.
• How troublesome are the symptoms?
• At the moment, what bothers the pa- 3 Specific questions
tient most? about symptoms in
organs
Often patients have already tried to treat
the symptoms on their own. Therefore, it Answers to the above questions can usually
is necessary to ask what medication they help to confine the injury or illness to a
have possibly taken. The medication needs specific organ system. The information and
to be considered as one of the possible examination forms can be used to further
causes of the symptoms (e.g., drug aller- clarify the patient’s situation:
gies). Patients should also be asked about • Head: pain, dizziness, unilateral
alcohol consumption. symptoms, recent injuries to the head,
Pain is a common reason for seeking spasms
treatment. The site of the pain and possible • Vision: loss of sight in one or both
use of pain-killers need to be clarified. Ask eyes, double vision, pain, redness in
the patient about factors that make the pain eyes, yellowness, discharge from eyes,
worse or better, and about the type of pain: watery or itching eyes
e.g., the pain is sharp or dull, continuous, • Hearing: hearing loss, ringing in ears,
fluctuating or altering in intensity. Also, any earache or discharge from ears
radiating pain should be inquired. • Mouth and throat: abnormally smelling
Some diseases can be ruled out by breath, soreness, swelling, difficulties
finding out about previous injuries and in speech or swallowing
operations. If the patient has had an • Neck: stiffness, enlarged lymph nodes,
appendectomy, it is obvious that lower or other swelling
abdominal pain can not be caused by
182
examination and recording the information
183
VII Structure and functions of the human body,
Table 10. Grading different responses according to the Glasgow Coma Scale
Speech capability
• answers questions matter-of-factly 5
• is confused, incoherent 4
• uses words out of context 3
• makes noises 2
• makes no noises even when provoked with pain 1
Motion control
• moves all limbs by himself or on request 6
• pulls hand away when feeling pain, and uses other hand to help (localizes) 5
• pulls hand away when feeling pain, without helping with the other hand (dodges) 4
• bends both arms towards the head while rotating them inwards when provoked
with pain (flexion) 3
• straightens both arms alongside the body while rotating them outwards when
provoked with pain (extension) 2
• does not move when provoked with pain 1
Add together the highest points given in each area of the scale. The total score ranges from 3
to 15. A total score of 8 or less indicates a clear disturbance, and the patient must be monitored
very closely.
184
examination and recording the information
185
VII Structure and functions of the human body,
186
examination and recording the information
187
VII Structure and functions of the human body,
188
examination and recording the information
189
VII Structure and functions of the human body,
Press the abdomen area carefully with patient use aids, such as a cane, when
both hands (Figure 89). Keep the lower walking?
hand (the palpating hand) relaxed and • Positions of the limbs. Movements,
press it with the upper hand (the press- shape of back, posture and mobility.
ing hand). Move the lower hand with • Swelling of the limbs. Muscle hollows
the upper hand sideways and feel for and lumps, asymmetry.
any lumps or other irregularities. • Skin of the limbs. Temperature borders
• Intestinal sounds. Check sounds of in- on the skin, colour of the skin, tempera-
testinal functioning with a stethoscope. ture of the lower limbs, asymmetry.
Usually growling can be heard due to • Movement and muscle strength. Asym-
movements in the intestines. Record metry.
any strong sounds, or total absence of • Tenderness when pressed. Tenderness
sounds, and abnormal sounds. in the limbs when pressed, tenderness
• Circumference of the abdomen. in the back or spine.
Measuring the circumference of the • Feeling the pulse in the artery. Asym-
abdomen and recording the changes metry.
will give an objective estimate of the
changes in the patient’s condition. 23 Neurological and
Mark the place of measurement on psychological status
the skin with a pen, so that follow-up of the patient
measurements can be taken from the
same place. Neurological symptoms may indicate a
• Distension in the rectum. Rash, le- severe dysfunction or an injury. There-
sions. fore, identifying the deficiency symptoms
• Swelling. Tenderness and lesions in the is important in assessing the urgency of
genital area. the need for care, and the severity of the
• The groin. Are there distensions when condition.
standing up? Do they disappear when
lying down? Enlarged or tender lymph Check the following:
nodes in the groin? • Movement of the limbs and pain in
them, moving around and problems
22 Upper and lower with moving. Is the patient able to
limbs and the back walk straight without support and stand
on toes and heels? Movements of the
When examining the back, the first step is neck, bending.
to check whether there are visible abnor- • Symmetry of facial expressions. If the
malities in the back, and then check the patient is not able to whistle normally
movements of the back. Find the sore areas or make a symmetric facial expression,
by lightly tapping the back with a hand. this might be an indication of cranial
Noting the sense of feeling in the limbs nerve damage.
and the rectum is important to detect nerve • Eyes. Symmetry of the pupils, reaction
entrapments (e.g., vertebral disc damage). to light, eyesight, disturbances in vi-
Record the following from a patient with sion, movements of the eyes, double
skeletal symptoms: vision.
