Medical Handbook for Seafarers

Heikki Saarni Leena Niemi

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

Telephone +358 (0)30 474 2543 Telefax +358 (0)9 477 5071 www.ttl.fi/bookstore

Participants in the preparation of the manuscript • Ari-Pekka Aarnio (37,40) • Eeva Ekholm (29) • Harri Kankare (11, 14) • Kari Koskela (23) • Leena Niemi (1, 2, 3, 4, 5, 9, 10, 11, 12, 13, 39, 41, 43, 45, 46, 47, 48, 49, 50) • Sinikka Niemi (7, 20, 44) • Petri Nieminen (21) • Erkki Nylamo (8, 28, 30) • Lassi Pakkala (16, 24, 25, 57, 58) • Heikki Saarni (15, 26, 27, 31, 32, 33, 34, 36, 38, 42, 49, 50, 51, 52, 53, 54, 55, 56) • Ulla-Maija Saarni (22) • Heikki Suoyrjö (35) • Erkki Säkö (6, 17, 18, 19)

Translated by a group of students from the Department of English Translation and Interpreting at the University of Turku.

Editor: Maisa Hurme Linguistics Editor: Terttu Kaustia Graphic Design: Aino Myllyluoma Photographs: Samuli Saarni Turku University Hospital, Department of Ophthalmology (Figure 13) Turku University Hospital, Department of Otorhinolaryngology (Figure 21) Turku University Hospital, Department of Dermatology (Figures 29–39) Drawings: Heikki Saarni

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

II Accident injuries and their treatment ...... 21 6 Skull injuries and cerebral haemorrhage...... 22 7 Injuries to the eye...... 24 8 Injuries to the abdominal area...... 28 9 Bone, joint and muscle injuries...... 30 10 Amputation...... 35 11 Burns and frost injuries...... 36 12 Heat-induced illnesses...... 38 13 Electrocution...... 40 14 Thermoregulation of organs and hypothermia...... 41 15 Near drowning...... 44 16 Poisoning...... 45

III Symptoms and diseases and their treatment ...... 51 17 Headache, and pain in the head region ...... 52 18 Vertigo...... 55 19 Alteration of consciousness and seizures...... 56 20 Eye problems and symptoms ...... 60 21 Illnesses of the ear and the throat...... 62 22 Problems of the mouth and the teeth...... 65 23 Chest pain and cardiovascular diseases...... 66 24 Difficulty in breathing...... 70 25 Diseases of the airways...... 72 26 Vomiting, fever and diarrhoea...... 75 27 Constipation and haemorrhoids ...... 78 28 Abdominal pain ...... 79 29 Obstetrics and gynaecological disorders ...... 84 30 Symptoms of the lower abdomen and acute diseases of the urinary organs 90 31 Sexually transmitted diseases (STD) ...... 93 32 Dry and itchy skin...... 97 33 Rash...... 98 34 Protective gloves and protective skin ointments...... 106 35 Joint and muscle pain...... 107 36 Mental disorders ...... 109 37 Alcohol and drugs ...... 113 38 Infectious and contagious diseases ...... 118 39 Diabetes ...... 122

IV Treatment procedures ...... 125 40 Securing the airways, intubation ...... 126 41 Measuring the blood sugar ...... 131 42 The drugs in the ship’s pharmacy and their use ...... 133 43 Drug injections ...... 135 44 Drug treatment of the eyes ...... 137 45 Intravenous (IV) infusion therapy ...... 139 46 Measuring blood pressure ...... 143 47 Wounds ...... 144 48 Retention of urine and catherization of urinary bladder ...... 152 49 Positioning, moving, and evacuating a patient ...... 153 50 Cleaning hands and instruments ...... 156

V Self-protection ...... 159 51 Self-protection and prevention of infections ...... 160 52 Vaccinations for seafarers ...... 161 53 Death on board ...... 162

VI Advice and instructions ...... 165 54 Radio Medical ...... 166 55 Confidentiality and seafarers’ health care ...... 168

VII Structure and functions of the human body, examination and recording the information ...... 171 56 Structure and functions of the human body ...... 172 57 Examining the patient ...... 181

VIII Forms ...... 193 58 Patient information ...... 194 59 Treatment on board ...... 204 60 Patient follow-up form ...... 205

The drugs mentioned in the book; concentrations, drug forms and treatment equipment ...... 206

Index ...... 210

FOREWORD

hen a vessel is at sea, it is often dif cult or even impossible to get a doctor on board or to transport the ill or injured patient ashore. The success of the treat- W ment depends on the medical know-how and treatment facilities on board. The captain of the ship is of cially 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 medical 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 sta 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 signi cantly change the basic situation of on-board treatment. All the treatment given on board depends rst and foremost on the know-how of the crew members. The equipment on board and even the nest 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 ndings, 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-eects 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 of cial, 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 ful ls 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 procedures may dier from those carried out on land. The book is targeted at healthy, working-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 system. 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 different 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.

Turku, Finland, 2007 The Editors Heikki Saarni and Leena Niemi EMERGENCY FIRST AID FIRSTAID I EMERGENCY 5 4 Shock 3 2 1 treatment requirement Classification ofpatientsaccordingto Stopping majorbleeding tract Foreign objectinrespiratory First aidofvitalfunctions I Emergency first aid

1 First aid of vital functions

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

1. Assessment of the situation What has happened Safety hazards at the scene (electrocution, fire, gases) 2. Protect yourself from danger Use protective clothing or other safety equipment and save the patient Eliminate safety hazards (e.g., switch off electric current, air the room) 3. Assess the condition of the patient 3.1. Patient is breathing Make sure that respiratory tract stays open 3.2. Patient is not breathing Open respiratory tract • remove any foreign objects • tilt head backwards Start cardiac massage • press 30 times Start mouth-to-mouth respiration • blow twice, check that the patient’s chest rises • if the chest does not rise, check the position of the head Check the pulse or signs of circulation; if there are none, continue resuscitation • rhythm of resuscitation: press 30 times, blow twice 4. Patient is bleeding Stop bleeding • raise the limb • press the wound with hands using dressings • if necessary, bind the wound with a pressure bandage 5. Patient is in shock Determine the cause of shock • bleeding • allergy 5.1. Shock caused by bleeding Place the patient on his/her back, elevate lower limbs Start intravenous infusion 5.2. Allergic shock Administer adrenaline (1 mg/ml) 0.5–1.0 ml

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

Figure 2. Lifting the patient’s jaw opens the respiratory tract

Figure 3. Listening to the patient’s breathing

Figure 4. Feeling for the pulse from the carotid artery

10 I Emergency first aid

Figure 5. The place to press is two widths of a finger from the lower edge of the sternum sternum (breastbone)

Figure 6. Cardiac massage is carried out with the heel of the palm, and the arms straight

Figure 7. Mouth-to-mouth respiration

11 I Emergency first aid

Resuscitation your other hand over the back of the first The person giving first aid should be at the hand. The pressing is done with the heel patient’s side, in such a position where it of the palm and the arms straight all the is easy to administer both mouth-to-mouth time, using the weight of your upper body respiration and cardiac massage. Resusci- (Figure 6). The sternum is pressed vertically tation is begun by opening the respiratory downward 4–5 cm. Press 30 times with tract. The tongue is the most common the arms straight: the rate of pressing is cause of blockage in the respiratory tract 100 presses per minute. You should count in unconscious patients. It can be removed aloud to ensure that the rate of the pressing from the pharynx by tilting the patient’s is consistent. head backwards, lifting the jaw up and After having pressed 30 times, mouth- putting pressure on the forehead (Figure to-mouth respiration must be started. With 2). The patient’s breathing is detected by one hand, the head is pushed backward placing one’s cheek in front of his/her from the forehead and the nostrils are mouth and nose, and simultaneously pinched closed with the thumb and fore- watching his/her chest: is the chest mov- finger. The jaw is lifted upward with the ing, can breathing be heard, or a flow of forefinger and middle finger of the other air felt? (Figure 3). If the patient does not hand. During resuscitation, the patient’s start breathing after the respiratory tract is head is kept tilted backward in this way. opened, resuscitation must be started. Mouth-to-mouth respiration is a rapid Check the patient’s circulation. Signs and effective way to oxygenate the patient. of functioning circulation are breathing, Take a deep breath of air, press your lips moving, coughing and swallowing. The tightly around the patient’s mouth, and time used for checking the signs of circu- slowly blow air into the patient’s lungs lation must not exceed 10 seconds. The (Figure 7). At the same time, follow how pulse can be felt by pressing gently on the the procedure is working by observing the carotid artery (Figure 4), where it can often movement of the patient’s chest. If the chest be detected, even if a pulse from the wrist does not rise while air is being blown, the cannot be felt. The right place to feel the air is going into the stomach. In this case, pulse may be difficult to find if the pulse is the procedure must not be continued slow and irregular, or weak and rapid. If the until the position of the patient’s head pulse is felt, but the patient is not breathing, is corrected. In addition, the mouth and mouth-to-mouth respiration is continued pharynx should be checked for possible to the rhythm of the helper’s breathing, i.e. foreign objects or secretion. If needed, from 12 to 16 times per minute. Whether the mouth and pharynx are cleared by the patient starts to breathe on his/her own turning the patient’s head to the side and must be observed all the time. removing the obstruction with a finger If there are no signs of blood circu- or a cloth wrapped around it. After this, lation and the pulse cannot be felt, the continue mouth-to-mouth respiration, this patient’s heart has stopped. Cardiac mas- time making sure the chest rises. sage must be started immediately. The right Blowing air into the stomach causes place to press is two widths of a finger from vomiting. If the patient is lying on his/her the lower edge of the sternum (Figure 5). back, during vomiting the stomach con- Kneel at the patient’s side with your arms tents pass into the lungs. This causes severe straight and shoulders directly over the irritation of the lungs and later even life- patient’s chest. Place the heel of your palm threatening pneumonia. on the patient’s sternum, and the heel of

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Table 1. Resuscitation of an adult

Procedure for an adult cardiac massage 30 presses location of pressing lower half of the sternum method of pressing with both hands one on top of the other depth of pressing 4–5 cm rate of pressing 100 times per minute mouth-to-mouth respiration 2 blows rhythm of resuscitation one first aider: 30 presses, 2 blows

The patient’s pulse and breathing must ● Consult a doctor via Radio be checked every few minutes. Return of Medical on using drugs. the pulse is checked from the carotid artery. If the pulse cannot be felt, resuscitation is continued. If the pulse is felt, the patient’s 2 When is resuscitation breathing must be checked. If the patient not started? is not breathing, mouth-to-mouth respiration is given. Resuscitation is continued Resuscitation is not started if the patient is until the patient’s body functions return, obviously dead, showing rigor mortis or responsibility for the patient is transferred livor mortis. to medical professionals, or the helper’s strength is depleted. A summary of the resuscitation steps and the resuscitation rhythm are shown in Table 1.

Resuscitation drugs The resuscitation drug found in the ship’s pharmacy is adrenaline (8/A, 1mg/ml). A dose of 1 ml is administered intramuscularly. Adrenaline constricts the peripheral circulation when the diastolic blood pressure 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 consciousness, 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 deteriorates 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

3 Stopping major bleeding

Major bleeding must be stopped as quickly If the bleeding has been abundant, the lost as possible. Especially if the bleeding blood must be replaced with intravenous is from an artery, the patient may lose a infusion to prevent potential shock. substantial amount of blood in a short If the limb is amputated, there is a time, which may quickly lead to shock. In bleeding crush injury, or stopping the arterial bleeding, bright red blood spurts bleeding is otherwise not possible, a with each heart beat. Venous bleeding is tourniquet must be placed above the site darker in colour, flows steadily and is less of the bleeding. However, there is danger abundant than arterial bleeding. involved in using a tourniquet. It must be so tight that it stops all circulation in the Follow these instructions to stop limb. If the tourniquet is too loose, it stops bleeding: only the venous circulation, but not the • If the bleeding is from a limb, elevate arterial circulation, and the patient may the site of the bleeding above the level bleed to death despite the tourniquet. Thus, of the heart. a tourniquet is always an extreme measure, • Apply direct pressure to the wound to be used only if the bleeding cannot be using a clean dressing to quickly stop stopped otherwise. the bleeding. In an emergency situation, if no dressing is available and the bleeding is severe, you can use your hand alone. • Place a clean dressing over the wound and use, for example, a roll of bandage or a matchbox to make a pressure bandage. • Tie the wound with an elastic bandage. • If the wound in a limb is large, splint the area of the wound during transportation. • Avoid moving the site of the wound, so that the bleeding does not start again.

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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

Table 2. Amount of bleeding in different fracture types

Type of fracture Amount of bleeding, ml Simple fracture rib 125/rib humerus 350–800 shin bone 500–1 000 thigh bone 1 000–2 000 pelvis 1 500–2 000 Compound fracture Amount of bleeding may be double that of a corresponding simple fracture.

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Table 3. Symptoms of bleeding shock in relation to amount of blood lost

Amount of blood lost Symptoms 10% (= 500 ml) no symptoms 15–25% (= 750–1 250 ml) slightly increased pulse (ca. 100/min) 25–35% (= 1 250–1 750 ml) increased pulse (100–120/min) pallor, cold clammy skin blood pressure 90–100 mmHg 50% (= 2 500 ml) pulse over 120/min blood pressure under 60 mmHg disturbances in consciousness

organs deteriorates. When systolic blood ● pressure has dropped to 60 mmHg, the Elevating the lower limbs enhances the circulation of the brain, the brain starts to suffer from oxygen deficien- heart and other vital organs. cy. The patient becomes restless or even aggressive. If the blood pressure keeps falling, the patient becomes confused, his/her level Dehydration is treated with intravenous of consciousness then diminishes further infusion therapy, that is, intravenous fluid until unconsciousness and death occurs. replacement (see Chapter 45 Intravenous The relationship between symptoms of (IV) infusion therapy). The oxygen supply bleeding shock and the amount of blood of the tissues is supported by giving oxygen lost is presented in Table 3. (e.g. 28%) with a mask. Do not give the Allergic (anaphylactic) shock is patient anything to eat or drink. caused by expansion of blood vessels due The patient’s condition and level of to paralysis of the muscles in the vessel consciousness must be continuously moni- walls. In this case, the normal amount tored, because his/her status may change of blood cannot sustain sufficient blood very rapidly, and the treatment should pressure, because the volume of the blood respond immediately to any changes. It is vessels has increased. The pulse is rapid, important to monitor the blood pressure, but the hands and feet stay warm, unlike pulse and temperature of the skin. Keeping in shock due to other causes. the patient warm, and calming and reassuring him/her help to reduce the body’s 3 Treatment need for oxygen. 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 allergen, the reaction can be prevented from recurring.

Figure 9. Injection into the tongue

● Treatment of allergic shock is always urgent and the first aid is always adrenaline.

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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.

Table 4. Classification of severely injured patients according to urgency of treatment need

Priority category Type of injury

I CATEGORY • laboured breathing (caused by chest injury, brain injury or blockage in respiratory tract) • traumatic shock (caused by bleeding and crush injury) • multiple fractures • burns, over 20% (but under 70%) • crush injuries to the face • severe arterial injuries in the limbs

II CATEGORY • unconsciousness without laboured breathing • chest injury without laboured breathing • injuries to the abdomen and urinary organs • burns, under 20%

III CATEGORY • spinal cord injuries • mild brain injuries • simple fractures

IV CATEGORY • severe brain contusions • crush injuries of chest and body • burns, over 70% • dying patients

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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 THEIR TREATMENT

6 Skull injuries and cerebral haemorrhage 7 Injuries to the eye Injuries to the abdominal area 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 ACCIDENT INJURIES AND THEIR TREATMENT II Accident injuries and their treatment

6 Skull injuries and cerebral haemorrhage

A skull injury that has caused a disturbance in consciousness can be verified either on ● Always consult a doctor about a the basis of what is known of the event, head injury via Radio Medical when or by carefully examining the skin in the skull area. In obvious cases, where the • headache deteriorates continuously injury can be detected by pressing with • there is double vision, numbness or the fingers, the patient usually has cerebral sense disorders contusion as well. This kind of injury requires immediate hospital treatment and • the level of consciousness changes often emergency surgery as well. from alertness to doziness, or there is a loss of sense of time and place Loss of memory is usually related to skull injuries, and this often lasts clearly • vomiting is continuous longer than unconsciousness. Loss of • one pupil is more dilated than the memory usually extends also to the time other before the injury. After the injury, the patient may first have headache, and may • there is bleeding from the ear or even be confused. Usually the symptoms nose even though these are not injured worsen in an upright position, so it is more comfortable for the patient to be • there is clear secretion from the lying down. The patient often experiences nose nausea or vomiting, and feels dizzy. If • a bruise appears behind the ears symptoms, such as stiffness of the neck, or around the eyes even though headache, nausea and photophobia, as these areas have not been injured well as neurological deficiency symptoms (numbness, lack of feeling, difficulties in • convulsions occur. mobility, disequilibrium) increase, this is always a sign of a more severe condition, for example, cerebral contusion or cerebral haemorrhage. The symptoms may worsen in only a few hours, or sometimes after a few days, when unilateral deficiency symptoms, such as paralysis, difference in pupil dilation, and speaking difficulties may appear. A patient with a skull injury must be The patient must rest as long as the sent to a doctor for further examination, symptoms last. Pain-killers or vertigo even if hospital treatment may not be medications usually are not of any help. necessary. After a concussion, possible Ordinary pain-killers can even be harm- skull fractures have to be examined, and ful, if a head injury has caused internal more severe brain damage has to be ex- bleeding, as many pain-killers increase cluded by either clinical examinations or the bleeding. visualisation.

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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.

2 Cerebral contusion 4 Epidural bleeding

A patient with cerebral contusion is usually Epidural bleeding is relatively rare, and unconscious for a longer time than a pa- usually occurs in children or young tient with concussion, but it is also possible adults. In epidural bleeding, venous blood that there is no state of unconsciousness penetrates between the dura mater and at all. Neurological deficiency symptoms the bone, and a lens-shaped blood clot usually last for several weeks, and may develops. The first symptoms are followed leave permanent damage. Sometimes by a remission, but neurological deficiency swelling or bleeding develops in cerebral symptoms deteriorate quite rapidly, within tissue, causing the cerebral pressure to hours if the bleeding continues. Imaging of rise. In this case, the symptoms will begin the head and surgery must be performed to worsen, and the patient’s condition de- urgently. teriorates. The patient must always be sent to medical care and treatment, preferably 5 Skull fracture to a hospital where his/her condition can be monitored for possible cerebral pressure Skull fracture may occur in connection symptoms. with all of the injury types mentioned above, especially epidural bleeding. 3 Subdural bleeding Usually a rather strong blow to the head is needed to cause a fracture. If the injury Subdural bleeding occurs usually in older can be detected by pressing with the fin- people and alcoholics. Sudden bleeding gers, the patient usually has a cerebral is relatively rare. In subdural bleeding, contusion as well. The injury requires im- venous blood penetrates the dura mater, mediate hospital treatment and often also and a sickle-shaped blood clot develops emergency surgery.

23 II Accident injuries and their treatment

7 Injuries to the eye

It is important to examine without delay the ● After an eye injury consult a doctor patient who has had an injury to the eye, as via Radio Medical if the possible swelling of the eyelid can make the examination more difficult later on. • a penetration wound is suspected In order to assess the type of injury • the injury does not heal in a few and its degree of severity, it is important to days inquire what the patient was doing when • the redness, pain or swelling in the the accident happened. The possibility that eye increases a foreign object is still in the eye has to be • there is discharge from the eye taken into account. If there is corrosive • changes in vision take place substance in the eye, first aid has to be started immediately. • double vision occurs. When examining the patient’s eye, the ability to see, the movements of the eye in different directions, and the condition The treatment of the eye depends on the of the eye’s anatomical parts (eyelids, con- type and severity of the injury and what junctiva, cornea, anterior chamber, pupil, has caused it. It is necessary to examine iris) has to be checked. It is important to whether the eye has been penetrated in examine the red reflex, because this gives the accident. If there is acid or alkali in the information about the condition of the eye, rinsing must be started immediately. eyes’ inner parts. The lack of the red reflex Any clean water can be used. Rinsing is is usually a sign of a more severe injury. done continuously for 30–60 minutes. If a penetration injury to the eye is sus- During rinsing, the eyelids have to be held pected, the area around the eye should be apart with the fingers, to allow the water to treated with special care, and the patient circulate under the eyelids. must be kept lying down. The damaged eye is covered with a patch and the patient 1 A foreign object is transferred as an emergency case to an in the eye ophthalmologist for further treatment. It is important to keep the patient calm. The most common eye injury is a foreign One symptom of an eye injury may be object on the conjunctiva, meaning that sudden pain and lacrimation (tears), caused there is something under the lower or upper possibly by a foreign object in the eye. Later eyelid, and the symptoms are severe pain on, the cornea may become reddish and the and lacrimation (tears). A sharp, angular patient may have photophobia. A strong feel- foreign object easily remains under the ing of something in the eye and photophobia upper eyelid and moves with the eyelid, can appear after a few hours’ exposure to scratching the sensitive cornea. The pain intense radiation (so-called snow blindness). disappears even if the foreign object is not Deterioration of vision after an injury may removed, because the tactile nerve endings be caused by internal bleeding in the eye or go numb. However, the pain starts again damage to the eye structure (detachment of within the next 24 hours, when photopho- the retina or the lens). Double vision may be bia may occur and the conjunctiva may a sign of an eye socket fracture, or damage become reddish. to the eye muscles.

24 II Accident injuries and their treatment

It is necessary to consult a doctor via Radio Medical if the feeling of something in the eye continues for over three days, even though the object has been removed from the eye, and drug treatment has been given.

Removing a foreign object from under the lower eyelid It is easy to remove a foreign object from under the lower eyelid by drawing the eyelid downwards with the fingers, so that Figure 10. Turning the upper eyelid up to the underside of the eyelid can be seen. remove a foreign object The object may then be wiped off with, for example, a cotton swab moistened with water.

Removing a foreign object from under the upper eyelid The upper eyelid is turned up to remove the object from under it. The patient sits with head straight and looks downwards, keeping the eye open all the time. The upper eyelashes are held with the thumb and index finger, and the eyelid is stretched downwards and outwards (Figure 10). The stem of a cotton swab is placed in Figure 11. Wiping a foreign object off the the middle of the stretched upper eyelid. interior surface of the upturned eyelid The cotton swab is held in place and the eyelid is raised and folded over the swab. The eyelashes are held all the time, so that the eyelid cannot return to its normal position. The cotton swab is removed. The foreign object on the eyelid is then removed with a cotton swab moistened with water (Figure 11). The conjunctiva of the upper eyelid is wiped lightly, beginning from the outer corner and moving towards the nose, even if there is no visible foreign object on the conjunctiva. The hold on the eyelashes is released, and the patient is asked to blink when the eyelid returns to Figure 12. A foreign object is removed its normal position. carefully from the surface of the eye with After the foreign object is removed, a corneal spud the pain usually stops. If it has scratched the cornea, the feeling that there is something in the eye continues. This state will improve by itself in a day or two as the

25 II Accident injuries and their treatment

cornea heals, but eye drops or ointment 3 Injuries to the eyelids, (chloramphenicol, 10/B) may be used for and eyes swollen shut a few days. The eye can also be covered with a light gauze bandage for 24 hours, A blunt blow to the eye area may cause if it helps the patient. bruises on the eyelids, which may swell the eye shut. In this case, examining the eye is Removing a foreign object difficult. The eyelids should not be opened from the cornea forcefully, because the sensitive inner parts A good spotlight and a magnifying glass of the eye may have been damaged, and are needed to detect a foreign object on forceful treatment may exacerbate their the cornea. The surface of the cornea is condition. The swelling resolves in about anaesthetized with oxybuprocain hydro- two weeks. chloride drops (10/C). The object can be Small wounds in the eyelids are sewn removed with a corneal spud (Figure 12). with thin suture thread, or the edges of An attempt can be made to remove a for- the wound are held together with but- eign object containing iron with a magnet terfly tape. The edge of the eyelid must that is drawn near the cornea. If the object be smooth after closing the wound, so leaves a rust circle behind, the patient that the eye can be closed tightly. If the must be referred to an ophthalmologist for edge of the eyelid is damaged, the patient further treatment. should be referred to an ophthalmologist After removal of the foreign object, immediately. eye drops or ointment are applied to the eye (chloramphenicol, 10/B). A light patch is placed over the eye for 24 hours.

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 applying anaesthetic drops to the eyes (oxy- 4 Bleeding into the buprocain hydrochloride, 10/C), and drops anterior chamber that constrict the blood vessels (tetrahydrozoline 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 chamber, the patient is ordered bed rest for a

26 II Accident injuries and their treatment

couple of days. A gauze bandage is placed 7 Corrosion wound over the eye to ensure that the eye stays at in the eye rest and the bleeding does not recur. The patient is referred to an ophthalmologist Corrosive substances damage the cornea as soon as possible, because bleeding and the conjunctiva. Alkalis cause more into the anterior chamber leads to the risk severe damage than acids. When an alkali of severe complications, such as a sud- reaches the moist surface of the eye, it first den increase in pressure inside the eye. destroys the surface layer of the eye, and Consulting a doctor via Radio Medical is continues to penetrate into the deeper always necessary. layers. In injuries caused by an acid, the surface layer of the eye is damaged, but 5 Bleeding under at the same time the acid precipitates a the conjunctiva protein barrier which protects the deeper layers. The harmless, but visible sign of a blunt If there is acid or alkali in the eye, blow to the eye may indicate bleeding un- rinsing must be started immediately with der the conjunctiva, in which a bright red plenty of water. Rinsing can be started by haematoma develops on the sclera (Figure the patient him/herself, or by someone else 13). This is not dangerous and needs no near the patient. Almost any clean water procedures or restrictions. can be used. The rinsing is done continuously for 30–60 minutes. During rinsing, 6 Penetration wound the eyelids have to be held open with the in the eye fingers, to allow the water to circulate under the eyelids. The majority of penetration injuries to the If there is precipitating alkali in the eye occur in the front part of the eyeball. eye, for example, slaked lime, the sedi- An injury caused by a sharp object or a ments should be removed from the surface fragment penetrating into the eye may of the eye with a moistened cotton swab. be difficult to detect, especially if the Anaesthetic drops (oxybuprocain hydro- penetrated part is elsewhere than in the chloride, 10/C) may be applied from time cornea. Typical signs of penetration are to time to the surface of the eye. a decrease in eye pressure, and bleed- After rinsing, chloramphenicol eye ing in the frontal parts of the eye and the ointment (10/B) is applied to the eye sur- anterior chamber. The shape of the pupil face for as long as there are symptoms in changes and the iris may protrude into the the eye, but no longer than 10 days. The penetrated part when the frontal part of the ointment prevents inflammation of the eye eye is penetrated. Damage in the posterior surface and the development of conjunc- parts of the eye is difficult to detect. tiva adhesions in the eyelids. In severe If a penetration wound is suspected corrosion cases, the patient is referred to in the eye, the patient is kept at rest and an ophthalmologist. the damaged eye is covered with a gauze bandage. The patient is referred to an oph- 8 Eye burns thalmologist as soon as possible. Flames cause burns on the skin of the eyelids and the eyelashes and eyebrows burn. Usually the surface of the eye remains intact, however, as it is covered by

27 II Accident injuries and their treatment

eyelids. A hot liquid may cause severe 9 Other eye symptoms burns under the eyelids. The conjunctiva is damaged like skin. The heat causes the sur- If the patient says, after a blunt blow to face layer of the cornea to become opaque. the eye, that he/she cannot see with the A solid hot object causes a local burn. damaged eye in the same way as before, In the case of all eye burns, it is i.e. the patient sees distorted lines, or the necessary to consult a doctor via Radio lines are less clear than before. This can Medical. After local anaesthesia, the burn be caused, for example, by bleeding in scar on the cornea should be removed the vitreous body, a rupture or detachment with a corneal spud in the same way as a of the retina, or dislocation of the lens. In foreign object from the eye. This helps the these cases, it is necessary to consult a damaged part of the cornea to heal more doctor via Radio Medical, and the patient rapidly. Afterwards the treatment is the must be referred to an ophthalmologist for same as for after removing a foreign object further examination. from the cornea.

8 Injuries to the abdominal area

1 Examination 2 Injuries and their symptoms Investigating what has happened and how the injury occurred gives a fairly good Injuries from blunt blows picture of the type and extent of the injury. A so-called blunt injury is caused by a hard There are often signs of external violence blow to the abdomen or the ribs. Usually on the abdomen, for example, bruises the cause of such an injury is a collision and contusions. Pain can be felt in the or, for example, a hard kick. Sometimes area of the injured organ or in the whole injuries can even be caused by a serious abdominal area. fall. Sometimes it is difficult to judge A rupture caused by a blunt blow whether, for example, a knife has really to an internal organ can lead to internal penetrated the abdominal wall, because bleeding. Sometimes the bleeding can it is possible that there is only an incision be insignificant and will subside by itself. wound. However, sometimes it is possible Usually, however, a rupture involves major to see from the shape of the wound and internal bleeding, which causes pallor, a from what is known of the event that it is an rapid pulse, and low blood pressure. Shock incision wound. Examining the wound by may follow rapidly and lead to death in a probing, i.e. feeling the depth of the wound few hours. Fractures of the pelvis and the with the fingers or with a thin instrument lumbar vertebrae also often lead to heavy is difficult and unreliable. Therefore, in bleeding into the abdominal cavity. uncertain cases it is always best to try to A blunt blow may also result in a transfer the patient to a hospital as soon rupture of the intestines or the urinary as possible. bladder. In this case, the contents of the intestines enter the abdominal cavity,

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 peritonitis, 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 patient 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

9 Bone, joint and muscle injuries

1 Bone injuries Bleeding may be substantial in bone fractures. In simple fractures, even major Bone fractures are divided into compound bleeding cannot be seen, and thus, the and simple fractures. In simple fractures, possibility of shock has to be kept in mind. the skin of the fractured area is not broken, In a shinbone fracture, for example, the whereas in compound fractures it is bro- bleeding may be 500–1 000 ml, in a femur ken. A compound fracture is more danger- fracture 1 000–2 000 ml, and in a pelvic ous than a simple one, because bleeding fracture 2 000 ml. In compound fractures, is more substantial, and blood vessels and the bleeding may be even greater. nerves are damaged more often, and there Major bleeding, related to fractures, is always a danger of infection. may lead to haemorrhagic shock. Always The symptoms of a fracture are pain, monitor the development of the patient’s swelling, an abnormal position of the limb, condition! and its abnormal movements or dysfunc- Nerves can be damaged in the frac- tion. The patient may actually hear or feel tured area, possibly resulting in permanent the bone breaking. Sometimes the only tactile and movement disorders. There is symptom of a fracture is local pain. pain especially when the bone ends rub

30 II Accident injuries and their treatment

against each other. In compound fractures water) solution. Cardboard, or inflatable or the risk of infection is high. vacuum splints may be used as a support, or any equipment available for the purpose First aid and primary treatment (Figure 14). The injured limb must be supported ad- A splint made of a hard material must equately to prevent bleeding, pain and always be padded. The splint must cover further injuries. If a fracture is not sup- the joint on both sides of the fracture. A ported, the moving ends of the fractured shorter splint does not support the limb bone may penetrate the tissue and nerves adequately. The splint must not hinder the near that area, and even the skin. blood circulation of the limb or chafe the If the limb is in an abnormal position skin. It has to be so firm that it does not because of the fracture, a doctor must be break or bend during the patient’s transpor- consulted via Radio Medical about the treatment procedures. In simple fractures of the long bones of the lower leg and the forearm, the limb or its part is pulled lengthwise to correct the abnormal position of the bone. The limb is then supported in this position. It is especially important to get the ankle into its natural position soon after the injury, because in an abnormal position it rapidly develops severe swelling, which hinders later correction of the ankle’s position. It is not worth trying to reposition fractures of the femur and upper arm. It is sufficient to straighten, and support the limb as well as possible. Figure 15. A sling supporting an injury of the upper limb ● Always consult a doctor via Radio Medical about fractures, especially if the limb is in an abnormal position.

Before splinting compound fractures, they are covered with sterile gauze bandages moistened with saline (common salt and

Figure 16. Supporting a fractured rib with Figure 14. Inflatable splint adhesive tape

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tation. The splinted limb should be set in an Spinal fracture elevated position and, if possible, place an A spinal fracture is always dangerous, be- ice bag on the fractured area (not in direct cause the spinal cord may be damaged and contact with the skin) to prevent bleeding the patient may become paralysed. There is and swelling. Usually it is enough to use a always reason to suspect a fracture of the sling to support fractures of the upper limb spinal column or the cervical spine (neck) and the collarbone (Figure 15). Additional if the patient has fallen from a height or support may be given by a second sling has been crushed by a machine. tied horizontally. The patient or an eye witness must be asked how the injury occurred. In ad- Fractured rib dition, the surroundings are observed. If A strong blow to the chest may break one the patient is conscious, he/she must be or more ribs. The fractured end of a rib asked about pain areas and possible numb may penetrate a pleural membrane or a or tingling areas. Numbness and tingling lung. This may lead to pneumothorax, a of the limbs are signs of injury to the cervi- life-threatening condition. cal spine (neck), and the patient must be The symptom of a fractured rib is handled even more carefully to prevent pain in the injured area, which worsens further damage. on deep breathing. Sometimes a crack- After checking the basic vital func- ing sensation may be felt in the fractured tions, attention is paid to injuries of the area to the rhythm of breathing. Usually spinal column (back bone) and the cervical the fracture is at the side of the chest. If spine (neck). First, the spinal column and the sternum is pressed when the patient is the cervical spine are observed without lying down, this causes pain at the site of touching, looking for bruises and scratches, the fracture. which may indicate spinal injury. After Painful breathing may be relieved careful observation, the spinal column and with a support bandage: the fractured the cervical spine are felt carefully with side is fastened with adhesive tape (Figure the hands, one vertebra at a time, without 16). Normal adhesive tape is suitable for moving the spine, and at the same time the purpose. If the pain does not disturb asking about areas of pain. Pain in the breathing, taping is not needed, and the spinal column and the neck area indicates fracture heals with time. a fracture, until otherwise proven.

● Always consult a doctor via Radio ● There is reason to suspect damage Medical about rib fractures, if to the spine, if the patient has • the patient is unconscious • more than one fractured rib • the patient feels pain in the neck • dyspnoea or in the mid-back, or these areas • breathing difficulties are painful to the touch • continuous cough • there is numbness, tingling or diminished tactile sensation anywhere • fever in a limb • abdominal pain • it is difficult or impossible for the • vertigo or a feeling of faintness patient to move his/her upper or when standing up. lower limbs

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lying on his/her back, with the head and whole body adequately supported. There is no need to hurry if the patient does not have other injuries and if his/her vital functions are normal. When treating a patient, it must be remembered that a (suspected) spinal injury should not prevent life-saving first aid. The patient’s vital functions (e.g. an unconscious patient is placed on his/her Figure 17. Supporting the cervical spine side) must be taken care of first. in a neck injury 2 Joint injuries • the patient’s level of consciousness varies, or he/she is under the influ- Joint injuries can be divided into sprains ence of drugs or alcohol and dislocations.

• the patient has extensive pains or Sprains some other injury, which prevents him/her from distinguishing neck In the case of a twisted knee or ankle, liga- symptoms. ments may be ruptured either partially or entirely. The limb or joint does not function normally, either because of the pain or a The whole spinal column is examined damaged structure. External bleeding is carefully in the same way. The functioning rare. The injury causes haematoma in the and tactile sensation of all limbs should be damaged area, often seen as swelling and checked. The patient is asked to move his/ a blue shade of the skin. The damaged area her fingers and ankles, and the fingers and is painful. toes are checked by pinching and touch- The patient must be asked about pain- ing. If the patient’s movements are not suc- ful areas and earlier injuries, because, for cessful, or if tactile sensation is diminished, example, a joint is easily injured again after spinal injury may be suspected. earlier ligament injuries. First aid is limited to preventing fur- The first aid in ligament injuries is ther damage, and the patient should be the application of cold, and compression, transferred on shore for further treatment. and keeping the injured limb elevated. The The movements of the head and neck must injured joint is supported and the limb is be minimized by supporting the head with lifted into an elevated position. A cold pack a neck rest when the patient is lying down is placed on the injured joint, and fastened (Figure 17). When placing the neck rest, with an elastic bandage. any unnecessary movement of the head must be avoided. Dislocations Several persons are needed to sup- In the dislocation of a joint, a bone in port and lift the patient. When moving a joint moves from its socket and may the patient, all movements in which the remain in an abnormal position. Usually patient’s back and neck may be bent or the joint capsule and ligaments rupture. twisted must be avoided. The patient must The most common dislocations are those be placed on a vacuum mattress or some of the shoulder and knee cap, followed by other transfer mat with a single lift. The dislocations of toes, fingers, femur, forearm patient is transported calmly and steadily, and lower jaw.

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The symptoms are severe pain, swelling of the joint area, inability to use the joint in a normal way, and possibly a clearly abnormal position of the damaged joint. The joint should be repositioned as soon as possible. Repositioning may be difficult and consulting a doctor via Radio Medical is often necessary. If repositioning is not successful, the joint is splinted in its current position, and the patient is transferred ashore for further treatment as soon as possible. Painkillers are needed, because the patient is tense and in pain. Bone fractures may also occur in connection with sprains and dislocations. This possibility must be examined, even if the dislocated joint is repositioned on board.

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, intravenous 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

2 Handling the it meets the requirements for replantation amputated limb as long as possible. After first aid, the patient and the The amputated part limb or its part is amputated limb parts must be transferred stored. The best place to store the limb ashore as soon as possible, preferably to during transportation is in a clean, air-tight a treatment facility where microsurgery is plastic bag. This is placed in a bucket or a possible. The surgery must be done within vacuum flask containing ice water (1/3 ice six hours of the accident for the amputated and 2/3 water). The amputated part must part to be replanted successfully. not be frozen, but it must be cooled, so that

11 Burns and frost injuries

1 Burns The skin and the underlying tissue are damaged by the heat. After the small blood Burns develop when the temperature of the vessels are damaged, plasma oozes abun- tissue rises above 45ºC. Burns are caused dantly from the burnt area. If the burnt area by, for example, open fire, hot steam, is extensive, abundant loss of plasma may hot liquid or a hot object, electricity or lead to shock. The first aid in burns consists radiation. Corrosive chemicals may cause of protecting the damaged skin area from damage resembling a burn. impurities and inflammation, and preventing the development of shock.

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 injury 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

First aid of a severe burn ● In the case of fire, the patient must be Consult a doctor and prepare to evacuate the patient as soon as moved to safety, and further injuries possible, if must be prevented. Burning clothes are extinguished by smothering the fire with • the burn is on the face a blanket or a carpet, for example. While • nasal hair is scorched this is being done, the patient is kept ly- • mucous secretion is charred, or the ing down, so that the flames cannot burn patient has difficulties breathing. the respiratory tract, neck or face. If the patient has been exposed to smoke, or carbon monoxide poisoning is suspected, If more than 15% of the total skin area has he/she must be moved into the fresh air im- burnt, intravenous infusion should be start- mediately. Symptoms of carbon monoxide ed within the first hour to prevent shock. poisoning may be headache, dizziness, The infusion flow rate is calculated accord- confusion and loss of consciousness. ing to the so-called Parkland formula, i.e. First aid procedures are the same as ¼ x patient’s weight (kg) x extent of burn in any life-threatening situation: make sure (%) = amount of fluid given intravenously, that the respiratory tract is open, and that ml/hour (drip chamber 20 drops = 1 ml). both breathing and blood circulation are Treatment is continued at this flow rate functioning. The state of the vital functions for 8 hours. Consulting a doctor via Radio must be assessed, and resuscitation started Medical is necessary. immediately, if necessary. In burns caused Pain medication is given to the patient by electricity, attention must be paid to the if needed. For a severely burned patient, possibility that the electric shock may have even morphine (20 mg/ml, 3/C) may be caused immediate cardiac arrest. given 0.2–0.4 ml subcutaneously. Moni- If a respiratory tract burn is suspected, toring the patient’s condition is of prime oxygenation of the tissues is supported by importance, as in all serious first aid situ- giving oxygen with a mask. Skin burns ations. All patients with over 15% burns in the face area, scorched nasal hair and must be transported ashore for further burnt nasal mucous membrane are signs treatment. of a severe respiratory tract burn. Local first aid and treatment of skin burn ● Always consult a doctor via Radio Medical, if The burnt area is cooled as soon as possible with water (temperature about 20ºC) for • the extent of a burn with blisters is 10–30 minutes. If blisters have developed over 15%, or a more severe burn on the skin, they must not be perforated, covers more than 10% of the skin’s but an ointment dressing is placed over surface area the blisters, with an ordinary bandage • the burn is on the hands, feet, face placed over it. or genitals The bandages are changed after a • smoke has been inhaled few days. Parts of the bandage adhering to • it is an electricity burn. the injured area may be soaked off with a rinsing solution. A patient in pain is given pain killers. If there are signs of inflammation in the burn area, such as hotness, redness or a rise in temperature, it is treated in the

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

2 Fainting due to heat The patient is moved to rest in a cool place, and water is sprinkled on him/her Fainting caused by heat occurs especially to cool down the skin. If the level of con- during the first days of a heat wave, and in sciousness is good, the patient is given connection with a sauna bath. Because of liquid orally, but if unconscious or con- the heat, the blood circulation is directed fused, intravenously. Consulting a doctor to the skin and lower limbs, while at the via Radio Medical is necessary. same time the circulation to the brain weakens, causing a temporary loss of con- 5 Heat stroke sciousness. Treatment consists of placing the patient in a cool place, lying down with Heat stroke is a rare, but extremely severe the feet in an elevated position. The patient condition. The organs cannot sufficiently may be given something to drink. eliminate the heat, which has either been produced in the body during physical exer- 3 Heat spasm tion, or which has come from outside the body. In this case, the temperature of the Sweating causes loss of water and salt, body rises excessively. If the body tempera- which may lead to heat spasm. Pain- ture rises above 42°C, cell damage begins ful muscle cramps usually occur in the in the body tissues. The most sensitive areas thigh, back or abdominal area. The level are the brains and the liver, but excessive of consciousness is normal, but the pulse heat may also affect the heart and cause is rapid. arrhythmia. First aid consists of stopping exertion, The symptom is usually sudden loss of having the patient rest in a cool place, and consciousness. At first, the patient is con- giving him/her slightly salty liquid to drink. fused, the pulse is rapid and blood pressure It is possible to get some idea of how much low. As the condition proceeds, breathing body fluid has been lost by comparing the becomes rapid and panting, and the patient patient’s weight to his/her earlier normal may vomit and have diarrhoea. weight. After heat spasm, the muscle pains Heat stroke should be diagnosed disappear in a couple of weeks. immediately, because starting treatment rapidly is crucially important. The patient 4 Heat exhaustion is placed on his/her side in a cool place, and water is sprinkled on him/her. The skin Sweating causes loss of water and salts and especially the head must be kept moist (sodium and potassium) from the body, all the time, and the cooling should be ac- and this may lead to heat exhaustion. The celerated by ventilation (for instance with a symptoms are sudden excessive fatigue fan). It is necessary to start intravenous fluid and weakness, headache, nausea and pos- replacement therapy (infusion therapy). sibly vomiting, confusion, heart palpitation Immediately after first aid, a doctor is and rapid breathing. The body temperature consulted via Radio Medical, and his/her is usually slightly raised, but sometimes it advice is followed. can rise to even over 40°C.

39 II Accident injuries and their treatment

13 Electrocution

Electrocution (electric shock) is usually ● In the case of electrocution, caused by careless handling of electricity or electrical equipment, or faulty conduct- • do not put yourself at risk ing wires or devices. The consequences to • turn off the current health from an electric shock depend on • detach the injured person from the the voltage and power of the current. source of electricity The symptoms of electric shock may • resuscitate. be tingling, muscle pain, burn, loss of consciousness, and possibly cardio-pulmonary arrest. Electricity may also paralyze the If the current cannot be turned off quickly victim, making him/her unable to detach by, for example, turning off a switch, dis- him/herself from the electric device. As a connecting the contact plug, or other simi- result, the damage caused by the electricity lar means, then, in low voltage accidents, is even more severe. the injured person may be detached using Be very careful when helping an a piece of dry wood, cord, or a piece of electrocuted victim. The victim conducts clothing. Never use a damp object or metal electricity as long as he/she is in touch object for this purpose. with the electric circuit. Damp clothes When the victim’s basic vital func- and environment conduct electricity well, tions have been checked, any possible while rubber gloves and boots are good burns caused by the electric current are insulation against electricity. Dry wood, treated. Monitoring the victim’s condition textiles and newspaper are fairly good carefully is crucially important, because insulators as well. arrhythmia and even cardiac arrest may occur even after the electric shock is over. It is especially important to monitor the ● Do not touch the injured person, unless you are certain that the heart beat. Preparations must be made to current is turned off. start resuscitation rapidly, if necessary.

Great care must be taken especially in high voltage accidents. The risk of damage from an electric arc is considerable, when one is approaching conducting wires, as an electric arc may extend a distance of dozens of centimetres from the wires. Proper rescue measures cannot be started until an electrician has cut off the high voltage current.

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

36 Normal body temperature 35 34 Hypothermia 33 Weakened decision-making and reasoning ability 32 Lowered level of consciousness 31 Arrhythmia, muscle fibrillation has ended, blood pressure not measurable 30 Unconsciousness, dilated pupils 29 28 27 26 There is no pulse or respiration, clinically dead 25 Ventricular fibrillation, cardiac arrest 24 23 22 21 20 Complete cardiac arrest 19 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

The functioning of the liver and the kid- Treatment of hypothermia neys slows down. The pulse and respiration ‘disappear’ First aid to a conscious patient altogether when the temperature of the A conscious hypothermic patient who is internal organs is about 26°C, and the able to move must be told to change his/her patient appears clinically dead. When the clothes for dry ones, and especially to pro- temperature falls below 25°C, ventricular tect his/her head. If necessary, other people fibrillation or cardiac arrest occurs. Com- may give their clothes to the patient. After plete cardiac arrest occurs when the tem- this, he/she should move about gently, to perature of the internal organs is 20°C. increase the body’s own heat production. The patient is guided to the best shelter The severity of hypothermia available, to room temperature. Artificial Assessing the severity of hypothermia is al- warming must be avoided, because it may ways based on measuring the temperature result in a burn to the cold-damaged and from the patient’s colon. If it is not possible sensitive skin. It is a good idea to give the to use a thermometer, the assessment may patient lukewarm sugary fluid to drink, be made with the help of observations and as this increases the energy storage. The clinical symptoms: patient must be encouraged: the desire to • If the victim’s skin feels cold at the live is powerful. mid-body from under the clothing, hypothermia is possible. Coolness of the limbs is not enough, because there may The first aid of an unconscious be several other reasons for that. hypothermic patient, or a hypothermic • If the victim is conscious and he/she is patient with a disturbed level of shivering, the temperature of the inter- consciousness nal organs is above 32°C. A continuing A hypothermic unconscious patient, or a fall in the level of consciousness and patient with a disturbed level of conscious- related hallucinations, clumsiness and ness, who cannot move, has to be treated indifference are signs of progressing extremely carefully. Careless turning of hypothermia. the patient, removing clothes, or rubbing • A victim in a state of deep hypothermia of the limbs and active warming of the may appear dead, but he/she must patient may cause a sudden so-called af- not be considered dead before being ter-drop phenomenon. In such a case, the warmed up, and the subsequent resus- cooled blood, which has remained in the citation efforts have proved futile. limbs, starts to move, and when the cool blood reaches the heart, it cools down the The situation must be evaluated carefully cardiac muscle and may cause ventricular but rapidly. What has happened and what fibrillation. is the condition of the victim? This information quickly gives an overall picture ● The limbs of a hypothermic patient of what has happened. The information must not be rubbed or moved about the events, the victim’s current con- unnecessarily. dition, and the extent of the temperature decrease make it easier for the doctor to assess the patient’s condition via Radio Wet clothes are taken off with the patient Medical. This information is also needed lying down, if this is thought to be neces- if the patient must be evacuated ashore for sary. There is no point in taking clothes off further treatment. an unconscious patient. The patient must

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

Breathing is impossible under water, but covered. Resuscitation is continued at the there is enough oxygen in the blood and place of rescue, and all the time during the pulmonary alveoli to sustain human me- transportation of the victim. It is difficult tabolism for 2 to 5 minutes. Lack of oxygen to declare a hypothermic patient dead, causes brain damage, and its severity in- because in this situation, weak clinical creases as the amount of carbon monoxide signs of life are not easy to detect. accumulates in the body, thus increasing After successful resuscitation, every the acidity of the blood, when breathing victim who has been submerged must be is not possible. monitored very carefully. Consulting a In northern regions, for example, the doctor via Radio Medical is always neces- waters are cool even in summer. This low- sary. If possible, the victim is transported ers the body temperature, slowing down for further treatment and monitoring to the the metabolism and decreasing the body’s nearest hospital on shore, because even need for oxygen. Thus, the survival time of after the basic vital functions and level of a submerged victim is prolonged. consciousness have recovered, there is a In some cases, victims who have great risk of so-called secondary drown- been submerged for over 30 minutes have ing. This means that suddenly, after several recovered completely, when resuscitated. hours, pulmonary oedema and breathing Therefore, resuscitation must always be insufficiency may develop. The symptoms started, even if the victim has been sub- are increased breathing difficulties and merged for a longer time. ‘wet’ rales heard from the lungs. Breathing The victim must be rescued from is rapid, and foam or mucus may appear the water as soon as possible. Cardio in the mouth. The first aid for pulmonary pulmonary resuscitation must be started oedema is giving the patient oxygen, while as quickly as possible. There is rarely so the patient is in a sitting position. To re- much water in the lungs that it affects move the fluid from the lungs, furosemide resuscitation. Therefore, time should not (10 mg/ml, 1/C) is given as a 2 ml injec- be wasted in attempts to remove water tion intramuscularly. The victim must be from the lungs. Resuscitation is continued evacuated on shore for further treatment until the person´s heartbeat has clearly reas soon as possible.

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 equipment. 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 immediately, whereas the effects of substances

45 II Accident injuries and their treatment

that are either swallowed or absorbed 5 Treatment of through the skin appear later. poisoning Poisoning may cause sudden, severe illness, vomiting, convulsions or diarrhoea. The first aid and treatment of a patient who Also doziness or unconsciousness may has been exposed to sudden poisoning is be caused by poisoning. Medications or in general the same as the treatment of alcohol bottles found in the premises may a patient who has fallen ill suddenly. In give a clue as to why the patient has fallen severe poisonings, ensuring breathing and ill or is unconscious. This may also provide functioning of the heart is of prime impor- information about the quality or quantity tance, and only afterwards is attention paid of the used substance. to other symptoms caused by poisoning, It must always be borne in mind that and their treatment. the patient is not necessarily suffering from Poisoning that has been caused by poisoning. An attack of illness (myocar- a sudden or a single strong exposure to dial infarction, cerebral haemorrhage) or a specific poisonous substance must be unconsciousness due to other causes (e.g. treated on board. Consulting a doctor via an injury) must not be excluded. Radio Medical is usually necessary. After the first aid given on board, the patient is 4 Protecting the rescuers usually transported for further treatment and preventing the on shore. situation from worsening ● In the case of poisoning

In the case of poisoning, especially the • protect yourself and others protection of the rescuer and first aid per- • help the exposed patient to safety sonnel must be ensured. An area where • ensure the victim’s basic vital there may be poisonous gases or vapours, functions should not be entered without appropriate • consult a doctor protective equipment (e.g. self-contained breathing apparatus, gas mask, protective • carry out the treatment gloves and protective clothes). • monitor the situation A person who has been exposed • consult the doctor again, to gaseous substances must be moved if necessary. into fresh air, away from the dangerous substance. If his/her clothes are soaked with the dangerous liquid, they must be 6 Preventing a substance removed as quickly as possible, and the from being absorbed skin must be cleaned with, for example, water. Remember your own protection Removing contaminated clothes and in this case, too (e.g. protective clothing, cleaning the skin prevent the further ab- gloves, face mask). Contaminated cloth- sorption of the substance from the clothes ing must be handled carefully to prevent and skin into the body. A substance which further exposure. has entered the body orally, stays for a few hours in the stomach before moving on and being absorbed into the blood circulation from the intestines. When the substance is still in the stomach, it is possible to try to prevent its further absorption.

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 chemical 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 fluids 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

example in mushroom and ethylene glycol Contaminated clothes are removed, poisonings). at the same time avoiding exposure In drug poisonings, intestine and heart oneself. After this, the skin is cleaned by symptoms often appear first, and later, cen- rinsing. Corrosion or burns caused by the tral nervous system or breathing symptoms. substance are treated. If the substance Sudden apnoea without specific prior can be absorbed through the skin, and symptoms may be related to overdoses of its amount has been excessive, possible some pain-killers. systemic symptoms are to be expected and An attempt must be made to clarify prepared for. the content of the swallowed substance, its quantity and when it was swallowed. 11 Eye exposure If the substance causing the poisoning is known, then Radio Medical may give de- Many corrosive or irritating substances, tailed information on how best to proceed in the form of splashes or vapours, cause in treating that particular poisoning. corrosion or irritation injuries to the eyes. If a corrosive chemical has caused Strong alkalis may corrode the cornea per- the poisoning, the patient is given water or manently even in a short time. However, other fluid in small quantities, altogether in most cases, the corrosion is superficial, 2–3 dl, to dilute the substance already in healing in a few days. the stomach. The patient is never made When a substance has entered the to vomit if he/she has swallowed some eyes, they must be rinsed for a sufficiently corrosive chemical or industrial solvent, long time, about 30 minutes. Because the because then the solvent easily ends up in eyelids tend to close, they often have to the lungs, causing pneumonia. be held open with the fingers, so that the rinsing liquid may reach as wide an area as possible in the eye as well as under ● A patient who has swallowed a corrosive substance must not be the eyelids. If there is severe pain in the made to vomit. eye, pain killers may be given orally at the same time as rinsing is started. After rinsing, anaesthetic drops (oxybuprocain The treatment of an unconscious patient hydrochloride, 10/C) may be applied on consists of maintaining the functioning the eye, and in more severe cases, the eye of the heart and breathing. It is usually may be covered with sterile gauze. enough to monitor the patient if he/she has alcohol intoxication, and if the patient 12 Poisonous substances does not have any injuries and has not taken drugs with the alcohol. Alcohol In most cases, the cause of alcohol in- 10 Poison splashed toxication is ethyl alcohol. In general, an on the skin intoxication of over 3.5 pro mille content of alcohol is considered a poisoning. A poisonous substance may irritate or However, habituation to alcohol greatly corrode the skin locally, or be absorbed influences the quality and severity of the through the skin and affect the whole body. symptoms. Drugs taken simultaneously Some substances have both a strong local with alcohol often influence the symptoms. irritating effect and general effects (e.g. Especially tranquillizers taken together phenol, fluorine hydrogen acid). with alcohol have an effect on breathing,

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

III SYMPTOMS AND DISEASES AND 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 SYMPTOMS AND DISEASES AND THEIR TREATMENT III Symptoms and diseases and their treatment

17 Headache, and pain in the head region

Headache is a symptom that can have with a sudden onset of headache that many different causes, e.g. fever, infec- clearly gets worse during exercise, and tions, circulatory disorders and poisoning. that lasts for a considerable time should Sometimes headache may be life-threaten- be transported to further examination by ing. a neurologist.