• Psychological state. Logical speech
• Walking. Is the patient limping, is there and behaviour. If an abnormality is
asymmetry, is the patient able to walk suspected, the patient can, for instance,
on his/her toes and heels, does the be asked to list numbers by adding
190
examination and recording the information
191
VIII FORMS
58 Patient information
• Preliminary information
• Basic vital functions
• Respiratory and cardiovascular diseases
• Musculoskeletal diseases and disorders
• Abdominal diseases and gynaecological ailments
• Conditions of ear, nose and throat
• Eye diseases, nervous system diseases, vertigo,
headache
• Urinary and sexually transmitted diseases
• Psychological symptoms
• Skin diseases
59 Treatment on board
60 Patient follow-up form
FORMS
Index
VIII Forms
58 Patient information
When did it start and how have the symptoms developed (date, time, where, what kind)
Drug allergy, what drugs, symptoms on using them: rash, itching, breathing difficulties
194
VIII Forms
CONSCIOUSNESS
Verbal response Opens eyes Motor response Total level of
(5–1 points) (4–1 points) (6–1 points) consciousness
195
VIII Forms
SYMPTOMS (Always check the patient’s preliminary information, see Preliminary information form)
Pain Shortness of breath Breathing sounds
196
VIII Forms
SYMPTOMS (Always check patient’s preliminary information, see Preliminary information form)
❏ posture and walking ❏ skin intact and healthy ❏ nothing specific ❏ swelling
normal ❏ cut/abrasion ❏ tenderness when pressed ❏ bump in muscle
❏ unable to walk on toes ❏ blood effusions ❏ swelling of joint ❏ node in muscle
❏ unable to walk on heels ❏ bruises ❏ redness of joint
❏ needs walking aid ❏ sense of touch normal ❏ warmth of joint Fracture
❏ abnormal posture ❏ sense of touch reduced ❏ limited movement of joint
❏ limbs unequal in length ❏ loss of feeling and numb- ❏ joint in abnormal position ❏ abnormal position
ness in anal region of joint or bone of
Swelling in leg limb
❏ swelling
❏ no swelling ❏ tenderness when
❏ equal swelling in both legs pressed
❏ unequal swelling in legs
If necessary, mark the location of symptoms and ailments on the figure below
Head
Shoulders
Upper arm
Elbow
Forearm
Wrist
Hand
• palm
• back of
hand
• fingers
Thigh
Knee
Shin
Ankle
Foot
• instep
• sole
• toes
197
VIII Forms
SYMPTOMS (Always check patient’s preliminary information, see Preliminary information form)
Pain Functioning of digestive Urinary Vaginal discharge Menstruation,
system symptoms pregnancy
❏ painless ❏ no discharge
❏ mild pain ❏ normal ❏ no symptoms ❏ bloody discharge ❏ normal
❏ strong pain ❏ sour belches ❏ frequent need ❏ white discharge menstruation
❏ steady pain ❏ vomiting to urinate ❏ pus discharge ❏ date of last
❏ wavelike pain ❏ bloody vomit ❏ stinging when ❏ odourless menstruation
❏ location of pain ❏ constipation urinating discharge ❏ contraception
❏ radiating pain (where to?) ❏ diarrhoea ❏ urinary retention ❏ smelly discharge (what kind?)
❏ what relieves or aggra- ❏ blood in stool ❏ possible pregnancy
vates the pain? ❏ black stool ❏ pregnant (how
❏ bright red blood in stool many weeks?)