1 Symptoms ● In cases of headache, always consult a doctor via Radio Medical if Sometimes tiredness or listlessness may precede a headache, which may last from • the patient describes the headache a few hours to a couple of days. The pain as the worst he/she has ever experi- itself can be one-sided and pounding, enced or it may be continuous, constricting or • the arm or lower limb on one side pressing pain, or the feeling of a tight becomes powerless, numb or para- band across the forehead. Sometimes a lyzed, or one side of the face seems headache can worsen if the patient moves to droop or, conversely, motion can ease the pain. • the patient has difficulty in speaking There may also be nausea and vomiting in • the patient has fever, stiffness in the connection with headache. neck, and skin rash Cerebral meningitis and brain fever • the headache worsens continuously (cerebrospinal meningitis) usually induces a severe headache that worsens during • the headache gets worse in physical physical exercise. Other symptoms include strain, and the patient has not had migraine earlier a lowering of consciousness, nausea, and typically tightness of the muscles of the • the patient vomits recurrently, and neck. Sometimes the patient also has sei- has no history of earlier migraine zures and is disoriented. • the patient has seizures A headache can also be caused • the headache lasts over 24 hours. by external factors such as a hangover. Persons who usually drink much coffee during the day, and suddenly stop doing If the headache seems to be related to so, will propably experience headache as stiffness of the neck and shoulder muscles, a withdrawal symptom. Severe poisoning it might be helpful to relax these muscles is often accompanied by headache (e.g. by warming them with a hot compress, carbon monoxide poisoning). massage, or stretching. Sometimes also physical exercise helps. 2 Treatment Once the possibility of a severe illness has been ruled out as the cause of The basic cause of the headache should be the headache, medical treatment can be investigated as thoroughly as the situation tried. In the early stage, or if it is mild, a permits. It is often necessary to consult a headache usually lessens with common doctor through Radio Medical. A patient painkillers (e.g. diclofenac 3/B). A person

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

Headache caused The pain is characteristically dull, and by cerebral meningitis is markedly aggravated on exertion, in Meningitis is inflammation of the lining which case the pain becomes pounding. around the brain. The symptoms of men- Nausea in the mornings is also related to ingitis vary, but nearly always include this condition. headache that worsens with exercise. The patient usually has fever and a stiff neck, as Headache caused in cerebral haemorrhage. Other symptoms by other illnesses may include sensitivity to light, nausea, Many respiratory infections, especially vomiting, drowsiness and confusion. The influenza, cause headache. The pain is symptoms may be milder in the case of usually constant, sometimes pounding. Of- viral meningitis, whereas in the case of ten the symptoms, such as fever, coughing, bacterial meningitis, the symptoms may sneezing and secretion of mucus, reveal appear quite suddenly. A person in the later the correct diagnosis. Maxillary sinusitis stages of bacterial meningitis may have also often causes a headache around the seizures and lose consciousness (pass out). cheek bones and the forehead. Typically, Meningitis is a life-threatening disease. the patient has difficulty in lowering his/her head. If the head is lowered, a constricting pain is felt in the area of the sinuses. The ● Consult Radio Medical immediately, if you suspect that someone might treatment includes treating the actual in- have meningitis! fection, and giving pain-killers if necessary. Other infections (e.g. ear ache, tooth ache, problems relating to the jaw joint, etc.) can Headache caused by also cause one-sided headache. an intracranial process An intracranial process that requires space causes headache by stretching the pain- sensitive meninx and intracranial blood vessels. There is about 1 dl of extra space within the skull, and when this has been taken up, the symptoms aggravate markedly. The most important causes of this type of headache are: • brain tumours • cerebral haemorrhage • expansion and malformation of the intracranial blood vessels • disruption in the circulation of cerebrospinal fluid.

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

Unconsciousness is a dramatic event that 2 Assessing the level of always requires immediate first aid and consciousness further examination. The level of consciousness should be as- 1 First aid in cases of sessed immediately in accordance with unconsciousness the Glasgow Coma Scale. The scale is also useful for noting changes in the level of When treating a person who has suddenly consciousness. lost consciousness, it is crucial to check for The highest scores from all areas of the presence of the basic vital signs and to assessment are added together. The range make sure that the patient of points is from 3 to 15. If the sum score • is breathing; if not, begin mouth-to- is 8 or less, a disruption in the state of mouth resuscitation consciousness is clear and the situation is • has a heartbeat; if not, begin cardiac serious. The patient’s condition should be massage monitored very carefully. • has open airways that also stay open.

56 III Symptoms and diseases and their treatment

Opening the eyes • eyes are open or the patient opens them spontaneously 4 • eyes are opened on request 3 • eyes are opened when provoked with pain 2 • eyes are not opened even when provoked with pain 1 Ability to speak • answers questions properly 5 • is confused, incoherent 4 • uses words out of context 3 • utters sounds 2 • does not utter sounds even when provoked with pain 1 Motion control • moves all limbs on request 6 • pulls hand away from pain and uses other hand to help (localizes) 5 • pulls hand away from 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

rator, if necessary. If the patient has trouble ● Always consult a doctor via Radio with breathing, oxygen should be given. Medical when a patient has lost consciousness. ● An unconscious patient should never be left unmonitored. 3 Further treatment of an unconscious patient If the patient does not regain conscious- Background information ness within a few minutes, intravenous The eyewitnesses should be asked about fluid infusion should be started if possible. how the loss of consciousness occurred Basic saline solution should be used, and and what they know about the patient. the speed of infusion should be 15–20 Important information includes details drops/minute (20 drops = 1 ml). An intra- about the incident, possible preliminary venous connection makes rapid treatment symptoms like seizures, medication, pos- possible. sible intoxication, injuries and previous illnesses. Other forms of treatment The level of blood glucose should be Monitoring and intravenous measured in all cases of unconsciousness, infusion therapy especially if the patient’s skin is cold and An unconscious patient is moved to a calm clammy to the touch. If the blood glucose and safe location. If the patient is breath- level is low (less than 3 mmol/l), 1 mg of ing, he/she should be placed lying down glucagon (8/C) should be injected subcu- on his/her side. If he/she has difficulty in taneously, or into the muscle. If there is no breathing, intubation is recommended. certainty about the level of blood glucose, Breathing is aided with a hand-held respi- glucagon can be administered, if a low

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 intramuscular 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 treatment. 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 alcohol, 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

20 Eye problems and symptoms

There can be infections, functional dis- Sudden infection of the margin turbances, and structural or degenerative of the eyelid symptoms in the various parts of the eye. An infection of the margin of the eyelid is Sometimes eye symptoms are connected usually caused by bacteria. The margin of with other illnesses or they can be side-ef- the lid is red and swollen, and discharge fects of, for instance, medical treatment. and crust form at the roots of the lashes. It may be difficult to open the eyes in the 1 Illnesses of the eyelids morning because of the encrustation. The eye should not be rubbed despite the pos- The most typical illnesses of the eyelid sible itching caused by the infection. are: stye, chalagion, infections and allergic reactions. The conjunctiva turns white in 2 Dry eyes infections of the eyelid. The proper treatment is to use eye Blinking the eyes normally spreads a thin salve containing chloramphenicol (10/B) 3 film of tear liquid on the surface of the eye, to 5 times a day. This is continued for two thus keeping the cornea and the conjunc- days after the symptoms have alleviated, tiva damp and clean. The symptoms of dry but no longer than 10 days altogether. eyes are a sensation of grittiness or itching An eye that secretes discharge is al- and burning. The eyes feel dry, but they ways cleaned with a cotton swab or ball may also feel wet. The symptoms worsen dipped in clean water before applying the in a room where the humidity is low or the salve. If the problem is not over in 10 days, air conditioning is very effective. The treat- consulting a doctor through Radio Medical ment is prescription-free artificial tears that is recommended. are applied several times a day.

Stye and chalagion 3 Red, itching and A stye is an infection of the small seba- discharging eyes ceous glands situated at the roots of the eyelashes. It sometimes appears as a small In an infection of the conjunctiva both eyes infected nodule on the edge of the eyelid. are red and ‘burning’, and especially in the Sometimes the entire margin of the eyelid mornings discharging. An allergic infection is swollen, red and tender. Later, a small of the conjunctiva is also often accompa- abscess develops. It may erupt on its own nied by a clogged nose and secretion of in a couple of days. clear mucus, sneezing or other respiratory A chalagion is a blockage of a gland symptoms. on the margin of the eyelid. It usually ap- If the infection is caused by bacteria, it pears as a hard lump, which can reach the can spread by touching, and therefore the size of a pea and usually is not tender to patient should be well instructed to take the touch. A small chalagion may go away care of hand hygiene. by itself, a larger one needs to be removed The eye should be cleaned. Cloram- surgically by a doctor. phenicol (10/B) eye drops or ointment is used for treatment. On the first day, the drops are applied once every hour. On the following days they are applied 4 to 6 times

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. tetrahydrozoline 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

21 Illnesses of the ear and the throat

Illnesses of the ear, nose and throat are very given 1.5 tablets twice a day, or, in case of common. They tend to heal by themselves, hypersensitivity to penicillin, one 150 mg and the use of antibiotic drugs should tablet of doxycycline (7/B) once a day. The therefore be considered carefully. It is typi- treatment should last 10 days. cal that in these infections the symptoms Obvious swelling on one side of the are similar regardless of whether they are pharynx together with severe pain in the caused by bacteria or by viruses. throat, difficulties in speaking and in fully opening the mouth, are severe symptoms, 1 Sore throat and suggest the presence of an abscess in the throat (peritonsillar abscess). The con- Most throat infections are viral in origin. In dition is treated with antibiotic drugs (for these cases soreness of the throat is related dosage, see above). Consulting a doctor to simultaneous symptoms of the common through Radio Medical is recommended. cold, e.g. coughing, a runny nose, and sometimes muscle soreness. Antibacte- ● Consult a doctor via Radio Medical rial treatment is ineffective against viral diseases. • if the throat is coated with white plaques and Absence of a runny nose or coughing suggests bacterial infection. The tonsils • the patient is unable to swallow his of the patient with a sore throat may be own saliva, or covered with whitish plaques (Figure • cannot fully open his mouth 21). Swelling and soreness of the lymph because of throat pain. nodes on the neck also suggests bacterial infection. If the nodes are not sore, a viral infection is suspected. A bacterial 2 Hoarse voice infection is treated with antibiotics. Phe- noxymethylpenicillin (660 mg/tbl, 7/A) is Sudden hoarseness of the voice is often caused by a viral infection of the larynx. Symptoms of the common cold are often present. The treatment is to rest the voice (talk as little as possible), to breathe hot steam and to take a cough mixture that inhibits coughing if necessary. Treatment with antibiotics should be considered if the symptoms persist for more than two weeks, or if other findings in the respiratory tract require it (e.g. strong suspicion of maxillary sinusitis). Smoking and the use of alcohol may prolong hoarseness of the voice.

Figure 21. Tonsils coated with white plaques

62 III Symptoms and diseases and their treatment

3 Ear wax in the alcohol helps to disinfect the skin of the external ear auditory canal. If there is ear wax in the auditory Ear wax helps protect the ear from infec- canal, water can easily block the passage. tions, among other things. Sometimes so In this case the treatment is to remove the much wax accumulates that when in- wax as described above. spected with an ear lamp, a reddish brown mass of impacted wax is visible in the 5 Itching of the ear outer auditory canal. There is no reason to remove the wax unless it causes symptoms. Itching of the auditory canal is a common If the impacted ear wax blocks the auditory problem. The cause may be a chronic in- canal entirely, it may not only weaken the fection of the auditory canal, for instance hearing, but also cause humming in the ear, a yeast or other fungal infection. A rash and even vertigo. In this case removing the may also be caused by irritation or by an wax is recommended. allergic reaction. Despite the itching, pick- Impacted ear wax should not be ing the auditory canal should be avoided, removed with a cotton swab, as this may as the thin skin of the canal can easily be easily push the blockage even deeper into ruptured, thus making the ear vulnerable to the auditory canal. The impacted wax can sudden infection. Repeated picking of the be softened with appropriate ear drops auditory canal can also prolong the itch. (wax-removing drops, 11/C). It is then Ear drops containing flumethasone- easier to remove the wax by syringing the clioquinol (11/A) can be used as a medical auditory canal. A softened blockage is treatment: three drops are dropped into removed by syringing the auditory canal the auditory canal while the patient is with water at a temperature of 37ºC. If the lying on his side. The drops are allowed temperature of the liquid used differs from to flow slowly deeper into the canal. This the temperature of the body, it will cause procedure is repeated 2 to 3 times a day. vertigo and nausea during the procedure. If the problem persists or recurs, examina- The procedure is repeated until the im- tion and treatment by an ear specialist are pacted wax is removed. The success of the recommended. procedure can be checked by examining the auditory canal with an ear lamp. If it 6 Pain in the ear is known that there is a hole in the ear drum, no water should be allowed into the The cause of pain in the ear is usually an auditory canal. infection in the auditory canal or in the middle ear. The symptom in both cases is 4 Water in the ear severe pain. In an infection of the middle ear, the pain is caused by liquid accumu- After washing the hair or swimming, some lating in the middle ear, causing the pres- water may remain in the ear. Usually the sure to rise. The pain eases if the tympanic water can be removed by tilting the head membrane ruptures and the pressure in and shaking it, or drying with a towel. If the middle ear is relieved. In an infection this does not seem to work, it is possible of the auditory canal, the symptoms are to try and remove the water by pouring a caused by an infection of the skin of the 40–60% solution of alcohol (e.g. vodka) auditory canal. Puss accumulates in the into the auditory canal. The alcohol mixes canal, the ear is sore, and there is deafness with the water and the mixture dries faster of the ear. than plain water. At the same time the

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 bleeding 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

22 Problems of the mouth and the teeth

Problems of the mouth and of the teeth For persons who are hypersensitive to rarely require immediate treatment aboard acetylsalicylic acid, one (or two) 500 mg ship. However, toothache, a broken or tablet of paracetamol (3/A) is given 2 to 4 detached tooth or a dislocated jaw do times a day. require first aid aboard ship. In the case of a bacterial infection in a tooth, a 660 mg tablet of phenoxymethyl- 1 A Dislocated jaw penicillin (7/A) is administered three times a day. For those hypersensitive to penicil- The jaw can be dislocated during yawn- lin, a 500 mg tablet of cefadroxil (7/E) is ing, for instance. The mandible (lower administered twice a day. The treatment is jaw bone) slips away from the anticular continued for 10 days. A dentist will repair surface of the maxilla (upper jaw) and the the affected tooth on shore. jaw is locked in an open position behind and above the anticular surface. Closing 3 A detached tooth the mouth is impossible. If the dislocation is only one-sided, the jaw appears A tooth that has accidentally come off crooked. should always be replanted if the jaw bone The treatment is to simply relocate the seems intact. The tooth is cleaned carefully jaw. The patient is sitting down; the helper in such a way that the surface of the root is places his/her thumbs against the molars not rubbed or unnecessarily touched. If the in the mouth, and supports the lower jaw tooth is not replanted immediately, it can with the other fingers. The jaw is pulled be preserved in milk or under the tongue down until the mandible clicks into place until replantation. as a result of the pull of the masticatory The tooth can also be replanted im- muscles (jaw muscles). The jaw often slips mediately. The dental alveolus from where into place very suddenly, so the helper the tooth came out should be rinsed with must be prepared that his/her thumbs will saline (salt) solution, using a syringe to most probably be caught between the spray the solution into the alveolus. The patient’s teeth. tooth is then pressed into place. If it is not possible to visit a dentist, treatment should 2 Toothache be started on board by giving the patient a 660 mg tablet of phenoxymethylpenicillin Toothache is caused by an infection of the (7/A) three times a day or, in the case of dental pulp, either because of caries or hypersensitivity to penicillin, a 500 mg because of a broken tooth. The infection tablet of cefadroxil (7/E) twice a day. The causes severe pain. There can also be an patient should be referred to a dentist for abscess at the root of the tooth. It may further treatment as soon as possible. be seen as a swelling of the surrounding gum. The abscess may even erupt into the 4 A broken tooth oral cavity. The first aid for toothache is pain If a tooth is broken or chipped, the remain- relief. One or two 50 mg tablets of di- ing part of the tooth can be protected with clofenac (3/B) are given 2–3 times a day. dental cement (14/A). If the dental pulp is

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.

23 Chest pain and cardiovascular diseases

The causes of chest discomfort or pain may 1 Caring for a patient be completely harmless, or they may be suffering from chest rapidly life-threatening. It has to be kept pain in mind always that the cause of chest pain may be coronary artery disease. On The aim of first aid is to alleviate the the other hand, severe chest pain may be patient’s symptoms and to increase the an indication of a ruptured aortic aneu- chances of survival. rysm, inflammation of the heart muscle, Treatment: pulmonary and musculoskeletal diseases • place the patient in a half-sitting and gastrointestinal diseases, as well as position psychological factors. • deliver oxygen with a mask A patient complaining of chest pain • give pain medication should always be taken seriously. Find- • give nitroglycerin ing out valuable background information • give acetylsalicylic acid. about the case makes consulting Radio Medical easier. The background informa- ● Consult Radio Medical. tion includes documenting when and in what circumstances the symptoms began, and how they developed. In addition, examining the patient’s general condition, Reassuring and positioning skin colour and skin temperature, pulse, the patient blood pressure, body temperature and The patient is placed either in a half-sitting other possible symptoms is important. or in a lying position. Oxygen is administered with a mask. A peaceful environment and calm behaviour help to reassure the

66 III Symptoms and diseases and their treatment

patient. Continuous observation of the monitored and observed carefully. Pulse patient’s general condition makes it easier and blood pressure should be taken regu- to notice rapid changes in the patient’s larly. If the patient experiences severe chest condition. Speaking in a reassuring man- pain, it is always necessary to consult a ner with the patient also helps the patient doctor via Radio Medical. to feel safe.

Pain medication 2 Causes of chest pain Diclofenac (3/B) as a 100 mg suppository Coronary disease or as a 3 ml intramuscular injection can Coronary artery disease develops when the be administered 3 times a day to alleviate coronary arteries which supply fresh blood pain. (Not to be given to patients allergic to the heart muscle, become narrowed. to acetylsalicylic acid!) This usually takes many years or even A patient who is clearly unwell and decades. A typical symptom is a pressing or suffering from severe chest pain of sus- smarting pain (angina pectoris) felt behind pected cardiac origin should immediately the breastbone during physical or mental be given morphine (20 mg/ml, 3/C), for stress. The pain often radiates to the left example, a dose of 0.2–0.6 ml intrave- arm, but it can also spread to the neck, nously, intramuscularly or subcutaneously. jaw and upper extremities or between the Morphine can be given repeatedly, but it shoulder blades. The pain usually lasts for must be noted that large doses can weaken a few minutes and is relieved by rest and breathing. nitroglycerin medication.

Nitroglycerin and Heart attack acetylsalicylic acid A heart attack (myocardial infarction) If the patient’s blood pressure is over occurs when a coronary artery suddenly 100/60 mmHg, a nitroglycerin tablet can becomes obstructed. An obstruction usu- be administered under the tongue to allevi- ally develops in an artery that is already ate cardiogenic chest pain. Nitroglycerin narrowed. When the left or right coronary dilates the coronary vessels, improving the artery is occluded, a sudden decrease in flow of oxygen to the heart muscle. A heart cardiac output or a disturbed heart rhythm attack or other illness causing chest pain may lead to sudden death. is suspected if four nitroglycerin tablets, The most common symptom of a heart administered one at a time at 3–5-minute attack is intense pain. The pain is similar intervals, do not help. to angina pectoris but more intense. The In addition, three 100 mg tablets of pain also lasts for more than 20 minutes. acetylsalicylic acid (1/B) should be given Rest and nitroglycerin medication give to the patient to be chewed if he/she is only little relief. not allergic to acetylsalicylic acid. A small Other signs and related symptoms of amount of acetylsalicylic acid works as an a heart attack include nausea, vomiting, anticoagulant, inhibiting platelet binding shortness of breath and excessive perspi- and blood clotting. ration. Widespread damage to the heart muscle may lead to rapidly progressing Other treatment cardiogenic shock. The patient becomes Diazepam (4/A) has a sedative effect, al- pale and the skin feels cold and clammy. leviating apprehension and anxiety. One The blood pressure drops and the pulse or two 5 mg tablets of diazepam can be becomes frail. given at a time. The patient needs to be

67 III Symptoms and diseases and their treatment

3 Other cardiovascular discomfort, a metoprolol tartrate tablet (1/ diseases D) 25 mg can be given 1−2 times a day. A heart rate over 100 or even 300 Congestive heart failure beats per minute is abnormally fast. Very The most common diseases that cause often this kind of tachycardia is a sign of congestive heart failure are hypertension heart disease or some other illness, such as and coronary artery disease. Congestive hypersecretion of thyroid hormone. Select- heart failure may develop in a previously ing suitable medication requires consulting healthy person during, e.g. a severe in- Radio Medical. flammation of the heart muscle, or during Atrial fibrillation is a relatively com- pregnancy. mon form of tachycardia. The typical Sudden heart failure causes pul- symptoms are palpitation, disturbed heart monary oedema, i.e. accumulation of rhythm, weakness and chest pain − espe- fluid in the lungs. The symptoms include cially when the heart rate is very rapid. difficulty in breathing even at rest, cold The treatment includes administration of bluish skin, and a rapid pulse. The veins one 25 mg tablet of metoprolol tartrate of the neck area are often distended. The (1/D) 1−2 times a day. Consulting Radio patient’s breathing becomes wheezy and Medical is necessary if the condition does his/her sputum may be foamy. Pulmonary not improve. auscultation with a stethoscope reveals Ventricular tachycardia and ven- râle in the lungs. tricular fibrillation are life-threatening Sudden pulmonary oedema is al- arrhythmias. The underlying problems are ways an emergency situation. After rapid coronary artery disease, acute myocardial assessment, a doctor must be contacted infarction, or diseases of the heart muscle. and the patient should be hospitalized as In ventricular fibrillation, the heart is un- soon as possible. The patient is placed in able to pump blood adequately. The pa- a half-sitting position and oxygen is deliv- tient suddenly loses consciousness, stops ered via a mask. A diuretic, for example, breathing, and the pulse is not palpable. furosemide (1/C) can be administered The condition is fatal unless cardiopulmo- 10−20 mg (1/2 –1 ampoule) intravenously. nary resuscitation is started immediately. Also 0.2−0.3 ml of morphine (20 mg/ml, A slow heart rate or bradycardia may 3/C) can be administered intravenously cause dizziness, faintness, weakness, chest or subcutaneously. If the patient’s blood pain, and even convulsions, or sudden loss pressure is over 100/60 mmHg, a 0.5 mg of consciousness. It is necessary to consult nitroglycerin tablet (1/A) can be placed Radio Medical before administering any under the tongue. drug, and the patient must be transported to hospital. Disorders of heart rhythm Most arrhythmias are harmless. Heavy High blood pressure and smoking and drinking of coffee, as well as hypertensive crisis staying up very late or having a hangover, There are no immediate symptoms in may provoke arrhythmia. Arrhythmias are high blood pressure or hypertension. In often symptom-free, but they can also be the long run, hypertension damages the unpleasant chest sensations or ‘missing internal organs, e.g. the heart and kidneys, heart beats’. If arrhythmias occur mainly at and may cause diseases such as coronary rest and not during physical strain, they are artery disease, congestive heart failure, usually harmless and require no medical renal failure, or a stroke. attention. If arrhythmias cause persistent

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 pulmonary 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

cyanotic (bluish) skin, restlessness, pain 4 Diseases of arterial and impaired consciousness. The condi- circulation, arterial tion is life-threatening and requires urgent thrombosis medical attention. First aid includes placing the patient Arterial thrombosis of a leg can be caused in a resting position and administering by a ruptured atherosclerotic plaque or a oxygen via a mask. Strong painkillers, blood clot formed in the heart. The condi- such as morphine, alleviate the pain and tion progresses rapidly. Sudden, intense the sense of oxygen deprivation. Morphine pain is felt in the affected leg. The distal can be given, for example, in 6 mg doses part of the leg turns cold and blue and no intramuscularly, or slowly via an intrave- pulse can be felt. The cessation of circu- nous cannula. Consult a doctor via Radio lation in the leg requires urgent medical Medical and evacuate the patient from the attention, because there is a great risk of ship as soon as possible. losing the leg.

24 Difficulty in breathing

Difficulty in breathing is a sign of inad- If the patient experiences difficulty in equate oxygenation. It may be caused by breathing, reassure him/her about the situ- narrowed airways due to, for example, a ation and place him in a sitting position. foreign body in the airways, allergic reac- Administer oxygen via a mask to improve tion, inflammation, or toxic gases. Another oxygenation. The cause of the breathing cause may be impaired functioning of the difficulty must be clarified, and appropri- lungs due to inflammation or a collapsed ate measures must be taken immediately. lung. The diminished oxygen transfer If the condition is severe, prepare for resus- capacity of blood, caused by decreased citation. After giving first aid, it is always blood volume (bleeding) or weakened necessary to consult a doctor via Radio stroke volume of the heart (congestive Medical. heart failure), leads to oxygen deprivation, resulting in breathing difficulties. Severe 1 Sudden difficulty lack of oxygen may cause blueness (cya- in breathing nosis) of the face and especially lips, and laboured breathing, even at rest. If sudden breathing difficulties occur during a meal, always suspect airway obstruction due to a piece of food clogged in the ● Causes of breathing difficulties: windpipe. The signs are sudden and severe • foreign body in the airways difficulty in breathing, or complete ces- • allergic reaction sation of breathing. The patient is usually • pneumonia unable to speak. At first, the patient can • collapsed lung be given sharp slaps between the shoulder • bleeding blades in order to remove the foreign body • congestive heart failure. from the windpipe. If this does not help, try

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

Spontaneous pneumothorax often fected side are silent or non-existent. begins with sudden one-sided pain and dif- Treatment aboard ship consists of ficulty in breathing of variable severity. The rest and pain medication. Consult a doc- breathing difficulty becomes more obvious tor via Radio Medical. The condition is during physical strain. The patient has no life-threatening and the patient should be fever or cough. Breath sounds on the af- hospitalized as soon as possible.

25 Diseases of the airways

Diseases of the airways are most com- 2 Treatment monly accompanied by cough and increased secretion of phlegm. The purpose It is not necessary to restrain coughing if of cough is to remove foreign material from it helps to loosen phlegm. Bromhexine the lower respiratory passages (bronchi (8 mg/tbl, 6/C), 1−2 tablets three times a and lungs). Besides pulmonary diseases, day can be given to ease expectoration. cardiovascular and musculoskeletal prob- The treatment should not be continued lems (ribs, muscles between the ribs) can for over two weeks, because the medi- also provoke chest discomfort. In addition, cine will start to induce mucus secretion diseases of the abdominal region can be and may thus prolong the symptoms. A manifested as symptoms felt in the chest. dry, barking cough is harmful. It can be treated with a cough mixture containing 1 Patient assessment antitussive (6/B). Coughing irritates the airways and Always interview the patient about the de- may narrow them. This may cause wheez- velopment and duration of his/her current ing and laboured breathing, which are airway symptoms and possible history of treated with salbutamol (6/A), one 2 mg similar problems. Auscultate the lungs and tablet three times a day, or two inhalations note the audibility and symmetry of the (0.2 mg/inhalation) at 4-hour intervals. breath sounds and possible râle. Measure If the patient’s general condition is the patient’s body temperature. poor or is weakening, or if the phlegm If the airway symptoms persist for over becomes thick and green, antibiotic medi- three days, or if the patient has breathing cation should be started. For a non-smoker, difficulties, wheezing or fever, consult a administer one tablet of phenoxymethyl- doctor via Radio Medical. penicillin (660 mg /tablet, 7/A) three times a day. For a smoker or a patient allergic to ● If the following symptoms occur, penicillin, administer one 500 mg tablet of consult a doctor via Radio Medical: cefadroxil (7/E) twice a day, or doxycycline • difficulty in breathing (7/B), one 150 mg tablet once a day. The • fever (over 39°C) medication is taken for 7−10 days. • wheezing breath sounds If antibiotics do not ease the symp- • asymmetrical breath sounds toms within a couple of days, consult a doctor via Radio Medical. • severe chest pain When the patient’s condition has • bloody or green phlegm. improved, consider transferring him for

72 III Symptoms and diseases and their treatment

medical and lung examinations. The risk Pneumonia of tuberculosis must be kept in mind, Pneumonia may develop within a few especially if the member of the crew hours. Typical symptoms include cough, comes from a country where tuberculosis coloured or bloody sputum, difficulty in is common. breathing, fever and often one-sided chest pain that worsens on breathing. Bacterial 3 Diseases of the airways pneumonia is often accompanied by a rapidly weakening general condition. Viral Common cold and influenza pneumonia may develop more slowly, The common cold is a viral inflammation of within a few days. the upper respiratory tract. The symptoms Auscultation of the inflamed lung include a moderate rise in body tempera- areas may reveal dry râle, but often the ture, runny nose, cough, muscle aches and breath sounds may be normal. general malaise. Antibiotic medication should always Influenza epidemics appear in the be started in cases of suspected pneumonia wintertime. Influenza causes a stronger (see above, Section 2 Treatment). In addi- inflammation of the airways than com- tion, diclofenac (3/B) one 50 mg tablet 2–3 mon cold. The signs, fever, cough, muscle times a day, can be given to relieve aches aches and general malaise usually last and to lower the temperature (not suit- 5–7 days. able for patients allergic to acetylsalicylic These viral infections are treated ac- acid!). Alternatively, one 500 mg tablet cording to the symptoms (rest and medica- of paracetamol (3/A) can be given three tion for easing the pain and lowering the times a day. temperature). Rest is recommended until If the condition does not improve the body temperature is normalized, even within 3−4 days, consult a doctor via 6−7 days. Sinusitis, pneumonia or bronchi- Radio Medical. A medical check-up, in- tis may occur as complications. cluding lung examination, should always be performed after pneumonia, especially Bronchitis as pneumonia may be the first sign of tu- Acute bronchitis is usually caused by a berculosis or lung cancer. virus. At first, the symptoms resemble those of the common cold. After a few Asthma days, other symptoms ease, but cough, Asthma is an inflammation of the bronchial increased phlegm secretion, and even a mucous membranes. It causes spasms feeling of pressure on the chest persist. in the bronchioles and thus difficulty in Often the patient has fever. At first, the breathing. phlegm is clear, but later on, as bacteria The first symptoms of asthma are become involved, it may turn greenish, usually cough and wheezing sounds brownish or yellow. during exhalation. Later on, difficulty in The patient with bronchitis requires breathing, increased mucus secretion basic care. Medicine for cough, pain and and yellowish sputum, may appear. These fever can be given, if necessary. If the condi- symptoms often appear in connection with tion persists or the patient has a high fever other airway inflammations. The symptoms or poor general condition, start antibiotic include wheezing cough at night, and dif- treatment (see above, Section 2 Treatment). ficulty in breathing during physical strain. Consult Radio Medical, especially if the pa- Dust and smoke induce the symptoms. tient’s general condition is poor. A medical Sudden asthma attacks aboard ship com- check-up is often necessary on shore. monly occur during physical strain or in

73 III Symptoms and diseases and their treatment

connection with an airway inflammation Tuberculosis (see Chapter 24 Difficulty in breathing). TB, or tuberculosis, is a disease caused by When asthma worsens, the rate of bacteria called Mycobacterium tuberculo- breathing increases, coughing starts, and sis. Although the bacteria can attack any wheezing sounds can be heard during ex- part of the body, they usually attack the halation even without a stethoscope. The lungs. The symptoms include cough that patient may experience a shortage of air is worse in the morning (sometimes with and difficulty in breathing. As a result, the haemoptysis, blood in the sputum), chest fear of suffocation may provoke hyperven- pain, breathlessness, night sweats, and tilation, deep and rapid breathing, which signs of pneumonia. In advanced disease, only worsens the condition. there may be extreme weight loss. An asthma attack is treated with 1−2 TB bacteria are conveyed by the air inhalations of salbutamol aerosol spray from one person to another. When a person (0.2 mg/inhalation, 6/A). The patient often with TB coughs or sneezes, the bacteria finds it easier to sit leaning forward. If these spread into the air, and the people nearby measures do not help, an injection of 125 may breathe in these bacteria and become mg of hydrocortisone (125 mg/ml, 5/C) is infected. given intramuscularly. Both medications can be given again after 3−4 hours. If SARS possible, oxygen is delivered via a mask. Severe acute respiratory syndrome (SARS) If the condition persists, give 0.5 mg of is a viral respiratory illness caused by adrenaline (1 mg/ml, 8/A) subcutaneously. a corona virus, called SARS-associated After giving first aid, consult a doctor via corona virus (SARS-CoV). SARS generally Radio Medical. begins with a high fever (temperature over >38.0°C). Other symptoms may include Chronic bronchitis and chronic headache, an overall feeling of discomfort, obstructive pulmonary disease and body aches. Some people also have Sputum secretion is typically increased diarrhoea. After 2 to 7 days, SARS patients in chronic bronchitis. Often many of the may develop a dry cough followed by alveoli in the lungs have been destroyed pneumonia. and, as a result, the lungs have become SARS seems to be spread mainly distended (emphysema). Over 90% of by close person-to-person contacts. The emphysema cases are caused by smoking. virus that causes SARS is thought to be The symptoms often begin with so-called transmitted most readily by respiratory smoker’s cough and become more severe droplets (droplet-spread) produced when as the years go by. It is essential to stop an infected person coughs or sneezes. smoking before severe and irreversible The virus also can spread when a person lung damage results. touches a surface or object contaminated with infectious droplets and then touches his or her mouth, nose, or eye(s).

74 III Symptoms and diseases and their treatment

26 Vomiting, fever and diarrhoea

Nausea, vomiting and fever are signs as- (2/C) three times a day in the form of sociated with a range of illnesses, inflam- tablets, suppositories or injections. If the mations and infectious diseases. Diarrhoea condition persists, consult a doctor via often occurs in inflammations of the intes- Radio Medical! tines, but it is not necessarily caused by an infectious disease. The illness causing the ● Consult a doctor via Radio Medical symptoms should be identified in order to if nausea is accompanied by treat it properly. • head or gastrointestinal trauma • impaired consciousness or 1 Nausea and vomiting disorientation • severe stomach ache or swelling of Reasons for nausea and vomiting the stomach The most common reasons for nausea and • bloody or coffee-coloured vomit vomiting are probably a viral infection and • fever over 39°C travel sickness or sea sickness. Vomiting • or if the nausea persists for over 24 can also be caused by a severe or even life- hours. threatening illness, for example, inflammation of the intestines or appendix, intestinal obstruction, incarcerated hernia, meningi- 2 Fever tis, increased pressure inside the skull, or drug, alcohol or other poisoning. Fever (arm pit temperature exceeding 37.5°C) is associated with inflammations of ● Reasons for nausea and vomiting: the body, for example, pharynx and other • viral inflammation airway infections, urinary tract infections, • sea sickness herpes, erysipelas, etc. Body temperature may fluctuate from high to normal, or even • drug, alcohol or other poisoning below normal as in malaria and blood • appendicitis, intestinal obstruction poisoning. Record the body temperature • increased pressure inside the skull. and its possible fluctuations, because it may be the only sign of malaria. Intense vomiting may rupture the vessels The cause of fever can usually be of the mucous membrane that lines the identified by observing the other symp- oesophagus, making the vomit bloody. If toms. Consult a doctor if the fever persists the patient has impaired consciousness or for over 2−3 days. Consultation is also is lying down, there is a risk that he/she necessary if a previously healthy adult has may aspirate the stomach contents into the a body temperature of 39°C or more. lungs, which will cause an obstruction of the airways or severe pneumonia. ● Consult a doctor via Radio Medical Treatment if the fever continues for more than three days or exceeds 39°C. The cause of the vomiting should be identified and treated. Possible dehydration As we now know, lowering the fever has should be treated by giving the patient no effect on the duration or progression plenty to drink. Vomiting can be restrained of an illness, but it makes the patient feel by giving metoclopramide hydrochloride better. The adult patient can be given one

75 III Symptoms and diseases and their treatment

or two 500 mg tablets of paracetamol (3/A) Treatment three times a day to lower a high body temperature. Dehydration When treating diarrhoea, the most im- 3 Diarrhoea portant measure is to replace fluid loss. Measuring the patient’s weight is an easy Diarrhoea means frequent emptying of way to estimate fluid loss and the need the bowels and loose stools. The most for fluids. common causes of diarrhoea are viruses, bacteria and food poisoning. Viral diar- The following drink recipe for treating diarrhoea usually spreads easily, causing rhoea can be tried aboard ship: symptoms at different times and even • 1 teaspoon of salt on different days in different people. The • 2−3 tablespoons of sugar symptoms appear almost simultaneously • dash of orange juice in the people who have eaten the same • 1 litre of water. contaminated food. Record the onset of diarrhoea, the The World Health Organisation’s drink number of defecatings per day, and the recipe can also be tried: colour of the stools. Ask the patient if there Add to one litre of boiled water is bright red blood in the stools. Black • 3.5 g of table salt (NaCl) = about one stools may indicate intestinal bleeding generous teaspoon (blood turns black when passing through • 1.5 g of potassium chloride (KCl) = the intestines). Black stools may also be about one level teaspoon caused by eating foods such as blueber- • 20 g of white sugar = about 7 level ries and liquorice. Bright red blood in the teaspoons

stools has usually bled from haemorrhoids. • 2.5 g of sodium bicarbonate (NaHCO3) The reason for the presence of black or red = about one level teaspoon. stools must be cleared up in a medical examination whenever possible. Medical treatment Diarrhoea can be treated with loperamide ● Consult a doctor via Radio Medical if hydrochloride (2/F). Give an initial dose • there is blood or mucus in the stools of two capsules, followed by one capsule • the stools are black after each bowel movement. The amount of loperamide hydrochloride should not • body temperature exceeds 39°C exceed 8 capsules a day. • there is severe abdominal pain or swelling Antibiotic drugs are ineffective if the diarrhoea is caused by a virus, or by food • the patient is severely dehydrated poisoning in which case the diarrhoea • diarrhoea persists for more than three days. begins after a few hours. Consult Radio Medical if the condition of an adult diarrhoea patient does An adult normally requires several litres not improve in a couple of days, or if the of fluids per day. In a warm climate the patient vomits or has a high body tem- need for fluids increases considerably. perature for over 24 hours. If consultation Diarrhoea, sweating, and possible vomit- is not possible, start antibiotic medication ing, drastically increase the need for fluids, with two 250 mg tablets of ciprofloxacin which may rise to even 10 litres a day. (7/C) twice a day. The treatment should be

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

Yersinia symptoms are diarrhoea, vomiting and Yersinia and salmonella bacteria cause leg cramps. It spreads mainly via drink- very similar inflammations. The symptoms ing water that is contaminated with the include fever, severe abdominal pain and bacteria. diarrhoea. An adult patient may, however, Diarrhoea and vomiting begin 2–5 have only mild symptoms. Yersinia infec- days after the infection. The faeces are often tion can be ascertained by laboratory watery, described as ‘rice boiling water’. tests, if complications such as joint pain The patient may lose large amounts of appear. fluids, as much as one litre per hour, leading to dehydration which can cause shock Cholera and death. Fluid replacement is extremely Cholera is an intestinal illness caused by important and must be started after the first a bacterium called Vibria cholerae. The symptoms show up.

27 Constipation and haemorrhoids

1 Constipation In the case of chronic constipation, the above type of medication is not suit- Constipation is a disorder of the bowel able. The most important form of treatment movement, which reduces the frequency of then is to increase the amount of fibre and defecation or makes it laborious. Normally, fluids in the diet. Exercising more will also defecation occurs every 8–72 hours. Con- facilitate bowel movements. Keeping to stipation is often accompanied by stomach regular meal times and defecating times ache and swelling, as well as flatulence often improves the condition. and pain in the rectum.

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

2 Assessment pain persists, consult a doctor via Radio Medical. If a patient suffers from abdominal pain, A continuous burning sensation in the assess the following: upper abdomen may result from hypera- • Pain: when, how and from what area cidity and requires medication that binds it started: suddenly or gradually; the the excess acid. Heartburn and gastric intensity and type of pain: continuous catarrh can be treated with medication or intermittent which binds the acid (2/A), taken half an • Vomiting: present or not, quality of hour after each meal. A more effective vomit, bowel movements treatment is to give one 20 mg tablet of • Behaviour: is the patient calm and omeprazole (2/B) every morning. behaving normally or in pain, restless, lying still or twisting and trying to find 4 Fluid balance a comfortable position • General condition: does the patient Significant dehydration can develop in 24 appear healthy or sick, is the skin hours, or even 4−6 hours. Basic infusion colour normal, flushed, grey or pale, solution (8/E) can be infused if the patient is the forehead warm and dry or cold has abdominal symptoms and is in danger and clammy of becoming dehydrated due to intense • Breathing: are the rate and depth nor- vomiting or diarrhoea. Intravenous fluid mal and calm, or agitated; is the patient replacement therapy (infusion therapy) gasping for air is important and even crucial while the • Pulse and blood pressure: measure patient is waiting for possible evacuation and record from the ship. • Temperature: measure from the armpit Consult a doctor via Radio Medical (not rectum) about the amount and rate of infusion. • Urine: test for sugar, protein, blood and Often, a one-litre bag of solution infused leukocytes with a test-stick. in two hours (drop rate about 150 drops per minute, 20 drops = 1 ml) may sig- ● Always consult a doctor via Radio nificantly improve the patient’s condition. Medical, if abdominal pain The following bags can be infused more • lasts for more than 4−6 hours slowly, so that the total amount of fluid • is accompanied by recurrent or given on one day is 2−4 litres, depending intense vomiting or fever. on the patient’s condition and response to treatment. (The infusion rate should be 30 drops per minute if the patient is given 3 Pain medication 2 litres of intravenous fluids in 24 hours.) The patient’s condition is continuously Abdominal problems are often accompa- monitored, and blood pressure and pulse nied by griping pain which can be treated measured and recorded on a patient chart. with diclofenac (3/B). One suppository The patient should urinate into a bottle, of 100 mg or 2–4 ml (25 mg/ml) as an and the amount of urine and the time of intramuscular injection can be given two urinating are recorded. To ensure that the times a day (not for patients allergic to patient gets optimal care aboard ship, acetylsalicylic acid!). Morphine should consult Radio Medical frequently. be given only if the pain is excruciating. In severe conditions, such as inflam- Pain medication is usually administered mation of the pancreas or peritoneum, once or twice if the pain is severe. If the and internal bleeding, more fluids may be

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.

Inflammation of the ovaries Inflammation of the ovaries and appendicitis cause very similar symptoms. It is dangerous to make a wrong diagnosis and, therefore, the condition should be treated as appendicitis.

Inflammation of the pancreas Pancreatitis is often related either to the use of alcohol (younger people, usually men) or gall stones (older people, usually women). The first inflammation often follows heavy drinking. Recurrence of pan- Figure 22. The site of the pain and creatitis is highly probable if even a small its shifting in appendicitis amount of alcohol is consumed. But recurrence is possible even without alcohol. The

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

probably suffering from gall stones and pancreatitis. This condition is rare, but rapidly life-threatening.

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 intermittent, 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 condition 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

begins to drop, and urine secretion dimin- Ulcerative colitis ishes. The patient needs immediate surgery Ulcerative colitis is quite rare, occurring to close the abdominal ulceration. Intrave- particularly in young persons. Bloody diar- nous fluid replacement therapy is started rhoea is the typical symptom. Ulcerative while waiting for transfer to hospital. colitis is well managed with drugs, but sometimes severe diarrhoea or bleeding Inflammation of the large may develop. Perforation of the large in- intestine testine is also a risk. Inflammation of the large intestine, colitis, is caused by inflammation or perforation Other causes of abdominal pain of the small mucous membrane bulges of Vascular diseases can provoke sudden the distal part of the intestine. The condi- abdominal pain, rupture of the main artery, tion may ease by itself or with antibiotic the aorta, and occlusion of the gastrointes- medication, but may also develop into tinal blood circulation. These conditions severe peritonitis or even blood poisoning. are rare in people under 60 years of age, The symptoms are usually pain and sore- and often impossible to treat on shore, ness of the left side of the lower abdomen. let alone aboard ship. Abdominal pain Antibiotics and intravenous fluid replace- is a typical symptom in many diseases, ment therapy are initiated while waiting including genitourinary and gynaecologi- for transfer to hospital. cal problems.

29 Obstetrics and gynaecological disorders

Although the causes of abdominal pain abdominal problems may be ruled out. are often the same in women and men, However, if there is a possibility of preg- anatomical differences may lead to female nancy, the patient should be asked whether abdominal pains caused by pelvic inflam- the abdominal pain has been accompanied matory disease, ovarian tumours and ec- with bleeding. Extra bleeding may signal topic pregnancy. On board ship, women’s a potential miscarriage or an ectopic abdominal pains are treated according pregnancy. If there has been extra bleed- to the principles presented in Chapter 28 ing during pregnancy, or if the bleeding is Abdominal pain. connected to abdominal pain, consulting a A female patient should always be doctor via Radio Medical is recommended. asked if there is a chance she might be The patient’s medical history should be pregnant. The time of her last menstrua- reviewed, and if she is pregnant and com- tion should be ascertained. It is worth re- plains of upper abdominal pain, her blood membering, however, that bleeding which pressure should be taken to exclude the resembles menstrual flow may be quite possibility of pre-eclampsia. normal during early pregnancy. When administering medicines, it If the possibility of pregnancy can should be remembered that some medica- be reliably excluded, then at least some tions are not suitable for pregnant women

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 bleeding 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

4 Herpes 6 Ovarian tumours and cysts The symptoms of genital herpes are often severe. Painful blisters and ulcers form on An ovarian tumour often causes a feeling the outer genital organs and the vagina, of pressure or tenderness in the lower and the outer genital organs are often abdomen, especially during exercise. An severely swollen. In addition to pain, the ovarian cyst, i.e. a closed sac filled with patient may have a fever, and her inguinal fluid, often disappears by itself without any lymph nodes are swollen. The patient severe symptoms. Sometimes a cyst may can be made to feel more comfortable by rupture, however, and cause severe, often giving pain medication and, for example, unilateral lower abdominal pain. The pain by washing the painful area with a hand is not accompanied by extra bleeding. shower. The patient should recover in a few days with no special treatment, but she 5 Infections in the uterus can be made more comfortable with pain and fallopian tubes medication. If the pain grows worse despite rest, hospitalization and surgery may be The most common single cause of pelvic needed. inflammatory disease is chlamydia bacteria, but the cause may also be gonor- 7 Ectopic pregnancy rhoea. The symptoms include bilateral (extrauterine lower abdominal pain and bloody vaginal pregnancy) discharge. If the infection spreads to the fallopian tubes and to the ovaries, the In a normal pregnancy, the fertilized ovum symptoms may also include increased attaches itself to the endometrium inside purulent vaginal discharge and fever. the uterus. In an ectopic pregnancy the Clearly unilateral lower abdominal fertilized ovum attaches itself outside the pain may signal an ovarian tumour, an uterus, most often to a fallopian tube. An ovarian cyst (a closed sac filled with fluid), ectopic pregnancy often causes symptoms or an ectopic pregnancy. Lower abdominal that are similar to those caused by a normal pain on the right side may be caused by pregnancy, including morning sickness appendicitis. Consulting a doctor via Radio and possible swelling and tenderness of Medical is recommended. the breasts. An infection in the lower abdomen The pregnancy cannot proceed in a can be treated with ciprofloxacin (7/C). fallopian tube without complications. An The patient should take two 250 mg tablets ectopic pregnancy usually ends in early three times a day for seven days. A more ef- spontaneous abortion, but sometimes the fective medicine, also suitable for a vomit- fertilized ovum grows until the fallopian ing patient, is cefuroxime (7/D). The patient tube ruptures. The rupture often leads to should be given a 750 mg intramuscular heavy internal bleeding, which can be injection three times a day. life-threatening if left untreated. If the pelvic inflammatory disease is The symptoms of an ectopic preg- accompanied by fever, consult a doctor via nancy include extra bleeding and lower ab- Radio Medical, and prepare to transport dominal pain caused by internal bleeding. the patient ashore for further treatment. The lower abdominal pain is sudden and severe, and often radiates to the shoulder area or the diaphragm. The rupturing of a fallopian tube is the most feared complica-

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

breathing or sounds wheezy, clean the mouth and nose of amniotic fluid, blood and mucus. If the infant is unresponsive or limp, you can try skin stimulation, i.e. gen- tle patting, to make him/her more lively. The umbilical cord should always be handled with clean gloves and instruments, because it is directly connected to the infant’s circulatory system. The umbilical cord should be tied, for example, with a piece of gauze or cotton thread. Tightly tie one thread around the umbilical cord at about two centimetres from the infant’s navel, and another thread at about four centimetres. When this has been done, the umbilical cord may be cut between the two threads. After the baby has been born, the mother can push out the placenta. The placenta usually detaches within half an hour after the baby has been born. Once the uterine cavity is empty, it contracts strongly, and the uterine veins collapse. If the placenta does not detach or the bleeding is heavy after the birth, try to control the bleeding by enhancing the contraction of the uterus. A suitable medication for this is methylergometrine maleate (15/B): 1–2 tablets three times a day. The contraction of the uterus can also be helped by placing the infant to the mother’s breast and gently pressing the uterus at the region of the mother’s abdominal wall. Do not pull the placenta by the umbilical cord even if it does not detach, because this may result in the turning over of the womb and heavy, incontrollable bleeding. Figures 26–28. Childbirth and giving If the placenta does not detach within assistance an hour of the birth, or if the mother is bleeding heavily, arrange her transportation to a hospital as soon as possible. To control the bleeding, plug the vagina with, for example, a pad of gauze. After the birth, the mother should be monitored for possible bleeding. Check the blood in the sanitary napkins, and weigh them to estimate the amount of blood. A clean sanitary napkin should be weighed

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.

30 Symptoms of the lower abdomen and acute diseases of the urinary organs

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.

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4 Prostatitis 6 Orchitis and epididymitis A symptom of prostatitis (inflammation of the prostate) is a mild, but unpleasant Orchitis (inflammation of the testicles) is ache in the lower abdomen, and perhaps almost always a complication caused by in the back as well. The pain can radiate mumps, whereas epididymitis (inflamma- to the inner thigh and to the testicle. The tion of the epididymis) can be caused by patient usually has no fever. The condition other bacteria or, for example, by tuber- is mild and harmless and does not call for culosis or sexually transmitted diseases. It immediate attention. is difficult to differentiate between these The patient should dress warmly, be- two conditions. cause cold can aggravate the symptoms. The symptoms are mild or severe Ordinary pain killers are sufficient treat- pain, and tenderness of the testicle which ment. The need for further examination is is often slightly swollen. The treatment is decided by a doctor on shore. to give pain killers and to order bed rest, if necessary. Scrotal support is provided 5 Urinary retention by underwear and a bandage. A cold pack can temporarily ease the pain. If the Urinary retention means that the bladder patient does not have mumps and a testicle can not be emptied. Urinary retention becomes very painful, the cause is prob- occurs mostly in older men who have ably torsion of the testis. This is common in prostatic hyperplasia (enlargement of the boys and in young men. The patient needs prostate). Urinary retention can develop an operation on shore as soon as possible, suddenly and unexpectedly, and usually because the testicle will go into necrosis after heavy alcohol use. The bladder may within a few hours. stretch and can no longer be emptied even when there is a strong need to urinate. 7 Paraphimosis Urinary retention is not immediately dangerous, but should be treated as soon as A tight foreskin (prepuce) can sometimes possible or at least within hours. get stuck behind the head of the penis The appropriate treatment for urinary (glans penis). The glans penis then swells retention is catheterization. This needs to and the foreskin tightens until it can no be done in sterile conditions, and without longer be retracted over the glans penis. force, in order not to cause damage to the The condition may look serious, but there urethra (see Chapter 48, catheterization is hardly ever danger of a severe circula- of urinary bladder). The catheterization tion problem. The condition can often be technique should be reviewed before car- treated by applying a cold pack around the rying out the procedure. When the blad- glans penis. When the swelling has abated, der is empty, the catheter is removed. The the edge of the foreskin can be firmly taken catheterized urine is tested with test strips between the thumb and forefinger and to rule out infection. retracted back over the glans penis.