EXAMINATION (First check consciousness, respiration and blood circulation, see Basic vital functions form)
Pressing the abdomen Pain Lumps Intestinal sounds
198
VIII Forms
SYMPTOMS (Always check patient’s preliminary information, see Preliminary information form)
Ear symptoms Nasal symptoms Facial symptoms Mouth and throat
symptoms
❏ none ❏ none ❏ none
❏ ache ❏ stuffiness ❏ tenderness, feeling of pressure on ❏ none
❏ irritation ❏ sneezing forehead ❏ pain when swallowing
❏ blocked feeling ❏ clear watery discharge ❏ tenderness, feeling of pressure ❏ swallowing difficulties
❏ pain on ❏ thick, coloured below eyes ❏ breathing difficulties
moving ear discharge ❏ tenderness elsewhere, where? ❏ feeling of lump in throat
❏ nosebleed ❏ tenderness when
moving jaw
EXAMINATION (First check consciousness, respiration and blood circulation, see Basic vital functions form)
Ear canal Eardrum Nose Mouth and throat
199
VIII Forms
SYMPTOMS (Always check patient’s preliminary information, see Preliminary information form)
Eyes Nervous system, vertigo, sense of touch Headache
200
VIII Forms
SYMPTOMS (always check the patient’s preliminary information, see Preliminary information form)
Urinating Leaking from the urethra Skin symptoms Other symptoms
EXAMINATION (First examine consciousness, respiration and blood circulation, see Basic vital functions form)
Pain Tenderness of the stomach Abdominal wall Lumps
201
VIII Forms
SYMPTOMS (Always check patient’s preliminary information, see Preliminary information form)
Physical symptoms Psychological symptoms
202
VIII Forms
SYMPTOMS (always check the patient’s preliminary information, see Preliminary information form)
Skin symptoms (where?) General symptoms Symptoms in other organs
203
VIII Forms
59 Treatment on board
(Record dates and times!)
Place of consultation:
Name of doctor:
Instructions given:
Name of drug and date of prescription Effectiveness of drug Dosage Duration of medical treatment
Other treatment
Further measures
Patient requested to consult a doctor on return home: no/yes, reason for referral, urgency
204
VIII Forms
180
41 V
160 V
40
140 V
39
120
38
100 o x
37 x Λo o
80 Λ Λ
36 x
60
35
Rate of respiration 20
34 15 ■
10 ■ ■
Notes: Blood pressure V (Systolic) Λ (Diastolic); Pulse x; Temperature (°C) o; Respiration rate ■
205
The drugs mentioned in the book; concentrations,
5. ALLERGY MEDICATION
A Adrenaline 1 mg/ml injection
B Cetirizine hydrochloride 10 mg tablet
C Hydrocortisone 125 mg/ml injection
D Prednisolone 5 mg tablet
206
drug forms and treatment equipment
207
The drugs mentioned in the book; concentrations,
Treatment equipment
3. Instruments
Anatomic tweezers
Clamp
Horner’s spud
Instrument chest
Needle holder
Safety pin
Scalpel
Scissors
Shaver
Splinter removal tweezers
Surgical drape
Surgical tweezers
208
drug forms and treatment equipment
209
Index
Index
abdomen 189 cardiac arrest 9
abdominal injuries 28 cardiac infarction 67
abdominal pain 79 catheterization 152
abscesses 101 cerebral contusion 23
addictive substances 113 cerebral haemorrhage 22
AIDS 96 cheek pain 64
airways; diseases 72 chest pain 66
alcohol 48, 113, 135 chest; structure and functions 189
alcohol poisoning 48 childbirth 87
allergic reaction 17, 71 chlamydia 95
ammonia 50 chlorine 50
amphetamine 115 choking 14
amputation 35 cholecystitis 82
anaesthetizing a wound 148 cholera 78
anaphylactic reaction 17, 71 cocaine 117
appendicitis 81 colitis 84
arrhythmia 68 common cold 73
arterial thrombosis 70 communicable diseases 118
asthma 73 concussion 23
asthma attack 71 condom 95
athlete’s foot 101 condyloma 96
attack of gall stones 82 confidentiality 168
back pain 108 congestive heart failure 68
back; structure and functions 190 consciousness 56, 184
bleeding shock 17 constipation 78
bleeding; stopping 15, 35, 145 contagious diseases 118
blood pressure 185 coronary artery disease 67
blood pressure, high 68 cyanide 50
blood pressure, low 69 dangerous cargo 45
blood pressure, measuring 143 death 162
blood sugar 131 debriefing 111
blood sugar, high 123 depression 111
blood sugar, low 122 diabetes 122
blood; structure and functions 174 diarrhoea 76
body temperature, lowered 41 digestive system; structure and functions 175
bone injury 30 diphtheria 121
breathing 184 dislocation 33
breathing difficulty 70 dizziness 55
bronchitis 73, 74 drowning 44
burn 36 drug abuse 113
cannabis 115 drug injections 135
carbon dioxide 49 drug poisoning 49
carbon monoxide 49 ear ache 63
210
Index
211
Index
212
Index
213