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

● If a person suspects that he/she is 3 Sexual behaviour and infected with a STD, or if symptoms the risks of different of a STD have developed after types of sexual contact sexual intercourse, his/her condition must be diagnosed and treated The risk of being infected with a STD in prior to further sexual intercourse, heterosexual contact is just as great as in order to prevent spreading the possible infection to others. in homosexual contact. Some sexually transmitted diseases can be asymptomatic for a long time. But being asymptomatic Only in critical situations should a patient does not mean being non-infectious. Some with a STD be treated on board ship. Such infections can spread even years after the situations include the ship being at sea for time when the patient was infected with a long time, or the patient having severe the disease, if not treated properly. symptoms. If you suspect that the patient has gonorrhoea, the proper medication is ● A person infected with a STD can ciprofloxacin (7/C). The patient should take remain infectious for years, even three 250 mg tablets in a single dose. If for the rest of his/her life. you suspect that the patient has chlamydia, Unprotected sex, even with a he/she should be treated with doxycycline, familiar partner, involves a serious one 150 mg tablet once a day for 10 days. risk of infection. If the treatment is started on board ship, it should be borne in mind that confirming Safe sex is the diagnosis afterwards is often impossi- • sex in a mutually monogamous re- ble. One must also remember that there are lationship, if neither partner has had some bacterial strains which are resistant previous non-treated infections to the above-mentioned treatment. This • kissing on the skin and lips is also a strong reason for refraining from • hugging, petting and caressing treatment on board ship until the bacteria • masturbating together. and suitable treatment for it have been determined. Sex with a possible risk of infection in- Anyone who is suspected of having a cludes STD should undergo a medical examina- • deep kisses tion and seek treatment immediately after • touching the genitalia with the mouth docking, regardless of whether they have • intercourse even with a condom, if the been treated on board ship or not. Even if condom breaks or slips off a person has been treated on board ship • urine or faeces getting in contact with and no symptoms have developed after the skin the treatment, he/she should refrain from • many sex partners, or a partner who is sexual intercourse until all other possible a prostitute or a drug addict. infections have been treated or ruled out on shore. Sex with a serious risk of infection includes • anal sex or intercourse without a condom • ejaculation or urine into the mouth • blood contact

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 4 Protection against Chlamydia is a urinary tract infection sexually transmitted caused by bacteria. The first symptoms diseases: The condom develop from one to three weeks after being infected. One out of five men (20%) The risk of getting a STD is considerably and three out of four women (75%) do not diminished by using a condom during notice any symptoms at all. every act of intercourse. The same applies In men, the symptoms include a clear, to oral sex. The condom should be used watery discharge from the urethra, and throughout the entire sexual act to prevent a burning sensation when urinating. In any contact with the mucous membranes. women, the symptoms may include vagi- A condom can be used only once. Old nal discharge. If left untreated, chlamydia condoms may break more easily than may cause uterine infections or infertil- new ones. ity in women, and epididymitis in men. Chlamydia may also cause arthritis which resembles rheumatoid arthritis. ● When correctly used, the condom gives protection against STDs. Syphilis Syphilis is a bacterial disease, which may When putting on the condom, always also remain asymptomatic. A few weeks check how it is rolled down. Pull the fore- after being infected, a red chancre, which skin back, and peel the condom over the gradually becomes an ulcer, forms on the erect penis. Make sure that there is no air skin or the mucous membrane (Figure 30). in the place reserved for the semen. Also, The ulcer feels hard, “like a button pressed be careful not to break the condom with into the skin”, and its base is smooth and sharp nails or rings. moist. The patient’s inguinal lymph nodes Immediately after the ejaculation are swollen but painless. the penis should be withdrawn from the The ulcer may be found in the genital vagina, still having the condom on it. area, but also on the tongue, inside the throat, on the lip, on the finger, or almost 5 Sexually transmitted anywhere on the body. The ulcer usually diseases heals by itself, leaving a scar. Once the ulcer has formed, antibodies to syphilis Gonorrhoea can be found (the Wasserman test). Gonorrhoea is a bacterial infection of the Once the ulcer has healed, the dis- mucous membranes. It is asymptomatic in ease still progresses, if not treated. About almost 50% of all cases. The first symptoms 1.5–2 months after the primary infection, develop a few days after being infected, the symptoms include swollen but pain- and may include itching and pain at the less lymph nodes, various skin problems, urethral orifice, followed by thick, yel- and possibly even iritis and renal damage. low, purulent discharge, and the need to Eventually, the symptoms usually disappear urinate often (Figure 29). If left untreated, by themselves, and the disease becomes gonorrhoea may result in prostatitis and asymptomatic. It nevertheless continues to

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 contaminated 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

does not protect from the infection. The risk of being infected depends on personal behaviour. A person who suspects that he/she might be infected with HIV should have a test done on his/her own initiative. These tests are performed free of charge at local health care centres, STD clinics, and AIDS support centres. It is possible to take the test anonymously. Figure 29. Purulent discharge from the urethral orifice in gonorrhoea

Figure 30. A crater-like painless lesion Figure 31. Condyloma on the penis caused by syphilis

32 Dry and itchy skin

1 Dry skin used, and it should be used only on areas where it is really needed. The more often Causes that soap is used, the milder it should be. Today’s problem is washing oneself too Skin reacts to the temperature of wa- often. The skin is soaped and washed in the ter. Hot water dissolves sebum from the morning before going to work and again in skin’s surface and softens the keratin layer the evening, and in shift work, after every even when soap is not used. Cooler water shift. As a result, almost everyone’s skin is less irritating and drying for the skin. dries, especially in the wintertime. If changing washing habits is not enough to maintain the skin’s moisture, Prevention cream-type lotion (unscented basic lotion) Prevention is the most important treatment should be applied to the skin after every for dry skin. Soap is replaced by a milder, washing, when the skin is still moist. The preferably unscented product which has lotion is easier to apply thinly when the been developed for dry skin. Less soap is skin is moist, and will not stain clothing.

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 inflammation 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

Table 5. Basic treatment of rashes

Skin rash Local treatment Systemic Exemplary Comments treatment disease Superficial rash, Hydrocortisone cream Cetirizine Eczema Consider the red, burning 1% (9/F) hydrochloride cause (Figures 32, 33, 34) (5/B), one 10 mg Polyvidone iodine tablet once a day solution 10% (9/A) + watery, purulent Neomycin-bacitracin Impetigo Contagious! ointment (9/D) Methylrosanilinium 0.5% solution (9/G)

Polyvidone iodine Cefadroxil (7/E) solution 10% (9/A) one 500 mg tablet + general symptoms Neomycin-bacitracin twice a day or (fever, malaise, etc.) ointment (9/D) Ciprofloxacin Methylrosanilinium (7/C) 250 mg 0.5% solution (9/G) 1 tbl x 2/day Deep rash, red, Heat pack, Cefadroxil (7/E) Abscess Rest, burning Neomycin-bacitracin one 500 mg tablet contagious (Figures 35, 36) ointment (9/D) twice a day or Ciprofloxacin (7/C) 250 mg 2 tbl x 2/day

Purulent ulcer Cleaning the wound Cefadroxil (7/E) Erysipelas, Rest, with warm water, one 500 mg tablet open abscess contagious! Polyvidone iodine twice a day or solution 10% (9/A) Ciprofloxacin Neomycin-bacitracin (7/C) 250 mg ointment (9/D) 1 tbl x 2/day

Blotchy rash Permethrin cream Cetirizine Scabies Clean clothes, with itching at 5% (9/H) hydrochloride treat all night, wrists, Hydrocortisone cream (5/B), one 10 mg family armpits, penis 1% (9/F) tablet once a day members

Pubic lice Malathion shampoo 0.5%

Sunburn Hydrocortisone Avoid the cream 1% (9/F) sun, use sun protective cream

Spread rash, Isolation Radio Medical symmetrical consultation (Figure 37) (allergy, virus, inflammation, infection) Broken skin between Miconazole cream (9/C) toes, crotch rash Methylrosanilinium (Figures 38, 39) 0.5% solution (9/G)

Itch Prevent skin from Cetirizine drying hydrochloride For treatment, see (5/B), one 10 mg eczema tablet once a day 100 III Symptoms and diseases and their treatment

by showering and cleaning the area with a Erysipelas skin-cleansing cream. After this, antibiotic Erysipelas is a deep skin infection caused cream is spread on the skin twice a day. by bacteria, located typically in a lower Because the disease is very contagious, limb. The bacteria get into the body good hygiene is crucial. The person must through a cut or an abrasion. not share towels, soap or clothes. Usually, the disease starts with sudden high fever, after which, within a few Folliculitis hours the inflamed area of the skin starts to Folliculitis (inflammation of the hair folli- swell and ‘burn’ strongly (Figure 36). The cle) is a bacterial skin disease which affects red area is usually sharply outlined, and hairy areas. Sweating and, for example, there may even be blistering or abscesses. engine room grease and oil on the skin The inflammation destroys lymph vessels block the follicles and cause infection. and the lymph circulation in the limb The symptoms are superficial, 1–2 mm is permanently weakened. This causes wide, white papulopustules (small pimples permanent swelling in the infected area, filled with pus), through which a hair often making it susceptible to new episodes of grows. The skin feels quite symptomless. erysipelas infection. Thorough cleaning with a brush and The treatment is antibiotic medication. soap is often sufficient treatment. If neces- Cefadroxil (7/E), one 500 mg tablet is given sary, antibiotic cream may be used. A skin twice a day for 10–20 days. Broken skin, disease that is caused by bacteria may through which the bacteria entered the spread if general cleanliness is neglected. body, for example, foot ulcers or broken skin between the toes, should be treated as well. Abscesses The skin must be kept in good condition after Abscesses are caused by staphylococcal it has healed to prevent the infection from bacteria. Typically, abscesses are located recurring. Reducing the swelling usually in the neck and in the armpits (Figure 35). requires wearing a surgical stocking. An abscess can develop in a few days or a week, from a small acne-like pimple into Athlete’s foot a red, burning ball deep in the skin. The Athlete’s foot is usually caused by a fungus patient may also have fever, feel generally which grows between the toes (Figure 38). ill, and have enlarged lymph nodes. A rash can also be present on the arch of Treatment with an antibiotic is the foot and on the sides of the foot. The always necessary. Cefadroxil (7/E), one 500 skin between the toes becomes lighter in mg tablet is given twice a day for 10–14 colour, sweaty and itchy. There may be days. Development of the abscess can be blisters, scaling and thickening of the skin advanced with a heat pack. Do not lance on the arch of the foot. or squeeze abscesses, because this may Local antimycotic medication is usu- cause the pus to spread to the surrounding ally sufficient to treat fungus between the tissues via blood circulation. An abscess toes (see Table 5). The treatment should last is filled with bacteria and, thus, can infect at least 4–6 weeks, to prevent recurrence others when it bursts. Good hygiene and of the disease. protection from infection are important. To avoid athlete’s foot, it is important Local treatment of a burst abscess is daily to keep the toes dry; moisture-absorbing cleaning with a shower. cotton or woollen socks should be worn. The feet are washed with acidic (pH about 3) washing fluid. After washing, the feet are rinsed carefully and dried well.

101 III Symptoms and diseases and their treatment

Figure 32. Dry, superficial eczema (atopic eczema)

Figure 33. Chronic hand eczema

Figure 34. Allergic contact eczema (caused by sensiti- zation to nickel)

102 III Symptoms and diseases and their treatment

Figure 35. Abscess in the neck

Figure 36. Erysipelas in the lower limb

Figure 37. Generalized widespread eczema

103 III Symptoms and diseases and their treatment

Figure 38. Fungal infection ‘athlete’s foot’ between the toes

Figure 39. Fungal infection in the flexure of the groin

Rash in the inguinal flexure and Scabies under the breasts Scabies spreads from one person to another Fungus can cause red, itchy eczema on by skin contact. It is caused by a mite (Sar- sweating, moist areas of the skin, for ex- coptes scabiei). The most typical symptom ample, on the bends of the arms and legs, is itching at night-time. Tunnels made by and under the breasts (Figure 39). The the mite can be seen in areas where the treatment consists of keeping these skin skin is thin, mainly in the armpits, wrists, areas dry, and dusting with miconazole and between the fingers, never on the neck powder. Using soap should be avoided, or on the face. In men, a typical place is as should mechanical irritation of the skin, the penis, which shows red, slightly raised for example, using a rough towel. Powder skin alterations. is sprinkled on the rash one to two times a The treatment starts with a thorough day for two to three weeks. wash and change of clothes. The patient’s skin is treated with permethrin cream (9/H), which is spread all over the skin, without

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

34 Protective gloves and protective skin ointments

1 Protective gloves long it takes to permeate the glove. The best skin protection is given by a seamless Work procedures and substances that are glove without a lining, under which a cot- handled at work should not harm the skin, ton underglove is used. so that special skin protection would not Protective gloves are personal. After a be needed. However, if this is not possible, workday they must be washed and rinsed also protective gloves are to be used. from the inside and hung up to dry. A worker Protective gloves differ, both in how should have several pairs of gloves, so that comfortable they are, and how well they they can be changed during the workday. protect. To be able to select the right gloves you need to know what substance will be 2 Protective ointments handled. In addition, note that: • The hands become sweaty in all rubber A protective ointment is not a substitute for and plastic gloves. Sweat causes the a protective glove. A protective ointment skin to soften and may trigger a rash. is effective only for a short time. Vaseline- • Rubber gloves may cause hypersen- type protective ointment offers protection sitivity, so plastic gloves are better in against water for a while, but it prevents this sense. the skin from breathing and can cause sweating and a rise in the skin’s internal It is important that the gloves are resistant moisture level. Protective ointments in- to chemicals. The manufacturer knows crease and speed up the absorption of the whether the gloves offer protection against handled solvents into the skin. In fact, the the handled substance, and how long it effect of using a protective ointment can takes before the substance permeates the be more harmful than if no ointment were gloves. If this information is not available, it used. Protective gloves are always a better is possible to test the suitability of the glove solution. Protective ointments are practical for the handling of a certain substance. Fill only because they make it easier to clean the glove with the substance and see how the hands after working.

106 III Symptoms and diseases and their treatment

35 Joint and muscle pain

1 Joint pain Treatment Sudden pain in a joint is usually connected Acute arthritis may be treated by soothing with an injury. There is reason to suspect the joint with rest and pain medication. For arthritis, if the pain has not been caused by pain relief one 50 mg tablet of diclofenac an accident or unusually heavy strain. (3/B) two to three times a day can be given. Patients who are allergic to salicylate may Symptoms and causes be treated with paracetamol (3/A), one or Typical symptoms of arthritis: two 500 mg tablets three times a day. • redness Applying an ice pack to the inflamed • warmth joint is often the best first aid. When the • swelling inflammation has calmed down, heat ap- • pain plication may replace the cold. Consulting • functional disability. a doctor via Radio Medical is necessary if the condition is severe and does not im- Arthritis may be caused by rheumatism prove with the treatment of the symptoms. (rheumatoid arthritis), in which case it On shore, a doctor can determine the is usually located symmetrically in both cause, and continue treatment according limbs. Sometimes it may occur as reactive to the diagnosis. arthritis, which may follow a genital or intestinal inflammation (i.e., chlamydial 2 Neck and shoulder pain infection or salmonella) after two or three weeks. In this case the arthritis is usually Tender spots in the muscles of the shoulder in only one limb. area are typical of muscle-based neck pain. The cause of chronic joint pain is The pain does not usually radiate to the usually osteoarthritis. This is a normal upper limbs, but sometimes numbness may phenomenon connected with ageing. occur in the hands. Muscular pain may Osteoarthritis in the large, weight-bearing spread to the upper neck and the back of joints is the most problematic, and often the head, to the upper arm, and even to leads to incapacity to work. the musculature of the forearm. Turning the On board, the most common cause head is often difficult. of arthritis is probably gout, which usu- Muscle relaxation is the most impor- ally appears at the base of one of the big tant treatment. Regular physical exercise toes. Gout is caused by uric acid, which prevents the symptoms. Pain medication crystallizes in the synovial fluid into sharp may be taken if needed, in same amounts crystals causing a severe inflammation of as in joint pain. the joint. An aching and burning sensa- Degenerative changes in the cervi- tion appears suddenly, and the joint area cal disk often limit the range of motion. A is swollen, red and warm. The pain attack slipped disk in the cervical region, a con- may strike after a convivial social evening. dition similar to sciatica, may occur even Some foods and also alcohol raise the uric in young people. The symptoms include acid level in the blood. pain which radiates to the upper limbs,

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 muscular 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

also degenerates with age. Good physical 5 Tendinitis condition (and thus blood circulation), as well as muscle balance of the body, and There is a risk of developing tendinitis, particularly of the lower limbs, help pre- especially if a job requires repetitive strain vent chronic back pain. on the same joint and working in cold, damp conditions. The wrists and ankles 4 Shoulder pain are most susceptible to tendinitis. When the joint is moved, a grating noise may The shoulder joint is susceptible to pain be- accompany the movement. This is caused cause of its structure. The joint has a wide by oedema in the carpal tunnel and an range of motion, and it depends almost inflammatory reaction. entirely on soft tissues for support. The treatment for tendinitis is usually In the first stages, shoulder pain is rest and pain medication. A splint or a treated symptomatically with pain medi- bandage prevents the joint from bending cation when needed. If the pain persists, a into extreme positions, warms the tendon course of treatment may be prescribed. For area and soothes the condition. The band- example, one 50 mg tablet of diclofenac age must not be too tight. Pain medication (3/B) 2–3 times a day for 10 days. Those may be used to relieve the inflammation, allergic to salicylate may be given one for example, a course of treatment with or two 500 mg tablets of paracetamol diclofenac (3/B), one 50 mg tablet 2–3 (3/A) three times a day. Shoulder tendinitis times a day for 10 days. Those allergic to usually responds well to anti-inflamma- salicylate may be administered one or two tory drugs. Chronic shoulder pain often 500 mg tablets of paracetamol (3/A) three requires surgery, such as tendon repair or times a day. If the condition persists, a visit pressure-relieving operations. to a doctor is necessary.

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

2 Treatment 4 Mental illnesses

Diazepam (4/A) relieves the tendency Panic disorder to spasms, calms the patient and makes Panic disorder is common in young wom- him/her drowsy. It may be given when the en. It is often connected with a dramatic patient is extremely anxious or restless. The life change. A panic attack usually devel- normal dosage in severe anxiety is 10 mg ops in minutes, and is often connected with three times a day. At most, 20 mg may be an overwhelming fear of losing control, or given at hourly intervals until the patient the fear of death. falls asleep. The anxiety and hyperventilation When the patient suffers from hallu- connected with a panic attack cause a cinations or other forms of severe mental variety of physical symptoms that add disorder, he/she may be given 20 mg of to the anxiety. Typical symptoms are, for diazepam to calm him/her. This dosage is example, palpitations, tremor, a choking given every 2 hours until the patient falls sensation, dizziness and chest pains, as asleep. An anxious or restless patient may well as numbness and tingling of the hands be a threat to him/herself or others, and and lips. The panic attack usually passes in needs to be monitored at all times. The 10 to 20 minutes, and the patient’s condi- patient should be transferred to shore for tion gradually returns to normal. continued treatment as soon as possible. For some patients, breathing into a paper bag helps relieve the hyperventila- 3 Sending a patient with tion. If the panic attacks recur frequently, a mental problems or 5 mg tablet of diazepam (4/A) three times suspected mental a day may be prescribed for the rest of the problems for treatment voyage. It is important to remember that diazepam affects the memory and weak- A person who behaves or speaks strangely ens the ability to perform tasks requiring may be schizophrenic. He/she should be accuracy. sent ashore for treatment before the condi- The symptoms of many illnesses, tion deteriorates and becomes hallucina- such as asthma, myocardial infarction tory. A hallucinating patient is a great risk and pulmonary embolism are similar to to himself and to the whole ship. those of the panic attack, and this makes According to the international rules it difficult to determine the true cause of and regulations, the officer in charge is the symptoms. However, a sudden asthma responsible for sending the patient for attack is accompanied by a clearly audible treatment. The officer in charge should wheezing breath sound, whereas a panic inform the doctor about the symptoms in attack is not. A patient suffering from an advance, because the patient’s own story infarction is usually middle-aged or older, may differ considerably from reality. As pale, cold and sweaty. In a panic attack, the ability to work is an important issue, the pain is localized to the chest muscles. the officer in charge should ask the doctor Pulmonary embolism often causes the to refer the patient for psychological tests skin to turn bluish pale in colour, and the to determine his/her ability to continue in condition is not relieved in the course of his/her occupation. 10 or 20 minutes.

110 III Symptoms and diseases and their treatment

Post-traumatic stress related to stress, tendency to substance disorder and debriefing abuse and chronic self-destruction, pre- A severe psychological trauma may eas- senting as drug overdoses and repeated ily lead to post-traumatic stress disorder. slashing of the wrists. Typical of the ill- The symptoms can be divided into three ness is also a craving for adventure, and a categories: sense of not belonging anywhere. That is • reliving the traumatic event in one’s why, in the past, people with a personality nightmares and hallucinations disorder often went out to sea. When an • avoiding anything resembling the trau- employee’s behaviour seems to be point- matic event (e.g., fear of the dark after ing to a personality disorder interfering a shipwreck) and emotional numbness with his work performance, psychotherapy – inability to feel, or a feeling of com- may be discreetly suggested. This could plete detachment help improve the possibly tense human • symptoms of increased alertness, e.g. relations among the crew on board. Trans- trembling and palpitations. These ferring the employee to work on shore is symptoms may lead to work incapac- also advisable. ity for months, and may sometimes become chronic. Depression The symptoms of depression include a de- After a traumatic event on board, such as crease in energy level and the inability to a suicide or a fatal accident, a psychologi- feel pleasure. Loss of appetite or overeating cal debriefing should be arranged within are also typical of the illness, as well as a 72 hours of the accident as a precaution lack of initiative, or difficulties in remem- against post-traumatic stress disorder. In bering and concentration. Early morning some shipping companies this procedure awakening, psychomotoric slowness, and is already common practice. In addition, lack of sexual drive, are often connected discussing the traumatic event with a friend with severe depression. or a colleague is often just as beneficial It is crucial to recognize depression as psychological debriefing. It should in time because it may lead to suicide. A be remembered, however, that drinking depressed patient must always be asked alcohol while discussing the traumatic whether he/she has ever thought of com- event cancels the beneficial effects of the mitting suicide. It is also important to find discussion. out whether the patient has ever attempted When an accident happens on board, suicide, or whether there is a history of it is important to inform the crew of the suicide in the patient’s family or among possibility of post-traumatic stress disorder, his/her friends. In both cases, his/her sui- so that every one recognizes the symptoms cide risk is higher than normal. in time and can seek help accordingly. The patient should also be asked Depression and substance abuse are often whether he/she has considered any par- connected with untreated and persisting ticular ways of committing suicide. If the post-traumatic stress disorder. patient has a plan, he/she must be closely monitored at all times, and must never be Personality disorder left alone. The possible means for com- Impulsiveness, a quick temper, black-and- mitting suicide by hanging, such as belts, white thinking, and mood unpredictability shoelaces and ties, and anything needed are some of the symptoms connected with for making a fire, must be taken away from personality disorder. Other possible symp- the patient. toms include momentary paranoid thinking

111 III Symptoms and diseases and their treatment

The patient must be informed of the may be a sign of schizophrenia worsening possibility of treating depression efficiently within the following weeks or months, or with both medication and psychotherapy, they may be connected with alcohol with- and that usually the symptoms ease in drawal symptoms, which appear within weeks. A depressed patient with suicidal hours after stopping alcohol consumption. thoughts must nevertheless be monitored The hallucinations should not be disputed around the clock until he/she is admitted with the hallucinating patient, but support- to hospital on shore. ing them is not advisable either. There is special cause for concern An anxious or restless psychotic pa- if a severely depressed patient becomes tient may be dangerous to him/herself or calm and serene. This could mean that others, so he/she needs monitoring at all the decision to commit suicide has been times. The patient may be given 20 mg (= made, in which case the patient needs to 4 tablets) of diazepam (5 mg/tablet, 4/A). be monitored even more closely. The dosage is repeated every two hours until the patient falls asleep. Mania Mania is the reverse state of depression. Mental problems connected with The patient seems abnormally elated and substance abuse energetic, his mood fluctuating between An alcoholic who stops drinking or cuts cheerful and irritable. A decreased need down his/her daily alcohol consumption for sleep, racing thoughts, poor reason- considerably, may develop symptoms of ing ability, and hyperactivity, are typical delirium tremens within hours. At first, the in mania. A manic patient may seriously patient has a severe hangover, and trembles endanger the safety of the ship and of the and sweats. Usually, towards the night crew. he/she loses his/her ability to concentrate Psychotic mania with delusions of and becomes restless and anxious. When grandeur is often relatively easy to rec- the condition deteriorates further, the pa- ognize, and a patient unaware of his/her tient becomes disoriented as regards time, condition must be transferred for psychi- place and other people, and starts to have atric treatment by compulsion. hallucinations. The restlessness and anxiety con- The most common hallucinations are nected with both mania and depression visual and tactile hallucinations, which can be relieved, for example, with 10 mg often involve large numbers of animals, of diazepam given three times a day. for instance, rats and bats. A typical patient with delirium tremens keeps beating the Acute psychosis air, trying to expel something invisible to Severe anxiety and sleeplessness lasting others. The patient’s life may be threatened, for a few days are often the first signs of as he/she may even jump overboard in or- acute psychosis, followed by psychotic der to escape from his/her “persecutors”. symptoms. Auditory hallucinations occur A patient with delirium tremens may commonly. The patient often hears strange be given 20 mg (= 4 tablets) of diazepam voices which are threatening and accusing (5 mg/tablet, 4/A). The dosage is repeated or offensive. The patient may often halluci- every two hours until the patient falls nate about other people conspiring against asleep. him/her or spying on him/her. Sometimes, If delirium tremens is suspected, it is motoric symptoms are connected with advisable to carefully examine the patient’s acute psychosis, i.e., either strong agitation head to exclude head injuries. Alcoholics or complete immobility. The hallucinations are prone to accidents, and a fall may

112 III Symptoms and diseases and their treatment

cause brain damage, such as haemorrhage, is a common drug-induced psychosis which in turn can cause disorientation. with symptoms such as hallucinations of Many drugs can also trigger short-term persecution, as well as auditory and visual hallucinations, which may be mistaken hallucinations. The contracted pupils of a for psychoses. Amphetamine psychosis heroin abuser often reveal drug abuse.

37 Alcohol and drugs

Alcohol – specifically ethanol – is the two-thirds of suicide attempts are consid- most common addictive substance. Other ered to involve alcohol). common drugs are cannabis (marijuana, Women who drink heavily during hashish, and hashish oil), amphetamines, pregnancy are at risk of having babies with opiates (heroin, morphine, opium), LSD a condition called fetal alcohol syndrome. and cocaine. This syndrome can result in growth defi- The use of these drugs may affect the ciency, nervous system problems, lowered capacity to work, as well as alertness and intelligence, and facial abnormalities in activity, which is why it is important to the child. recognize a drug abuser in the workplace. Drinking too much too often causes A drug addict may suffer from a variety of physical damage, increases the risk of symptoms, either due to the effects of the contracting some diseases, and worsens drug, or drug withdrawal symptoms. It is other diseases. Excessive drinking over important to take into account the pos- time is associated with sibility of drugs in assessing the cause of • stomach disorders, such as gastritis and any symptom. The first aid in drug-induced bleeding from stomach ulcers problems depends on the situation. Con- • high blood pressure (which can lead sulting a doctor via Radio Medical is often to a stroke) necessary. A summary of drugs and their • arrhythmias properties is shown in Table 6. • liver cirrhosis • cancer of the mouth, throat and gul- 1 Alcohol let • brain damage Alcohol suppresses the part of the brain • sleep disturbances that controls judgement, resulting in a loss • depression of inhibitions. It also affects physical co- • inflammation of the pancreas ordination causing blurred vision, slurred • alcohol epilepsy speech and loss of balance. Alcohol is im- • sexual problems, impotence plicated in a large proportion of fatal traffic • obesity. accidents, assaults and violent incidents. Alcohol dulls the brain. Although al- Alcohol intoxication cohol initially makes people feel relaxed, Drinking a very large amount of alcohol long-term excessive use can ultimately at one time (binge drinking) can lead to increase anxiety and cause depression. It unconsciousness, coma, and even death. is also related to problems with sleeping, In general, an alcohol concentration of mood swings, violence and suicide (about over 3.5 pro mille content in the blood

113 III Symptoms and diseases and their treatment

is considered a poisoning. However, ha- • a strong urge to drink bituation to alcohol greatly influences the • difficulty controlling drinking type and severity of the symptoms. Injuries • physical withdrawal symptoms, such related to drunkenness may decrease the as sweating, shaking, agitation and level of consciousness further. In such nausea when trying to reduce drink- a case it is difficult to distinguish the ing symptoms caused by alcohol intoxication • a growing tolerance to alcohol (need- from those caused by the injury. Vomiting ing larger quantities to get the same when unconscious can lead to death by effect) suffocation. • gradual neglect of other activities Mixing alcohol with other drugs is • persistent drinking even though it is extremely dangerous. This includes pre- obviously causing harm. scribed and ‘over-the-counter’ (OTC) drugs such as sleeping pills, cough medicines or Problem drinking occurs when a person antihistamines, as well as illicit drugs such is not dependent on alcohol, but drinks as cannabis, ecstasy, cocaine or heroin. enough to cause actual physical or psy- After giving first aid, always consult a chological harm. doctor via Radio Medical for instructions on further treatment. Cut down drinking If you think you are drinking too much, Alcohol withdrawal syndrome keep a ‘drinking diary’, noting how much The alcohol withdrawal syndrome may alcohol you drink each week. It will reveal occur when continuous and heavy drink- if you are drinking within safe guidelines. ing of alcohol stops. Milder forms of It will also help you identify the situations the syndrome include tremulousness that you need to avoid to cut down your (‘shakes’), seizures, and hallucinations, drinking. which typically occur within 6–48 hours These tips may help cut down your after the last drink. alcohol consumption: A more serious form of the syndrome, • do not drink at all on board ship called delirium tremens, involves profound • go out later, so you start drinking later confusion, hallucinations, and severe over- • replace your ‘usual’ drink with one activity of the autonomic nervous system, containing less alcohol beginning typically 48–96 hours after the • skip the ‘quick drink’ at lunchtime or last drink. after work The patient with delirium tremens • keep at least two alcohol-free days a may be given four 5 mg diazepam tablets. week The dosage is repeated every two hours • do something else than go to have a until the patient falls asleep. Consultation drink with Radio Medical is recommended. • drink more slowly, or take non-alcoholic drinks between alcoholic ones Alcohol dependence • buy beers and wines with a lower When consumed frequently or in large alcohol content, and keep a supply of quantities, alcohol is addictive. A person non-alcoholic drinks at home is generally considered to be dependent • set yourself a limit of, for example, on alcohol when he/she has experienced three to four units (men) or two to three or more of the following symptoms three (women) for any one occasion during a year: • find other ways to relax.

114 III Symptoms and diseases and their treatment

2 Cannabis products wit. The mucous membrane of the mouth (marijuana, hashish, is dry. Amphetamine also eliminates the hashish oil) sense of hunger. Sweating is severe, and urinating is often difficult. Long-term use Cannabis (Cannabis Sativa, hemp) is a causes hallucinations and sleeplessness. plant that belongs to the nettle genus. Visible weight loss and needle marks on The narcotic effects are derived from the the arms or, in the more experienced user, leaves and flowering tops of the plant. elsewhere in the body, are signs of severe The active ingredients are cannabinoids addiction. (tetrahydrocannabinol, THC), which are There are several amphetamine de- smoked in either marijuana cigarettes, also rivatives which share the basic chemical known as ‘joints’, or in a pipe, or mixed structure of amphetamine (MDMA, MDEA, with tobacco. MDA). Their effects are similar to those of The effects vary among individuals; amphetamine. When under the influence cannabis may cause hilarity or giggling, of the drug and when the effects start to but also depression. The user’s conception fade, the addicts are often a danger to of time and place may be blurred, and themselves and others. An addict can be the ability to estimate speed, especially recognized in the same way as an am- in traffic, often deteriorates. The mucous phetamine addict. membranes in the mouth dry up so that the tongue tends to stick to the palate. Panic 4 Khat attacks are possible. The user can be recognized by dilated pupils and bloodshot Khat is used by chewing the fresh leaves eyes. Other typical symptoms are high and tops of the khat bush. The active pulse rate and high blood pressure, as well ingredient is cathine, cathinone, which as low blood sugar. The mucous membrane affects the central nervous system. The in the mouth is irritated. users believe that their thoughts are clear and that they are continuously achieving 3 Amphetamine and something, and succeeding in everything its derivatives (ecstasy, they do. This happens when, in fact, methamphetamine) they are doing almost nothing. Typical symptoms are high pulse rate and blood Amphetamine is a synthetic drug produced pressure, but insomnia, stomach ache and by boiling. The active ingredient is a phenyl pulmonary problems are also possible. A derivative, amphetamine, which is injected user may become psychotic. into a vein, sniffed up the nose like cocaine, or taken orally in a self-made pill. 5 Opiates (opium, Amphetamine can be in the form of pow- morphine, heroin) der, paste or liquid. The smell is unique, and it is said that “once you have smelled The opium extracted from the poppy plant it you will never forget it”. Amphetamine is refined into morphine, and further refin- stimulates the central nervous system, and ing produces heroin. The active ingredi- thus, affects all body functions. In addition ents are opiate alkaloids, morphine and to a feeling of euphoria, it raises the pulse codeine. Morphine and heroin are taken rate and blood pressure and dilates the pu- intravenously or smoked. pils. The user is often sweaty and agitated, Opiates are paralyzing substances self-confident, aggressive and has a ready which cause fatigue and loss of appetite.

115 III Symptoms and diseases and their treatment

Table 6. Drugs and their properties

Immediate Recognizing Negative Drug Appearance Usage Addiction effect the addict effects Cannabis brown, black or smoked in a euphoria, bloodshot passivity, lack psycho- Hashish greenish slabs or pipe talkativeness, eyes of initiative, logical crumbs cheerfulness apathy mixed with hashish smell, used in choco- tea, sweets or withdrawal pipe or other mental late or as oil cigarettes equipment, disorders profundity finding the drug in the dangerous in fatigue, panic, possession of traffic disorientation, the addict deteriorated sense of speed

Marijuana green or brown smoked as a similar to as with hash- similar to psycho- fibres, seeds cigarette hashish but ish hashish only logical milder in those with both ends severe addic- of the joint tion twisted

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

may stop very small possible breathing contracted death from pupils overdose effects of heroin are more severe

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Immediate Recognizing Negative Drug Appearance Usage Addiction effect the addict effects Cocaine white powder sniffed up the similar to restlessness damaged physical nose ampheta- nasal and psy- mine, but dilated pupils septum chological smoked more short- term sweating, speaking injected high pulse through one’s rate nose

needle marks addiction

nosebleed AIDS, jaundice

mental disorders, death Ampheta- different sized injected into agitation, restlessness addiction physical mines tablets muscle or vein anxiety and psy- dilated pupils brain 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

They relieve both physical pain as well as 6 Cocaine psychological anxiety. Opiates cause a feeling of euphoria, and a severe addiction The active ingredient in cocaine is cocaine develops rapidly, possibly even after the hydrochloride. It can be sniffed up the nose, first time of using the drug. used intravenously or smoked. Cocaine is An addict can be recognized by the a light-coloured substance: crack is lumpy, contracted, very small pupils and needle and ‘freebase’ is a fine powder. The effects marks on the arms or elsewhere in the are similar to those of amphetamine, and body. If deprived of the drug, the addict an addict can be recognized in the same becomes sweaty, nauseous, shivery, and way as the amphetamine addict. may have diarrhoea. The fear of withdrawal symptoms makes the addict dangerous, 7 Hallucinogens because he/she is willing to do anything (LSD, psilocybin, PCP) at all in order to get another dose of the drug. Hallucinogens cause hallucinations. Their effect depends on the dose and on the addicts’ individual differences.

117 III Symptoms and diseases and their treatment

38 Infectious and contagious diseases

Infectious and contagious (communicable) ● Always consult a doctor via Radio diseases are caused by bacteria, viruses, Medical if you suspect a contagious parasites and fungi. An infected patient disease. may or may not have symptoms. The micro-organisms may enter the body in food It is often difficult to diagnose a contagious or water, be transmitted by insects (insect disease on the basis of the symptoms only. bites), by touch, or they may enter the body The medication available on board ship, through the airways. Poor hand hygiene or medications in general, are not effec- further spreads the disease from one person tive in all contagious diseases. Thus, the to another. Sexually transmitted diseases treatment on board depends mostly on the spread by touching and body fluids. symptoms. The aim is to relieve the symptoms and make the patient as comfortable 1 Symptoms as possible until he/she can be transferred to shore for further tests and follow-up Contagious diseases may display a variety treatment. The prevention of dehydration of symptoms. Typical symptoms are fever, is crucial. fatigue, headache, nausea and intestinal problems. Widespread skin reactions are 3 Isolating a patient also typical. with a suspected The symptoms may develop rapidly, infection even within hours, or may take days to develop. Very rarely can the cause be diag- If it is suspected that a patient has been nosed without laboratory or other tests. infected with a contagious disease, he/she must be isolated from the rest of the ship 2 Examination and crew to prevent the disease from spread- treatment ing. Further need for isolation may be decided after consulting a doctor via Radio Measures should be taken to find out Medical. whether a patient has done something It is usually enough that the patient that could have led to the infection. It is stays in his cabin and only essential visits important to find out whether the patient are allowed. The patient and others on has eaten or drunk something possibly board must take care to wash their hands contaminated or inadequately prepared, or often enough to prevent the disease from whether anyone else on board has similar spreading by hands or items touched. symptoms. It is also important to know If it is suspected that the disease when the meal or other event took place. spreads easily, the isolation should be All symptoms must be recorded. A stricter. Only the person responsible for patient with fever should be asked about treating the patient may be allowed in sweating, shivering, and the stages of the the cabin, and preventive measures must fever (don’t forget malaria!). A follow-up be taken in treating the patient. Protec- form (at the end of the book) makes it tive clothes and gloves must be worn. To easier to monitor the patient’s condition. prevent droplet infection, anyone treating

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 investigation 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,

119 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-

120 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

Diabetes is a metabolic disorder caused without ever having to take medication. by inability of the pancreas to produce However, most patients need medication insulin (Type 1 diabetes in children and sooner or later. young adults), or the insufficient action of insulin and inadequate insulin secretion 3 Low blood sugar (Type 2 diabetes in adults). (hypoglycaemia) 1 Type 1 diabetes The blood sugar is too low when there is more insulin in the body than is necessary. Type 1 diabetes is mostly a disorder of This often occurs in a situation when the children or young adults, but there is also patient takes his/her insulin medication, a possibility of developing the illness later but has eaten less than usual, and that is in life. Type 1 diabetes requires life-long why the dose of medicine lowers the blood insulin replacement therapy, because it is sugar level more than needed, and the a consequence of the destruction of the blood sugar consequently falls too much. insulin-producing pancreatic cells (e.g., Typical symptoms are, for example, after inflammation of the pancreas). a feeling of hunger, faintness, dizziness, nervousness, shaking, sweating, pallor, 2 Type 2 diabetes palpitations, irritability, quarrelsome behaviour, unconsciousness and spasms. If Type 2 diabetes is caused by insulin resist- the blood sugar level continues to fall, it ance, or the impaired action of insulin in leads to unconsciousness, which is referred the body. The pancreas produces insulin, to as insulin shock. but the body cannot use it effectively. The Raising a conscious patient’s blood blood sugar level rises slowly, and in the sugar level is done best by giving the pa- beginning of the illness the patient usually tient rapidly absorbent sugar orally. Quick does not have any symptoms at all. That alternatives for raising the blood sugar level is why Type 2 diabetes is often discovered are: two table- spoonfuls of honey or syrup, by chance. 8 to 10 lumps of sugar dissolved in water, Most Type 2 diabetics suffer from a a small handful of raisins, a glass of fruit metabolic syndrome, which, in addition to juice or a sugar-containing beverage, a diabetes, is manifested as obesity, the over- banana, or a couple of apples. weight accumulating especially in the ab- The unconscious diabetic in insulin dominal region, high blood pressure, and shock always needs immediate help. He/ abnormal blood fat values. The metabolic she may be given 1 mg of glucagon, in- syndrome may be treated without medica- jected either under the skin, or preferably, tion, namely, by losing weight, following deep into the muscle, where it is absorbed a low-fat and high-fibre diet, and physical more rapidly. The unconscious patient exercise. It often takes only a slight, about must never be given anything to drink be- 5–10 kg decrease in weight to essentially cause the liquid easily blocks the airways improve not only the blood sugar level, but and the patient may suffocate. If there is also the high blood pressure and fat values. no glucagon (8/C) available, and it is ab- Some Type 2 diabetics control their illness solutely sure that the unconsciousness is merely by dietary changes and exercise, cased by hypoglycaemia, the patient lying

122 III Symptoms and diseases and their treatment

on his side may be given a table-spoonful susceptibility to inflammations. For exam- of honey spread on the mucous membranes ple, recurring urethritis or inflammations inside the cheeks. If the patient’s condition of the skin are also possible. When the does not improve in 5 minutes, consulting a blood sugar level rises further, the classic doctor via Radio Medical is necessary. symptoms of diabetes begin to develop: When the patient regains conscious- increased secretion of urine, thirst and ness, his/her blood sugar level should be weight loss. The patient’s breath may smell monitored with a blood sugar metre. After of acetone. recovery he/she needs to be given long- Elevated blood sugar may be best lasting carbohydrates like dark bread and assessed with a test strip from a drop of fruits. blood taken from the patient’s fingertip. If the patient has clear symptoms, and the 4 High blood sugar blood sugar is over 20 mmol/l, intravenous (hyperglycaemia) fluid therapy must be started together with the administration of 0.1 ml (= 10 units) Insulin regulates the sugar metabolism in of insulin (Insulin Actrapid 100 units/ml, the body. Without insulin the body can 8/B) subcutaneously. When giving insu- not use the sugar properly, and the sugar lin, a syringe size of 1 ml must be used concentration in the blood rises. The excess for adequate dosage. The blood sugar is sugar passes through the kidneys into the measured hourly. Medical consultation urine, and is secreted in the urine, tak- is necessary before the administration of ing with it liquid and energy. The typical another dose of insulin. symptoms of hyperglycaemia are increased Especially in Type 1 diabetes, large volume of urine, dehydration, increased quantities of ketones may build up in the thirst and weight loss. body, which may lead to acid poisoning, In Type 1 diabetes, the symptoms are ketoacidosis. This is usually caused by usually distinct and develop rapidly within neglecting the regular insulin injections days or weeks of onset. In the beginning, or constant overeating, which leads to a the Type 2 diabetic may have no symptoms rapid increase in the blood sugar concen- for a long time, and the illness is often di- tration. The patient may be drowsy, even agnosed by chance when the sugar level unconscious. The fruity acetone odour is measured. due to the ketones may be noted in the If diabetes remains untreated for a patient’s breath. If prolonged, the condition long time, especially Type 1 diabetes, the may lead to drowsiness and unconscious- blood sugar level may rise too high even in ness. Type 2 diabetes, on the other hand, a short time, and so-called ketone bodies rarely leads to ketoacidosis. Ketoacidosis is begin to accumulate. They are produced as always a severe condition and requires im- a result of the incomplete burning of the mediate transfer of the patient to shore. fatty acids released into the bloodstream from the fat tissue. Typical symptoms are 5 Differentiating nausea, vomiting, abdominal pain, and a between low and high fruity odour of the breath due to acetone. blood sugar The situation may lead to unconsciousness. A diabetic may be unconscious either due In Type 2 diabetes, the blood sugar to insulin shock (too low blood sugar) or, level rises slowly, and the symptoms ap- more rarely, ketoacidosis (too high blood pear over a longer period of time. Typical sugar). The symptoms caused by too low symptoms are fatigue, listlessness and and too high blood sugar levels are shown

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

Too low blood sugar Too high blood sugar Sudden Slow, develops within (6–)12–24 (sometimes preceded by Beginning hours disorientation) Excess insulin in the bloodstream: Cause Insulin deficiency: neglecting the a meagre or delayed meal or treatment, neglecting or forgetting missing a meal, excess physical the insulin injection, new diabetes strain especially before a meal, abundant consumption of alcohol

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)

Nervous, aggressive, sometimes Behaviour before Drowsy, sometimes disoriented confused unconsciousness

Sweating (not always), Symptoms Strong thirst and dry mouth, shaking, preceding headache, feeling of hunger, unconsciousness severe nausea, vomiting, faintness, abdominal pain, sometimes nausea and vomiting, constipation, disorientation, blurred vision, spasms (often connected with shortness of breath, unconsciousness) fatigue Low (under 3 mmol/l) Blood sugar High (usually over 15 mmol/l)

Sugar usually –, Urine Sugar ++++ Acids – or weak + Acids ++++

Glucagon 1 mg into muscle, Treatment Always an emergency, intravenous if the patient is conscious: sugar/ fluid therapy, consultation via Radio honey/syrup Medical, insulin

124 III Symptoms and diseases and their treatment URES

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 TREATMENT PROCED TREATMENT IV Treatment procedures

40 Securing the airways, intubationIV 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.

Figure 40. Intubation equipment

127 IV Treatment procedures

IV Treatment procedures

Figure 41. Tilt the head backwards

Figure 42. Insert the laryngoscope into the mouth with the blade in the midline

Figure 43. Lift the blade of the laryngoscope until you see the vocal cords

128 IV Treatment procedures

Figure 44. Insert the endotracheal tube to the right depth

Figure 45. Inflate the cuff of the endotracheal tube with air, with a syringe

Figure 46. Attach the breathing bag to the endotracheal tube and begin to give air

129 IV Treatment procedures

• Slide the blade of the laryngoscope Possible problems in performing into the pharynx. The laryngoscope intubation has been correctly placed if theIV whole Treatment Intubation procedures is often a life-saving procedure. length of its blade eventually touches However, problems may occur in perform- the patient’s tongue. The blade is in ing the intubation. The most common deep enough when your hand touches problems are: the patient’s chin. • The lamp of the laryngoscope is not • Begin lifting the laryngoscope handle working, or gives only a dim light. upwards along the line of the handle. • The blade of the laryngoscope is not in • Visualize the vocal cords that are lo- the middle of the tongue or on the right cated uppermost, deep in the pharynx side, and the patient’s tongue does not (‘white sails’, Figure 43). move aside sufficiently. • Guide the endotracheal tube with your • The larynx does not come into sight right hand into the airways so that the (continue ventilation with the mask!). scale on the tube at the level of the • The performance is hasty. Try again corner of the patient’s mouth shows in a very calm manner, following the 22 at most for men, and 20 at most for instructions. women (Figure 44). • Breath sounds can be heard from one • Inflate the air cuff of the tube by push- lung only. This means that the tube is ing 10 ml of air with a syringe into the too deep and the air is going only into cuff (Figure 45). Attach the tube to the the right lung. Deflate the cuff and corner of the patient’s mouth with tape. gently pull the tube out a couple of Make sure that the tube remains at the centimetres. Inflate the cuff, blow and right depth the entire time! check the breath sounds again. • Begin giving oxygen with a breathing bag (Figure 46). • Listen to both lungs with a stethoscope to make sure that breath sounds are heard from both lungs. • Insert a pharyngeal tube to prevent the possibility that during a spasm the patient bites the endotracheal tube in two.

130 IV Treatment procedures

41 Measuring the blood sugar

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

Figure 47. Clean the fingertip with a cleansing swab

Figure 48. Prick a hole on the side of the fingertip with a needle or lancet

Figure 49. Wet the test area of the test strip with a drop of blood

Figure 50. Compare the colour of the test strip with the colour scale on the container

132 IV Treatment procedures

42 The drugs in the ship’s pharmacy and their use

There are no international regulations con- handling the ampoule, so that the drug in cerning the content of a ship’s medicine the ampoule remains sterile. chest. Nearly every country has issued its own regulations determining the medi- 1 Drugs, pregnancy and cines the ship under the flag of that country breast feeding must have on board. The European Union (EU), in its directive 29/92 EC determines Certain drugs can harm the developing the groups of medicines which the ships in foetus. Pregnant women should therefore the European Union must have. Though the be given drugs with caution. In all treat- medications listened in this book comply ment situations, it should be carefully with the EU directive mentioned above, considered what drug to use or, if in fact, all of them might not be widely used in the patient could manage without any all the EU countries. drugs. The majority of drugs pass into the Each drug is named according to the foetus from the mother’s blood circulation. non-proprietary name (so-called generic However, sometimes treatment with drugs name). The generic name makes it pos- is necessary, and the risk to the baby is sible to identify different parallel prepara- smaller with the drug than without it. tions. As the trade names vary in different National and international catalogues countries, you need to know the generic always state whether a drug causes or might name of the drug when purchasing drugs cause risks to the foetus, and whether it is from abroad. suitable for use by breast-feeding mothers. Drugs come in many different forms: If the drug catalogue does not definitely tablets, suppositories, mini-enemas and state whether the drug can be used or not, injections. The fastest effect is obtained a doctor must always be consulted before with an injection given intravenously, and administering medication to a pregnant the slowest when a tablet is taken orally. A woman. glass of water must be drunk when swallowing a tablet. Otherwise the tablet might ● Consider carefully before giving get stuck in the gullet. drugs to a pregnant woman. One whole disposable ampoule of a Ask a doctor for instructions! drug usually corresponds to a single adult dose (the neck of a glass ampoule is broken when it is opened). The exception to this 2 Fatigue-causing rule is a morphine ampoule, which should ‘triangle’ drugs not be given all at once but, for example, in three parts, at intervals of a few minutes. A Some drug packages in the ship’s pharmacy large single dose of morphine could result have a red warning triangle. The triangle in respiratory failure. indicates that the drug has been found to A drug in liquid form may also be cause fatigue and to lower attentiveness. in an ampoule with a rubber cork, and Drugs marked with the red triangle must can be taken in doses from the ampoule. not be used at all if a person’s work duties Good hygiene must be maintained when require unconditional alertness (e.g. helm or watch duty).

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 together they have a depressive effectIV Treatment on is prolonged. procedures 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 For example, diazepam (4/A) causes fatigue the treatment continues. 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

● An injection into the tongue is 4 Drugs and alcohol always successful and efficient. Alcohol enhances the effects of drugs that have a depressing effect on the central After primary treatment, continue to treat nervous system (‘triangle drugs’). Their the patient either by giving him/her hydro- combined effect can be unpredictable, and cortisone intramuscularly or prednisolone may even lead to respiratory arrest. This tablets orally. At this stage consult a doctor should be kept in mind, for example, when via Radio Medical. administering drugs to a person under the influence of alcohol. That is why a drunken patient has to be monitored very carefully ● After primary treatment, consult a doctor about further treatment via during his/her treatment. Radio Medical. ● Drugs and alcohol must not be used The use of the drug that possibly caused simultaneously. the allergic reaction should be discontin- ued immediately. Furthermore, try to find out whether it was the drug or some other Alcohol causes gastric irritation. It there- simultaneous factor that may have caused fore increases the harmful effects of drugs the reaction. If the reason for the reaction that irritate the stomach (e.g. painkillers was a drug allergy, the patient must never and antipyretics). again be given that drug! Alcohol reduces the motility of the gastro-intestinal tract, which may weaken the absorption and effect of some drugs. If a person uses alcohol, he/she often neglects to follow the instructions for drug use.

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 Treatmentbetween theprocedures 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.

An injection can be given under the skin Intravenous injection (subcutaneous injection, s.c.), into a mus- A drug given intravenously takes effect in cle (intramuscular injection, i.m.) or into a seconds. Because the drug is given intra- vein (intravenous injection, i.v.). venously, there is risk of blood contact in this method. The person giving the drug Subcutaneous injection should therefore use protective gloves. The A subcutaneous injection is used, for administration technique for intravenously example, when giving insulin. The most given drugs is for the most part the same as

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

44 Drug treatment of the eyes

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 wiping it clean. Figure 51. Eye drops are dropped into the opened lower eyelid

137 IV Treatment procedures

of the drug bottle must be marked on the bottle. • The patient bends his/her headIV back Treatment- procedures wards and looks up. In this position the sensitive cornea is partly under the upper eyelid and the drop will not hit it. • The lower eyelid is pulled downwards. • One drop of the medication is dropped into the palpebral fissure of the lower eyelid (Figure 51). If the drop hits the eye only partly, another drop is given. Figure 52. Eye ointment is applied into Be careful not to touch anything with the opened lower eyelid the tip of the drop bottle: not the patient’s eyelashes or eyebrows, and • Check that the drug is the correct not the fingers of the person giving one, and that the use-by date has not the drug. expired. • The patient closes his/her eyes gently. • The patient bends his/her head back- • Wipe off the extra drug from the palpe- wards and looks up. bral fissure with a sterile swab. • The patient’s lower eyelid is pulled • The drop bottle is closed so that downwards. the edge of the cork does not touch • 0.5–1 cm of ointment is squeezed from the mouth of the bottle. The drug is the tube onto the inner surface of the stored according to the instructions lower eyelid, so that the tip of the tube on the package. (Remember the expiry does not touch the eyelid (Figure 52). date!) • The patient closes his/her eyes gently, after which he/she gently blinks the 2 Eye ointment eye so that the ointment forms a light membrane on the conjunctiva and Eye ointment is packed in small tubes cornea. equipped with a long nozzle. Since the • Any extra ointment is wiped off with a ointments at first blur the vision slightly, sterile swab. they are generally applied for the night. • Before closing the ointment tube, Eye ointment is applied in the following squeeze out a small amount of oint- way: ment and wipe the tip of the tube with • The person applying the ointment a clean, sterile swab. This helps to keep washes his/her hands. the drug sterile.

138 IV Treatment procedures

45 Intravenous (IV) infusion therapy

Inserting an intravenous (IV) catheter and • protective gloves starting intravenous infusion is necessary • intravenous solution (basic intravenous in many diseases and accidents. Intrave- fluid, either in a bag or a bottle) nously given fluid replacement, in other • stand for the solution bag/bottle words, intravenous infusion, may save the • IV administration set patient’s life. If a patient is in danger of • tourniquet going into shock (insufficient blood circu- • catheter lation for the body’s needs), for example, • antiseptics for disinfecting the skin due to severe diarrhoea, vomiting, bleed- • adhesive skin tape. ing or burns, the situation can be stabilized with intravenous infusion therapy. It is also Priming the tubing possible to administer medications via the First, prepare the IV administration set intravenous catheter, when the patient can- for use: not take them orally (due to stomach pains • Close the roller clamp on the IV set, or vomiting) or when the medication has and insert the spike of the IV set into to take effect quickly. the solution bag or bottle. With a bottle, the air vent of the drip chamber should 1 Intravenous infusion be open; with a bag, closed. • Squeeze the drip chamber of the IV set Necessary equipment half full of fluid (Figure 54). The equipment needed (Figure 53) must be • Open the roller clamp, so that the assembled before beginning the IV therapy. tubing is filled with fluid and all air These are: bubbles are expelled.

Figure 53. Equipment needed for intravenous infusion

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• Take the IV catheter from its package and spread out its wings. IV Treatment• Stretch procedures the skin at the insertion site tight with a thumb, to stabilize the vein during insertion. • Grip the catheter with the other hand (Figure 56). • Pierce the skin with the catheter at a 30–45 degree angle to the skin on top of the vein, in the direction of blood flow (towards the heart). When the catheter has pierced the skin and the wall of the vein, direct it into the vein parallel with the skin. When the tip of the catheter has pierced the wall of the vein, blood will appear in the chamber of the catheter. • Push the catheter into the vein about 0.5–1 cm. Then pull the metal needle inside the catheter (not the plastic catheter!) outwards about 1 cm and push the plastic catheter fully into the vein. Figure 54. Filling the drip chamber • Open the tourniquet, press the vein with a finger and remove the metal • Close the roller clamp and suspend the needle (Figure 57). tubing on the IV stand. Joining the IV administration set to Inserting the catheter into the catheter and starting infusion a vein (Figures 55–59) Next, attach the prepared IV tubing to the There is a risk of blood contact with the catheter as follows: patient when the vascular access is being • Remove the protective cap from the opened. The use of protective gloves is thus end of the tubing and attach the tubing necessary. The lighting should be good to the catheter (Figure 58). during the procedure. • Tape the catheter with its wings to the skin. Procedures in inserting the catheter: • Make a loop in the tubing and tape it • Wrap the tourniquet around the pa- to the skin (Figure 59). The loop will tient’s forearm or upper arm. The veins prevent dislodgement of the catheter at the back of the hand, especially the if the tubing is touched. y-branches of veins, are the best inser- • Hang the IV bottle or bag above the tion sites (Figure 55). Veins that are patient and open the roller clamp. poorly visible can be brought out by • Adjust the roller clamp for the proper tapping them gently with the fingers, flow rate. The flow rate is determined massaging a cool limb, or lowering the by counting the number of drops in the limb slightly. drip chamber per minute (20 drops = • Clean the insertion site thoroughly with 1 ml). The infusion rate depends on an antiseptic swab, from the centre the situation: a bleeding shock may outwards. require as much as 200 drops/min,

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Figure 55. Wrap the tourniquet around the forearm and clean the insertion site with an antiseptic swab

Figure 56. Push the catheter into the vein; blood should appear in the chamber of the catheter

Figure 57. Pull the metal needle inside the catheter outwards, and then push the plastic catheter deeper into the vein

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while a standard flow rate is 15–20 The infusion does not work. What drops/min. is the problem? • Monitor the infusion constantly,IV Treatmentand If the fluid procedures 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.

Figure 58. Press the catheter with a finger and connect it to the tubing

Figure 59. Secure the catheter in place with skin tape and start the infusion

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46 Measuring blood pressure

A normal blood pressure is 120–140 / 2 Measuring blood 70–85 mmHg. The upper, systolic value pressure with a represents the pressure in the arteries when stethoscope the heart is contracting. The lower, diastolic value represents the pressure in the arteries Blood pressure should be measured in a between the contractions of the heart. If quiet environment. Furthermore, before blood pressure is measured carelessly and the measurement, the patient should be hastily, the readings can be even 10–20 allowed to relax for 10–15 minutes, so that mmHg higher than the real values. the measuring situation corresponds to the The blood pressure is higher when patient’s normal condition. a person is standing, lower when sitting down, and lowest when lying down. Procedures for measuring blood pressure Anxiety, tension, and pain, as well as many from the arm: diseases, and physical exertion raise the • Remove any clothing that constricts the blood pressure. arm. Preferably the whole arm is bare during the measurement. 1 Measuring instruments • Wrap the deflated cuff snugly around the upper arm. Start wrapping from Sphygmomanometer the rubber bag part, ending with the (blood pressure gauge) Velcro tape. The air tubing from the cuff In a sphygmomanometer meant for adults, should point toward the patient’s wrist. the rubber bag part of the cuff should be at The tubing should not cover the elbow least 14 cm wide and 40 cm long. fold, from which you listen to the pulse with the stethoscope. Stethoscope • Make sure that the chest piece of the When you place the stethoscope in the stethoscope is in auscultation mode ears, make sure that the angle of the ear- and place it at the middle of the elbow pieces is slightly upwards, in the same fold over the artery. direction as the ear passage. If the angle • Pump air into the cuff and follow the is downwards, hearing is weakened as the pressure from the sphygmomanometer. earpieces point towards the wall of the Raise the pressure about 30 mmHg auditory passage. higher than the patient’s assumed blood Most stethoscopes have both a bell pressure level. and a diaphragm mode for auscultation. • Lower the cuff pressure slowly by Make sure before the measurement that deflating (about 2 mmHg decrease in you have chosen the right side of the chest pressure per second). piece for listening. This can be checked by • Follow the meter reading; at the same lightly tapping with the fingers the side that time listen with the stethoscope for the will be placed on the patient. If you can appearance and disappearance of the hear the sound via the earpieces, measure- pulse as the pressure decreases. ment is possible. • Lower the pressure steadily, without in- terruptions, until the pulse is no longer audible. Do not raise the pressure again

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in the middle of the measurement. All 4 Measuring blood pressure must be released before start- pressure without ing remeasurement. IV Treatment a stethoscope procedures

The measurement reading is based on au- Diastolic blood pressure can be deter- ditory observation. When the cuff pressure mined only with a sphygmomanometer decreases to the level of systolic pressure, and a stethoscope. However, it is possible blood starts flowing into the brachial ar- to measure the systolic pressure even tery with the pulse. This is heard as a low, without a stethoscope. Take the reading pulsating sound. Record the reading at by feeling the wrist pulse at the same time which the sounds are first audible (systolic as you deflate the cuff. Systolic pressure pressure). is the pressure level when the wrist pulse When the cuff pressure decreases becomes perceptible. further, the pulsating sound becomes distant and disappears completely, as 5 Estimating blood blood flows freely in the brachial artery. pressure without a Record the reading at which the sound of gauge the pulse disappears completely (diastolic pressure). In an emergency situation, it is possible to make a rough estimate of blood pres- 3 Repeating the sure even without a sphygmomanometer measurement by feeling the pulse in both the wrist and the carotid artery (at the neck). If the wrist The measurement should be performed pulse is perceptible, blood pressure is at least twice. Deflate the cuff completely over 80 mmHg. If the wrist pulse cannot between measurements, and take a new be detected, but the carotid pulse is still measurement after a few minutes. perceptible, blood pressure is at least 60 mmHg. Feel the pulse with the tips of the index and middle finger. The pulse should not be felt with the thumb, because then the measurer’s own pulse is also felt.

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.

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There are risks associated with the use of a tourniquet. Since a tourniquet is helpful only when it is so tight thatIV the Treatment cir- procedures culation in the whole limb is blocked, the tissues in the extremity may become damaged from lack of oxygen. Furthermore, a tourniquet causes intense pain in the limb. A tourniquet that is too loose prevents only venal circulation, and the patient will lose blood through the arteries faster than when a tourniquet is not used.

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 treatment 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.

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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

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● Consult a doctor via Radio Medical Generally use simple interrupted before closing large wounds, stitches. Each stitch is tied individually puncture wounds or bite wounds.IV Treatmentwith a reef procedures knot (Figures 68 and 69). The stitch should be made so that the edges of the wound only just touch each other. Equipment The number of stitches required depends Before beginning, assemble the following on the length of the wound and on how equipment (Figure 64): easy it is to keep the edges of the wound • antiseptics for disinfecting the skin together (Figure 70). • anaesthetic equipment: syringe, 2 When the stitches are ready, cover needles, local anaesthetic the wound with a sterile gauze dressing • sterile gloves (2 pairs) and secure it. The stitched wound must • surgical drape with a hole be kept dry. • instruments: surgical forceps, needle holder, scissors Removing stitches • suture thread Stitches are removed after 5–10 days, • gauze dressings and bandages, depending on the location of the wound skin tape. (from the face sometimes even after three days to prevent excessive scar formation, After the wound is cleaned, put new, whereas the stitches on a wound on a sterile gloves on before you start closing thick-skinned palm, for instance, can be the wound. left for even a couple of weeks). Lift a stitch with the forceps so that Anaesthetizing the wound you can cut it between the knot and skin, First anaesthetize the edges of the wound either with scissors or with a stitch cutter. with lidocaine (10 mg/ml, 13/A, Figure 65). Next, pull the stitch from the skin. Inject local anaesthetic with a thin needle into the skin and immediately below it 3 Infected wound and around the edges of the wound at one or lymphangitis (infection more injection sites, so that the treatment of lymph vessels) area is sufficiently anaesthetized. The total amount of anaesthetic should not be over Symptoms of an infected wound include 20 ml. Wait for 10 minutes for the anaes- redness and swelling of the edges of the thetic to take effect. After this the wound wound, hotness, ache or pain, and pus should be cleaned again. draining from the wound. The patient may Begin stitching by pushing the needle also have fever. with the needle holder at a right angle Remove all dressings from the in- through the skin at the edge of the wound fected wound and clean it twice a day by (Figure 66). While pushing, turn the needle rinsing with warm water. Cleansing can so that its tip comes out through the skin of be assisted by mechanically scratching the the other edge of the wound. If the length pus away, e.g. with a clean cotton stick. of the needle is not sufficient for this, turn After cleaning, spread bacitracin ointment the needle so that its tip appears in the (9/D) on the wound. Always apply new middle of the wound. Then grip the needle dressings after treatment. If the infection again and continue the stitch from inside does not subside in a few days, or if the the wound through the skin of the other redness of the wound area and the pus side of the wound (Figure 67). discharge increase, start antibiotic medication, one 500 mg tablet of cefadroxil (7/E)

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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.

Figure 64. Suturing equipment

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IV Treatment procedures Figure 65. Anaesthe- tize both edges of the wound

Figure 66. Push needle through the skin at a right angle

Figure 67. Pull needle through the other edge of the wound

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Figures 68 and 69. Close a stitch with a reef knot

Figure 70. The number of stitches should be enough to keep the edges of the wound lightly together

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48 Retention of urine and catheterizationIV Treatment of proceduresurinary bladder

If the urinary bladder does not empty 1 Instruments needed spontaneously, it has to be emptied by for catheterization catheterization. In men, prostatic hyper- trophy is the usual reason that prevents The instruments needed for catheteriza- the bladder from being emptied. Women tion are: very rarely need catheterization. The uri- • catheterization package nary tract is vulnerable to infection, and – sterile gloves therefore, absolute cleanliness is neces- – kidney bowl sary in catheterization to reduce the risk. – sponges Before catheterization, a doctor should – anatomic tweezers be consulted via Radio Medical about the • cleansing solution (0.5% chlorhexi- necessity of the procedure. dine, 16/A) • local anaesthetic gel (2% lidocaine, 13/B) ● Catheterization of urinary bladder needs to be performed carefully • catheter and with absolute cleanliness. • urinal.

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 urethra, Figure 71). An assistant, if available, holds the other end of the catheter. Figure 71. Anatomy of male urethra

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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.

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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, poisoning, 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

Table 8. Examples of recommended positions depending on the patient’s condition

Patient´s condition Position Unconscious, breathing Always on the side to keep the respiratory tract open and to prevent the tongue from pressing against the pharynx Chest injury On the side, the injured side downward to prevent possible bleeding from the injured lung to the uninjured lung Breathing difficulties or chest pain Preferably half-sitting to keep the pressure as low as possible in the chest area, and to allow the patient to breathe easily Abdominal pain Usually a supine position or on the side with knees bent, abdominal muscles relaxed. Sometimes the patient prefers a sitting position Sprain, fracture or bleeding in limb Injured limb elevated to prevent swelling, bleeding and pain Shock A supine position with legs elevated to secure sufficient blood circulation and intake of oxygen to the basic vital organs, such as the heart and brain

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

ation and the previous factors connected to ● Notify the shipping company about the incident, as well as the treatment given the evacuation, so that, if necessary, on board. The patient should alsoIV haveTreatment the patient’s procedures family can be noti- with him/her the contact information of the fied as well, and the preparations ship and the shipping company. for moving the patient back home The ship’s own shipping company can be started: should also be notified about the evacu- • time ation, so that it can begin the necessary • place procedures to ensure the quality of the • personal information about the treatment and to move the patient back to evacuated person the home country. • reason for evacuation • condition of the evacuated person • means of evacuation.

50 Cleaning hands and instruments

Whenever a nurse treats injuries and is 2 Handling disposable exposed to the blood and excretions of instruments patients, there is the possibility that he/ she may be infected as well. The nurse The instruments used on board are kept or the instruments can easily pass on an in a sterile, covered container. Disposable infectious disease to other patients or vice instruments are kept in a dry, clean place, versa. where their wrappings remain intact and dry. The sterilization date is marked on the 1 Washing hands wrapping. Once the wrapping is opened or damaged (e.g. gets wet), the instruments It is important to wash your hands before are no longer usable. treating a patient even when using sterile After being used, disposable instru- gloves. Wash your hands with plenty of ments such as knives, hypodermic sy- soap and water. Rinse the soap well from ringes and needles are placed in a separate, your hands and dry with a clean towel. puncture-resistant, and covered container. Rub chlorhexidine solution (16/A) on your The container should be clearly marked, hands and allow to dry. Finally protect your indicating that its contents might be infec- hands with sterile gloves. tious. Ready-made yellow waste containers After the treatment, take off your are available. A full waste container can gloves and throw them into the rubbish be destroyed as agreed, either by the oc- bin. Excretion and blood on the gloves cupational health service or the pharmacy must not be touched with bare hands (risk delivering medications to the ship. of infection!). Finally wash your hands once again with soap and water.

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 before use. In an emergency, strong alcoholic solution is also acceptable.

157

ION

V SELF-PROTECTION

51 Self-protection and prevention of infections 52 Vaccinations for seafarers 53 Death on board SELF-PROTECT V Self-protection

51 Self-protection and prevention of infections

Infectious diseases are caused by bacteria, When treating a patient, sterile gloves viruses, parasites and fungi, which may must always be used. When giving mouth- pass into the body along with water and to-mouth respiration, a disposable mask is foods, as well as by insects, touching, or used, if possible. (The mask can always be air. Diseases can also spread from person carried around, e.g. on a key chain.) to person because of poor food and hand hygiene. Sexual diseases are transmitted ● Always put on sterile gloves before through blood or contact with secretions. touching the patient!

1 Avoiding the risk of infection when If you think that you might be infected by treating a patient on a patient, you should notify, for example, board the occupational health service of the shipping company. More detailed inves- It should be borne in mind that blood and tigations will then be conducted to find body fluids are always possible causes of out if there really is an infection. The oc- infection (e.g. hepatitis and AIDS). Pierc- cupational health service also takes care of ing the skin with a needle or knife that the juridical issues (occupational accident has come in contact, for example, with reports, etc.). blood or secretions always poses a risk of infection. Cleaning of instruments and surfaces All used disposable instruments are placed ● Blood and body fluids are always possible sources of infection. in an undamaged, leak-proof container, and they are handled as hazardous waste. Non-disposable instruments are first When handling articles and clothes con- washed thoroughly with soap and water taminated with body fluids or secretions, and then disinfected for future use. Con- sterile gloves must be used, and it is also taminated treatment rooms and surfaces important to ensure that they do not cause need to be cleaned immediately after the a risk of infection for other people. Con- treatment with liquid disinfectant contain- taminated surfaces must be cleaned with ing chlorine (2% chloramine solution or a disinfectant. 0.25% sodium hypochlorite solution) or If your own skin has come in contact phenol. Finally, all the surfaces must be with a patient’s blood or secretions, it wiped with 40% alcohol solution. Sterile should be washed immediately with soap gloves should be used all the time when and water, after which it should be disin- cleaning. It is important to remember fected (e.g. by rubbing it with hand rub the risk of infection when handling used solution containing 40% ethanol). This is gloves. a precaution, because the patient’s blood or secretions may always pose a risk of infection.

160 V Self-protection

2 Preventing the Bottled drinks are safer than other spreading of infectious drinks. The products of large international diseases companies are well controlled and should be preferred. Ice cubes are often made It is often via the hands that infections are from tap water, and should therefore be passed from one person or place to anoth- avoided. er. Taking good care of hand hygiene is the Protect yourself against mosquitoes basic element in preventing infections from and mites with insect repellents and in- spreading. When washing is not possible, secticides, and use clothes that cover you use alcoholic hand rub solution: rub the well. In the tropics, use a mosquito net in solution on your hands and let it dry. regions where malaria is prevalent. All casual sex contacts, especially ● Washing your hands is an effective if unprotected (without a condom) pose way to avoid infectious diseases! a high risk of infection. In addition to ac- Use alcoholic hand rub solution! tual sex diseases, e.g., hepatitis B is easily spread through sexual intercourse. Swimming and wading in shallow wa- Water and foods are the most common ter in tropical regions exposes to a variety sources of infections. Avoid raw and un- of parasites and micro-organisms which dercooked foods. Peel or rinse fruit in clean may be difficult to get rid of later. water before eating.

52 Vaccinations for seafarers

A seafarer’s vaccinations need to be up-to- One vaccination usually protects date. In some countries it is possible to get against one disease. The vaccine against basic vaccinations free of charge at public hepatitis B, for instance, protects only health care centres. The vaccines for other against that and not against other infectious than basic vaccinations can be purchased inflammations of the liver, which may be on prescription from a pharmacy, and taken equally dangerous as hepatitis B. And there to the person giving the vaccination. is no vaccine for HIV yet. A seafarer should consider well in ad- No vaccine guarantees 100% pro- vance which vaccinations to take and when tection. Therefore, in addition to the vac- to take them. Vaccinations should be taken cinations taken, it is important to behave in good time before going to sea, as they sensibly and avoid infections. often have side effects. For instance, when The vaccination recommendations of leaving for less developed countries, it is the authors of this book are listed in Table recommended to take some extra vaccina- 9. Yellow fever vaccine is the only one tions already in you home country instead mandatory for entry to certain countries. of having to consult a local practitioner in Information on recommended vaccina- some developing country. For example, tions for travellers is published annually by infectious hepatitis and HIV/AIDS are often the World Health Organisation (WHO). spread by infected needles.

161 V Self-protection

Table 9. Recommended vaccinations for seafarers (Vaccination against yellow fever is the only mandatory one)

Vaccine Persons to be vaccinated Need for booster vaccination Tetanus Every seafarer Every 10 years Diphtheria Every seafarer Every 10 years, given together with tetanus vaccine Polio Every seafarer Every 5–10 years depending on the region visited Yellow fever Mandatory when travelling to Every 10 years Africa and South America Cholera Persons staying in areas with poor Every 2 years food and water hygiene Typhus Persons staying in areas with poor Every 1–3 years depending on the food and water hygiene vaccination Hepatitis A Persons who Every 10–20 years a) travel and stay outside Europe, the USA and Canada b) maintain sanitation equipment on board Hepatitis B Persons responsible for medical No need for revaccinations treatment on board, especially if there are Asians or Africans among the crew

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

TIONS

VI ADVICE AND INSTRUCTIONS

54 Radio Medical 55 Confidentiality and seafarers’ health care ADVICE AND INSTRUC VI Advice and instructions

54 Radio Medical

1 Radio Medical system tors, however, do not know the seafarers’ level of medical readiness, and this makes Medical treatment on board ship is sup- it more difficult to give correct advice that ported by a system called Radio Medical. is understandable and can be carried out Nowadays, the term telemedicine would optimally. be more appropriate, because the system no longer uses traditional radio waves. The 2 Treatment on board official Radio Medical services are based ship and consultation on international agreements and are free of through Radio Medical charge for all ships. The satellite connections of medical problems are also free of Telemedicine can never replace the treat- charge. With the help of the telecommu- ment skills on board ship. It can only help nications system, a doctor on land can be and support the treatment! consulted any time, day or night, wherever the ship may be. ● Consultation through Radio Medical Radio Medical messages are always can never replace the ship’s own signed by the captain of the ship. Since the treatment readiness. Keep your radio connections have improved, ships treatment skills up to date! more often directly consult their own national doctors, the company’s occupational health physician, a medical treatment The person responsible for treatment on centre in their home town, or some other board must always proceed in the follow- already familiar treatment unit. ing order: The benefits of a consultation depend 1 Find out the general condition of the to a great extent on how well the person patient. seeking advice can describe the illness or 2 Give the patient immediate, vital first accident to the doctor, as well as how well aid and treatment. he/she can understand and carry out the 3 Keep record of the course of events, instructions given by the doctor. In some the condition of the patient and the situations, sending a picture via a com- treatment given. munication network can make it easier to 4 Plan possible further treatment. communicate and exchange information. The problem of consulting through When personal skills are sufficient Radio Medical is often that the doctor • The patient is treated on board ship, giving advice does not know the working or the treatment continues on board conditions on board the ship, nor what until the patient can be transported for medical equipment might be available on further treatment on land. board. The person seeking advice should therefore be ready to give information When personal skills are not sufficient about these facts. • Contact a doctor on land. On board ship, the person taking care • Describe the course of events. of the patient is, in practice, the eyes, ears • Describe the condition of the patient. and hands of the doctor on land. The doc- • Explain what treatment has been given.

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

Keeping exact records Patient follow-up When consulting through Radio Medical, The condition of the patient is always pen and paper should always be at hand. monitored even after the treatment. The The contents of the messages are care- follow-up helps to ensure that the patient’s fully written down. It is easier to receive condition is stable or progressing favour- the messages if they can be recorded ably. The follow-up times are recorded with, for example, a dictaphone. The re- on a follow-up form (date, time, patient’s ceived instructions can then be listened condition, such as temperature, pulse, to afterwards, and the contents can be blood pressure, etc.). confirmed. Good basic knowledge of the patient’s New consultation initial condition makes consultation easier If the condition of the patient does not im- and faster. The patient does not have to be prove as expected, or it takes a turn for the examined again in the middle of the call in worse, a doctor is consulted again. order to answer the doctor’s questions.

Carrying out the procedures and recording them The treatment procedures that have been carried out are entered into the ship’s treatment log.

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 injury 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

● Maritime employers may need 3 Disclosing medical access to medical records to fulfil records to outsiders their statutory obligations regarding seafarers’ health care. The captain, the ship’s nurse or another crew member who is responsible for treatment on board cannot disclose any 2 Medical records and individual or family secrets acquired while the captain of the ship performing professional duties. The obligation to maintain confidentiality also applies Regardless of the vessel type, the captain to the person appointed by the maritime of the ship is always responsible for the employer to be responsible for health care medication and the treatment given on on board. board. He is responsible for drug provi- sions and drug usage; he signs the Radio ● Confidentiality regulations also Medical messages and is, for example, apply to the captain of the ship. in charge of calling for the medical helicopter. In the role of the ship’s doctor, he has right of access to the crew’s medical Either the patient’s written consent or the records. The captain is also the shipping statutory right to such medical records is company’s (employer’s) representative, so required before confidential information combining these roles might sometimes can be disclosed to outsiders. In public cause problems in interpretation. health care, often an oral or otherwise implicit patient authorization is enough for the transferring of patient data. ● Maritime safety may require that the captain of the ship receives information about seafarers’ health.

169

OF THE N AND ON

VII STRUCTURE AND FUNCTIONS OF THE HUMAN BODY, EXAMINATION AND RECORDING THE INFORMATION

56 Structure and functions of the human body 57 Examining the patient STRUCTURE AND FUNCTIONS FUNCTIONS AND STRUCTURE EXAMINATIO HUMAN BODY, RECORDING THE INFORMATI VII Structure and functions of the human body, examination and recording the information

56 Structure and functions of the human body

Giving proper medical treatment and 2 Circulatory system examining sick or injured persons appro- priately requires basic knowledge of the The heart, arteries and veins form the location and functioning of the internal circulatory system (Figure 74). The heart organs. pumps blood to all organs through the arteries, and the blood returns to the heart through the veins.

1 Musculoskeletal system The heart The musculoskeletal system consists of the The heart is basically a four-chamber au- bones and the joints that connect them, as tomatic muscular pump (Figure 75). The well as the muscles (Figure 73). The bones heart of an adult is the size of the owner’s of the extremities are so-called long bones; fist, and weighs about 300–350 grams. The the skull and the bones of the chest and heart consists of two ventricles and two pelvis are so-called flat bones. Bones are atria. The atria help the blood flow into surrounded by a tight bone membrane, the ventricles. The left ventricle pumps under which lies the actual hard bone blood into the systemic circulation to surface. The bone is living tissue, which nourish the body with oxygen and other self-repairs after an injury by forming new nutrients. The right ventricle pumps blood bone under the bone membrane. The bone into the pulmonary circulation, where the marrow is softer and more porous than the carbon dioxide in the blood is replaced by surface bone. New blood cells are formed oxygen. The coronary arteries that branch in the marrow. from the base of the aorta (the main artery Cartilage forms a sliding surface from the left ventricle) are responsible for between the joints, which are surrounded the circulation of the heart (Figure 76). by a tight capsule of fibrous tissue contain- In coronary heart disease and cardiac ing a small amount of synovial fluid. The infarction, these veins are obstructed and muscles are responsible for movement. the heart is deprived of oxygen, causing There are hundreds of muscles, and even chest pain. The resting heart rate is 60–70 a simple movement requires the simulta- beats/minute. The heart pumps about 70 ml neous action of several muscles. Tendons of blood at each beat. The frequency of the join the muscles to the bone, enabling the heart rate, i.e. the pulse and volume of the movement of the joints. heart increase when the oxygen demand There are mainly two opposite types and consumption increase during exercise. of muscles in the extremities: extensors Atricular fibrillation refers to the atria con- and flexors. These so-called striated vol- tracting so rapidly that the contractions untary muscles are used to move the body. turn into fibrillation, ending the pumping The smooth muscles, on the other hand, activity of the atria. Ventricular fibrillation form the walls of the intestines and veins, is the equivalent state in the ventricles. which the central nervous system and Due to the fact that the contraction of the peripheral nerves control according to the ventricles is a vital part of the circulatory needs of the body. system, the blood flow ceases during ven-

172 VII Structure and functions of the human body, examination and recording the information

Skull

Cervical spine Clavicle

Scapula Breastbone (sternum) Humerus Ribs Spinal column Elbow bone (ulna) Radius Pelvis Sacrum Wrist (carpus)

Thigh bone (femur)

Kneecap (patella)

Shinbone (tibia) Fibula Ankle (tarsus)

Figure 73. Human skeleton

Pulmonary artery Aorta Heart

Liver Lungs Spleen Kidney

Intestines

Figure 74. Circulatory system

173 VII Structure and functions of the human body, examination and recording the information

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 VII Structure and functions of the human body, 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.

4 Respiratory system 5 Digestive system

The respiratory system consists of the nose, The digestive system consists of the gas- pharynx, larynx, trachea, the bronchi trointestinal tract: the oesophagus, stom- and two lungs (Figure 77). Both lungs are ach, small intestine, large intestine, rectum surrounded by a smooth, double-layered and anus, as well as the teeth, tongue, pleural membrane (pleura). The outer salivary glands, liver and pancreas (Figure layer is connected tightly to the wall of the 78). The pancreas is situated behind the thorax, while the inner layer is connected stomach. The intestinal canal is located mainly in the abdominal cavity, which is separated from the thoracic cavity by the Clavicle Larynx diaphragm. It extends from the lower end Bronchus of the stomach to the anus. The abdominal cavity is lined by the peritoneum, which Pleura partly covers the intestines and allows Lungs them to move rather freely in the abdomi- Ribs nal cavity. The digestive system breaks down Sternum the food into a suitable form for the body, absorbs and stores nutrients, and plays a Figure 77. Respiratory system role in removing the waste products from

175 VII Structure and functions of the human body, examination and recording the information

Nasal cavity constantly. It is situated mainly in the middle and lower parts of the abdominal Epiglottis cavity, and is attached to the back of the Trachea abdominal cavity with a part of the perito- Oesophagus neum called the mesentery. The walls of the small intestine are plicate and covered with Liver villi, which increase the absorptive surface Stomach area manifold. The food is further processed in the small intestine, and absorbed into the lymphatic vessels and veins. The Large intestine small intestine ends on the right side of the Appendix Small intestine hypogastrium, where the large intestine begins. The large intestine is a tube that Rectum is over a metre long and is clearly thicker than the small intestine. It rises from the right side of the hypogastrium, turns left after the liver and continues down after Figure 78. Digestive system the epigastrium. The last part of the large intestine is called the rectum. After passing the body. through the small intestine, most of the liquid is removed from the food in the large The gastrointestinal tract intestine. The appendix, a less than 10 cm The tongue moves the food to the teeth, long atrophic part of the intestine, is situ- which cut and grind it into smaller pieces. ated at the beginning of the large intestine, The enzymes in the saliva, secreted by the to the right of the hypogastrium. salivary glands, begin to break down the nutrients. The different tastes are distin- Pancreas and liver guished by different receptors or taste buds The pancreas is an oblong gland situated on the tongue. behind the stomach, weighing about 100 The oesophagus is a 25 cm long tube grams. Pancreatic juice is secreted through through which the food passes from the the pancreatic duct to the midpart of the throat into the stomach. Its upper part is situ- duodenum. The pancreatic juice neu- ated behind the trachea, and the lower part tralizes the acid and the liquified food is located behind the heart, going through that come from the stomach. It is rich in the diaphragm to the upper part of the enzymes that break down the food into stomach. The stomach is a J-shaped sack- absorbable particles. The pancreas also like organ. It produces hydrochloric acid produces insulin, which influences the and enzymes to break down the food. The blood sugar metabolism. acidity of the stomach kills most of the mi- The liver is situated on the right crobes in the food. The food is then moved side of the epigastrium, mostly protected from the stomach into the small intestine in by the ribs, the right lung and the dia- small amounts. The amount and quality of phragm. It acts as a digestive gland and the food and the structure of the body affect secretes bile into food. The veins of the the emptying of the stomach. digestive tract go through the liver, so The adult small intestine is a tube the nutrients absorbed from the intestine which is about 3 metres long, and twisted first go through the liver and only then into innumerable folds. It moves almost continue on their way to different parts

176 VII Structure and functions of the human body, examination and recording the information

of the body. The liver also functions as a storage place for nutrients. Furthermore, with the urine. About 1 500 litres of blood the liver removes harmful substances pass through the kidneys each day. About from the blood circulation and excretes 1.5 litres of urine are produced daily, them together with bile into the intestine, which means that normally more water is through which they are then removed excreted from the body along with urine, from the body together with the faeces. than with perspiration, breathing and The bile produced by the liver is stored in faeces combined. The urine flows from the gall bladder, located under the liver at the kidneys through the renal pelvis and the end of the bile duct. During a meal, the ureters into the bladder. When the the gall bladder contracts and releases amount of urine in the bladder exceeds bile into the food matter. If a part of the 300–400 ml, the urge to urinate begins. bile crystallizes, it cannot be secreted via Emptying the bladder, i.e. urinating, takes the bile ducts into the intestine. Instead, place voluntarily by releasing the urethra the precipitate blocks the bile ducts and sphincter. In women, when the pelvis initiates a painful bilious attack. muscles weaken as a result of ageing, for example, there may be some involuntary 6 Urinary system leakage of urine. In men, on the other hand, urinating may become more difficult The urinary system consists of the kidneys, with age when prostate enlargement makes the ureters, the bladder and the urethra the urethra narrower. (Figure 79). The kidneys are situated at the back of the abdominal cavity under 7 Reproductive system the diaphragm, on both sides of the spine above the waist. They are covered by a The female reproductive system consists thin capsule and a fatty layer, which also of two ovaries, the fallopian tubes, the attenuates blows. uterus and the vagina (Figures 80 and The main function of the kidneys is 81). The ovaries produce the eggs, which to remove harmful substances from the travel through the fallopian tubes into the blood and to excrete them out of the body uterus. Between puberty and menopause, an egg is released from the ovaries once a month. If the egg is not fertilized, it is removed along with the surface layer of the endometrium of the uterus. If the egg is fertilized, it attaches to the endometrium in the uterus, where the developing foetus gets its nutrition. In this case, menstrua- Suprarenal tion also stops. The uterus opens to the glands vagina through the cervix. Normally, there Kidneys Aorta are fungal and bacterial organisms in the uterus to maintain its ability to resist infec- Ureters Inferior tions. The female external genital organs Bladder vena cava consist of the labia major and the labia minor, between which is the opening of the vagina. Directly above it is the opening of the urethra. Figure 79. Urinary system

177 VII Structure and functions of the human body, examination and recording the information

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 meninges, 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.

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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 surrounded by the white sclera. The trans- equilibrium (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 behind the iris and becomes thicker or ear External Eustachian canal auditory drum 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, examination and recording the information

Sebaceous gland skin blood vessels and perspiration. The skin also plays a role in the body’s immune Stratum defence system. Hair corneum Epidermis 12 Endocrine system

Dermis The body’s metabolism is mainly controlled by different hormones. The glands that produce them, the so-called endocrine Arrector muscle glands, are the thyroid, parathyroid and Sweat gland suprarenal gland, the testicles and the Figure 86. The skin ovaries. The thyroid gland, located in the neck below the ‘Adam’s apple’, produces the hormone thyroxin, which maintains 11 The skin the body’s metabolism. The parathyroid glands, which are connected to the thyroid The skin is composed of two layers: the gland, secrete the parathyroid hormone epidermis, or outer layer, which is covered calcitonin to maintain the calcium bal- by the cornified layer (stratum corneum), ance. The suprarenal glands are above the and dermis, or lower layer (Figure 86). The kidneys. They produce so-called ‘stress epidermis is renewed as the dermal tissue hormones’, such as cortisone and adrena- grows. The tactile nerve ends, the skin lin. The testicles and the ovaries produce blood vessels, the sebaceous and sweat the sex hormones. glands, as well as the roots of the hairs, The pituitary gland, which is located or follicles, are found in the dermis. The at the base of the brain behind the para- thickness of the skin mostly depends on nasal sinuses, controls the functions of the thickness of the stratum corneum. The the other endocrine glands, such as the skin on the eyelids is less than 1 mm thick, thyroid gland, the testicles and the ovaries. while the skin on the soles of the feet can On the other hand, it itself produces a be several millimetres thick. part of the hormones, for example, growth The skin covers and protects the hormone and the hormones affecting body. Furthermore, the skin is involved fluid balance. The brain also controls the in regulating the body temperature by functions of some organs that produce adjusting the evaporation of heat via the hormones.

180 VII Structure and functions of the human body, examination and recording the information

57 Examining the patient

General principles 1 Medical history

The examination can be divided into The patient’s medical history, anamnesis, two parts: the patient’s medical history is often the most important factor in deter- and the actual examination. The former mining the correct treatment. Inadequate includes interviewing the patient and or misleading preliminary information may clarifying what has happened, the latter lead to an incorrect assessment and treat- is the physical examination. Basic vital ment. The information may be ambigu- functions need to be investigated, and es- ous, in which case the person responsible sential vital functions, breathing and blood must come to a conclusion on how to act. circulation, must always be secured before Collecting information from a severely ill further procedures. patient can sometimes be difficult. In these Many diseases that are encountered cases, other staff members can help in giv- on board are mild and easy to diagnose, ing information. and identifying them does not require extensive interviewing or examination. 2 First symptoms However, patients with a severe illness must be interviewed and examined thor- The appearance of the first symptoms (that oughly. Finding out what has happened is, the time when the patient first noticed helps to clear up how the injury originated, symptoms related to the present illness) and often helps in assessing the type and is assessed as accurately as possible, in severity of the injury. All examinations days, or in sudden cases even in hours. and procedures must be recorded on the This is done using units of time (e.g. days, examination form, which is then attached hours), whereas vague definitions of time to the treatment log book on the ship (see (e.g. a long time, some time) should be Chapter 58 Patient information). avoided. The situation in which the symp- Follow-up of the patient’s condition is toms first appeared (e.g., when the patient crucial! Many severe illnesses can begin was strained, resting or eating) should be with mild symptoms, but the course of the clarified. Usually it is best to let the patient illness can change rapidly. All changes and explain the situation first, and then ask procedures must therefore be recorded. specific questions. The treatment plan must be checked and modified when necessary. Exact records of Preliminary information needed: the patient’s condition and the procedures • What is wrong, what happened? are also needed as a support when con- • When did the patient start feeling ill sulting a doctor through Radio Medical. – date, time? Patient examination is covered in more • First symptoms – what, where, what detail in the sections of this book dealing kind? with different illnesses and injuries. Dia- • Has the patient suffered from similar grams of the particular organs can be used symptoms in the past? in the examinations and when recording • Other symptoms/illnesses – what? information. • Has the patient been treated in hospital – when, why, where, any operations?

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• 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 instrument 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 VII Structure and functions of the human body, examination and recording the information

• Lungs: dyspnoea, coughing, secretion In the case of a non-invasive injury, of phlegm, pain in chest due to a fall, for instance, if the injury can • Heart: chest pain and possible radiating not be located, the patient’s chest must pain, shortness of breath due to strain, be examined first, then the abdomen, swelling of feet pelvis, head, spinal column and limbs. • Stomach: pain, changes in digestive The possibility of an injury to the cervical functioning, vomiting, diarrhoea, spine (neck) must be taken into account, yellowness of eyes or skin, black or particularly when examining or moving an bloody faeces unconscious, injured patient, as there is a • Urinary organs and genitals: stinging risk of paralysis! or pain when urinating, lower ab- The basic equipment needed for the dominal or lower back pain, swelling examination are: a sphygmomanometer in the groin, and possible lesions or for measuring blood pressure, a torch, discharge from the penis, normal or stethoscope, thermometer and a watch. irregular menstruation, date of previ- The more silent the examination room, the ous menstrual period, or possibility of easier it is to examine the patient. pregnancy • Skin: changes in the skin 5 Vital functions • Endocrine glands: abnormal fatigue, thirst, or loss of weight The vital functions of breathing and • Back and joints: pain and radiating heartbeat must always be checked and pain, swelling, burning sensation or secured before continuing with other stiffness in joints. examinations. A severely ill patient is interviewed quickly and briefly. If possible, 4 Examining the patient additional information is gathered during the actual examination. Any external After a detailed interview, the site of the bleeding is stopped; pressing the wound injury or the disease can often be deter- with a hand is sufficient as first aid. In the mined. This area should then be examined limbs, a tourniquet should be used only and, if necessary, the examination can be in exceptional cases, such as amputation expanded. If lung or heart disease is sus- or severe crush injury. The final bandaging pected, it might be necessary to examine should not be done until the bleeding has the abdominal area as well. been stopped. A part of the examination can be carried out during the interview. The colour of ● Before doing anything else: the skin and sclera, presence of dyspnoea, and the psychological state of the patient 1. Check to see if the patient is conscious, awake or can be waken up. can be assessed while talking. When the patient complains about 2. Make sure that the patient is breath- symptoms on one side of the body, this ing. If not, open the airways and start mouth-to-mouth respiration. side is compared to the healthy side. If the right and left sides are different, this often 3. Feel the pulse. If there is no pulse, indicates an abnormality, illness or injury. give resuscitation by pressing the chest. The differences are recorded. When suspecting an abnormality, the examiner can compare it to the same area in a healthy person, a co-worker, for example.

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6 Level of consciousness breathing. Breathing can be assessed by placing one’s own cheek or back of the The level of consciousness is assessed with hand in front of the patient’s nose and the so-called Glasgow Coma Scale (Table mouth, by listening to the breathing in 10). The principal scoring criteria are open- front of the nose, or by pressing an ear to ing the eyes, ability to speak, and motion the patient’s chest. control. The scale clarifies the situation on Breathing frequency, shallowness the spot, and also when communicating and fragmentary breathing are assessed. with Radio Medical. The breathing frequency of an adult when at rest is 12–16 times per minute. Breath- ing is normally even and effortless and ● Consult a doctor through Radio Medical if the total score is 8 or less. breathing frequency is stable. Breathing that becomes rapid is the first sign of a breathing problem. Breathing that slows 7 Breathing down is a sign of a threatening apnoea. Problems of uttering even short sentences Determine whether or not the patient is can indicate problems in breathing or pain- breathing by observing the movements ful breathing. If breathing problems have of the chest and listening to the patient’s caused a lack of oxygen, the face begins

Table 10. Grading different responses according to the Glasgow Coma Scale

Opening the eyes • eyes are open or the patient opens them spontaneously 4 • eyes are opened on request 3 • eyes are opened when provoked with pain 2 • eyes are not opened when provoked with pain 1

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 VII Structure and functions of the human body, examination and recording the information

to turn pale and ultimately blue. Blue- ness can best be seen on the lips. When listening with a stethoscope, the breathing sounds are quiet and sound similar from both lungs (Figure 87). Stronger breathing sounds, wheezing and rasping sounds are a sign of constriction caused by asthma, excretion of mucus, or inflammation. Any deviating breathing sounds, related to inhaling or exhaling, must be examined. The sounds should be similar on both sides of the chest; different sounds indicate an abnormality. For instance, an injured person might have a collapsed lung, making the breathing sounds quieter on that side than on the healthy side, or they may not be heard at all. Figure 87. Breathing sounds are checked The smell of the patient’s breath may on both sides reveal the problem. The smell of ethanol suggests the use of alcohol, while the smell rate, the regularity of the pulse must also of acetone might be caused by ketoacidosis be considered. The heart rate can change associated with an abnormally high level according to the rate of breathing, but this of blood sugar. is normal. An elevated pulse rate can be the first sign of severe bleeding or exacer- 8 Pulse bation of pain and breathing difficulties. The pulse is felt with the fingertips. The 9 Blood pressure thumb is not suitable for feeling the pulse because the examiner’s own pulse might The normal blood pressure in adults is be confused with the patient’s. The wrist 120–140 mmHg (systolic) / 70–85 mmHg artery is the primary place for feeling the (diastolic). Blood pressure is always taken pulse. If the blood pressure is low (below twice, because it can change depending 80 mmHg), and the wrist pulse can not be on the situation. If there is any doubt about felt, the pulse should be taken from the the validity of the measurement, it should carotid artery on the neck. be taken again. In the lower limbs, the pulse can be Blood pressure is usually measured felt from the groin, behind the knee, from with a sphygmomanometer, but it can the ankle behind the malleolus medialis also be roughly estimated without the or the metatarsus. The pulse in these ar- instrument. If the wrist pulse can be felt, eas should be checked especially in leg the systolic pressure is above 80 mmHg. If injuries. the wrist pulse can not be felt, but the neck The normal heart rate in adults is pulse can still be felt, the systolic pressure 50–100 beats per minute. There are many is between 60 and 80 mmHg. There is a factors affecting the resting pulse, such as definite threat of shock if the systolic pres- age, sex, physical condition, liquid bal- sure is below 90 mmHg and the pulse over ance, fever, nervousness, fear, pain and 120 beats per minute. Blood circulation in possible medication. In addition to the the myocardium and oxygen intake begins

185 VII Structure and functions of the human body, examination and recording the information

to decrease if the systolic pressure falls be- 11 Other examinations low 90 mmHg. When the systolic pressure is below 70 mmHg, blood circulation in The patient’s examination is continued the brain begins to weaken. systematically, one body part after another, until the state of all basic vital functions has been clarified and their functioning ● The situation is always serious, when secured. – systolic blood pressure is below 90 mmHg, or 12 Body temperature – diastolic blood pressure is above 130 mmHg. A change in body temperature is usually a Consult a doctor via Radio Medical! sign of a disturbance. A rising temperature can indicate inflammation or imminent heat stroke, and a falling temperature 10 Skin temperature might be a sign of hypothermia. It is usually sufficient to measure the temperature Skin temperature is assessed at the same from the armpit. In more severe cases, the time as the pulse, and information is ob- temperature and the temperature borders tained about the state of the peripheral of the limbs should also be measured. Any circulation. The skin of a feverish patient changes in temperature during follow-up is usually exceptionally warm, because should be recorded. Temperature changes the body is trying to release excess heat may indicate an underlying illness (e.g. through the skin. When injured or ill, the fluctuating temperature in malaria). patient’s body tries to protect the circulation and oxygen intake in vital organs like the 13 The skin heart and the brain by slowing down the circulation in the limbs, muscles and the The skin of the face and some parts of the skin. The skin thus turns pale and cold. limbs is visible even without the patient Especially when the patient is injured, undressing. Always check the patient’s it is very important to assess the state of • skin colour, especially yellowness his/her peripheral circulation. If the border • skin temperature and moistness. between cold and warm skin in the upper limbs changes, this might indicate a de- A rash needs to be examined more thor- crease in the amount of circulating blood. oughly; this usually requires the patient As bleeding continues, the skin temperature to undress. Redness, signs of scratching, border moves up toward the shoulder. spots, cysts, lesions and secretions from When assessing the temperature, it these are recorded. Assess whether the is important to take into account the tem- skin changes are restricted to the surface perature of the environment. If the patient layer of the skin, or whether the skin has is exposed to cold, the extremeties will thickened at the site of the rash. Chart the cool down even without bleeding. Alcohol location and extent of the rash. expands the capillaries and thus increases peripheral circulation, so the skin might 14 The face feel warm even if the patient is losing large amounts of blood. Skin changes, swelling, muscle functions (ability to make facial expressions), and loss of feeling on the face should be

186 VII Structure and functions of the human body, examination and recording the information

noted. Visible injuries, lesions or bruises • Vision. Eyesight is always checked are recorded. Check possible asymmetry separately in each eye, and the other of facial movements (e.g. one side of the eye is covered during the examination mouth does not move when speaking). with a hand, for example. If eyesight has weakened, the patient can be 15 The eyes asked to count the examiner’s fingers and to tell from what distance this can The general appearance of the eyes is no longer be done. Near vision can be examined. Are they bloodshot, or is there assessed by asking the patient to read discharge from the eyes? Check possible aloud texts with different-sized print. bleeding and eye movements. In addition, • Field of vision. The extent of the field examine the following: of vision can be examined by sitting • Colour of the sclera (whites of the opposite to the patient, about one eyes). In particular, record any yellow- meter away. With one eye covered, ness or redness of the conjunctiva. Is the patient is asked to focus the other the redness caused by distended blood eye on the examiner’s eye on the same vessels or is the reddish area even? side. The examiner moves a finger from • Symmetry of the pupils and reaction to outside the field of vision and asks the light. Normally both pupils are the same patient to tell when the finger can be size. If their size differs, note which is seen. Thus, the examiner can estimate smaller and which larger. When light is the extent of the patient’s field of vision directed to the eye, both pupils should by comparing it to his/her own. contract simultaneously. • Possible damage to the cornea, espe- 16 The ears cially penetration injuries. A magnifying glass can be used as an aid. The After the patient’s symptoms have been condition and curvature of the eye are determined, the outer ears, external audi- best observed when the light is directed tory canals and ear drums are examined diagonally. with an ear lamp (Figure 88). The painful • State of the anterior chamber and ear is compared to the healthy one. The clearness of the aqueous humour. following points need to be checked: Normally aqueous humour is clear. • Outer ear. Appearance, bruises, scrapes If it is red or cloudy, and if light pen- and swelling. Does the patient feel etrates it as if in fog, the front part of pain when the outer ear or ear lobe the eye may be infected, or there may is moved? be bleeding in the anterior chamber • External auditory canal. Condition due to an injury. of the skin, possible accumulation of • Eye movements. Eye movements are wax, and openness of the canal. Does examined if the patient complains of the patient feel pain when the outside double vision or when assessing the of the canal is pressed? severity of skull injuries. The patient • Secretion from the external auditory follows the examiner’s fingertip with canal. Bloody secretion can be caused his/her eyes to the left and right, up by an injury to the skin of the audi- and down. The examiner observes the tory canal or to the eardrum. Bleeding symmetry of eye movements and asks from the canal after a severe skull about possible double vision in dif- injury might be the only sign of a skull ferent eye positions. Record all jerky fracture. movements.

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18 Mouth and pharynx, neck

Noting the smell of the patient’s breath is important in examining the mouth and pharynx. The condition of the patient’s teeth, tongue and pharynx is checked using a torch. The tongue can be pressed down with a spatula to get a better view of the pharynx. Assess the movements of the tongue and face muscles. Also consider: • Smell of the breath. Smell of alcohol Figure 88. The state of the outer auditory canal and eardrum is examined with an or acetone. ear lamp • Condition of teeth and gums. Caries or cavities, gum abscess, loose and broken teeth (injuries), bleeding from • Eardrums. Is the eardrum visible and the gums. intact? Examine its light reflection • Movement of the tongue. If the tongue and colour. A healthy eardrum is light bends to one side when pushed out, in colour, reflects light, and is clear, this might indicate brain damage due whereas an infected eardrum is red- to a blow to the head. Bite marks on dish. When a healthy person holds his the tongue might indicate an epileptic nose and blows air into it, pressure seizure. should be felt in both ears. If pressure • Redness in the pharynx, and possible is not felt, the eustachian canal to the coating, swelling of the tonsils, lesions nasopharynx might be obstructed. A and cysts. rustling sound indicates that there is a • Lymph nodes on the neck. The lymph hole in the eardrum. Record any differ- nodes are felt under the angle of the ences between the ears. mandible on the neck. • Hearing test. Hearing can be tested, • Movement of the jaw. Tenderness in for instance, by checking whether the the jaw joint. patient can hear a clock ticking. 19 The neck 17 The nose The movability of the neck is assessed when In addition to symptoms (stuffiness, sneez- suspecting meningitis or encephalitis. ing), check the following: • Secretion from nose. Clear, watery se- Note! Be very careful when moving the cretion or bloody or purulent secretion neck of a patient who is unconscious from one or both nostrils. or complains of neck pain, numbness • Shape of the nose. Dislocation, swell- or weakness in the limbs, because these ing. symptoms may be caused by a cervical • Changes in the skin. Rash, bruises. fracture. When the neck or head is moved, • Face symptoms. Possible tenderness the fracture may worsen and cause pres- on the cheekbones and forehead when sure, damaging the spinal cord, and the pressed. patient might become paralysed.

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20 The chest • Pressing the stomach. When examining a patient with chest pain, always When examining the chest, always check check the upper abdomen as well also the blood circulation by measuring for tenderness when pressed. Record blood pressure and checking the pulse. In tender areas. addition, consider the following: • Cough. Is the patient coughing? Is the 21 The abdomen cough dry or is mucus present, is there phlegm? Is the phlegm clear and thin, Examining a patient with stomach symp- or thick and yellow? Is the phlegm toms always includes checking the blood bloody? circulation and respiratory organs. Listen • Breathing frequency. Are the chest to the lungs and measure the pulse and movements symmetrical when breath- blood pressure (see above). Pressing the ing? Is the breathing effortless or stomach is essential. Testing the urine with constricted? The patient’s voice; is the a quick ‘stix’ test is often recommended. patient too weak to speak? Women should be asked about the date • Symmetrical breathing sounds. Are of their last menstrual period and the pos- there wheezing or rasping sounds when sibility of pregnancy. Contraception meth- the patient breathes in and out? Listen ods may also be inquired, and whether a to the lungs with a stethoscope or by condom has been used throughout the pressing your ear to the chest. Listen intercourse. to the lungs from the left and the right side, and compare the sounds. Record Note the following: any differences between the sides. • Shape of the stomach. Symmetry. • Pressing the chest. Note! Press the • Scars from operations or due to other chest very gently at first, because press- causes. Stomach operations, injuries. ing may be extremely painful when, for • Tenseness of stomach muscles and ten- instance, a rib is broken. derness. Check possible radiating pain.

Figure 89. When feeling the abdomen, the lower hand is relaxed and palpates the area, the upper hand is used to move the lower hand

189 VII Structure and functions of the human body, examination and recording the information

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

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7 each time to the previous number. 24 Drawing conclusions When there is suspicion of a brain injury caused by an accident, the patient The main symptoms should be recorded can also be asked about recent familiar during the interview. The examination events. forms (at the back of the book) for each organ will help in the examination and in Psychological assessment is very limited recording information. The forms should on board, and usually requires extensive be copied and filled out during the in- testing and long-term follow-up even on terview and attached to the log book on land. Mental illnesses and psychological board. The decisions about further proce- symptoms can be clarified by checking dures are made according to the interview, the following: symptoms and examination findings. If • Physical symptoms. Dizziness, nausea, there is uncertainty regarding further pro- aches, perspiration, tremor. cedures, consult a doctor through Radio • Psychological symptoms. Problems in Medical. Examination forms can also be sleeping, nightmares, depression, apa- faxed to the doctor, who will quickly be thy, problems with memory, tiredness, able to form an opinion about the patient’s exhaustion, anxiety and fear. condition. • Changes in appearance and behaviour. Changes in movements, speech, 25 Follow-up, social interaction, mood and level of reassessment of the consciousness. situation and checking the treatment After the interview and the examination, try to find out whether the patient is suf- Even after a treatment protocol has been fering from obsessions, alienation from started, the patient’s condition must be reality, hallucinations, hearing voices or checked regularly. If the treatment is not seeing visions, disorientation or apathy, helping as expected, or there are unex- introversion, or is hyper-active or over- pected changes in the patient’s condition, talkative. the need to stop or change the treatment must be reconsidered.

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

The drugs mentioned in the book; concentrations, drug forms and treatment equipment

Index

FORMS VIII Forms VIII Forms

58 Patient information

Preliminary information (to be filled out for each patient) Date Name of patient Identity code

What is the ailment, what has happened

When did it start and how have the symptoms developed (date, time, where, what kind)

Fever, shivering, temperature fluctuation, measurements

Self-care, own attempts to treat the ailment, medication, other treatment

Similar symptoms previously, when

Other symptoms or conditions, what

Previous hospitalization, when, why, where, operations

Medication, what, why, strength, dosage, last taken

Drug allergy, what drugs, symptoms on using them: rash, itching, breathing difficulties

Alcohol, time when last used, possible current intoxication

Do any other people on board have similar symptoms

194 VIII Forms VIII Forms

Basic vital functions (to be filled out for each patient) Date Name of patient Identity code

CONSCIOUSNESS Verbal response Opens eyes Motor response Total level of (5–1 points) (4–1 points) (6–1 points) consciousness

❏ oriented (5 pts) ❏ spontaneously (4 pts) ❏ obeys commands (6 pts) Glasgow coma ❏ confused (4 pts) ❏ on command (3 pts) ❏ localizes pain (5 pts) points total: ❏ disconnected words (3 pts) ❏ to pain (2 pts) ❏ withdraws from pain (4 pts) ❏ incomprehensible sounds (2 pts) ❏ no response (1 pt) ❏ abnormal flexion (3 pts) ______points ❏ no response (1 pt) ❏ abnormal extension (2 pts) (alarming, if 8 ______points ❏ no response even to pain (1 pt) points or less) ______points ______points RESPIRATION Respiration rate (rate x/min) Respiration sounds Breath smell

❏ normal (10–20/min) ❏ normal, symmetrical ❏ no odour ❏ rapid, shallow ( /min) ❏ not audible ❏ ethanol odour ❏ rapid, deep ( /min) ❏ rasping inhalation ❏ acetone odour ❏ intermittent ❏ wheezing inhalation ❏ other odour ❏ slowed ( /min) ❏ rasping exhalation ❏ wheezing exhalation ❏ different sounds in right and left lung BLOOD CIRCULATION Pulse (rate x/min) Blood pressure ( / mmHg)

❏ undetectable ❏ normal (120–150 / 70–90) ❏ normal, regular (50–100/min) ❏ high ❏ rapid ❏ low ❏ slow ❏ irregular ❏ wrist pulse felt (blood pressure > 80 mmHg) ❏ neck pulse felt (blood pressure > 60 mmHg)

195 VIII Forms VIII Forms

Respiratory and cardiovascular diseases (Specification of symptoms)

Date Name of patient Identity code

SYMPTOMS (Always check the patient’s preliminary information, see Preliminary information form) Pain Shortness of breath Breathing sounds

❏ none ❏ none ❏ no abnormal sounds ❏ mild pain ❏ mild shortness of breath ❏ rasping inhalation ❏ strong pain, where? ❏ severe shortness of breath ❏ wheezing inhalation ❏ radiating pain, where? ❏ rasping exhalation ❏ wheezing exhalation ❏ different sounds in the left and right lung Coughing Speech Nausea

❏ none ❏ patient is able to form com- ❏ no nausea ❏ coughing plete sentences without ❏ nausea ❏ excretion of phlegm shortness of breath ❏ vomiting ❏ clear ❏ patient is unable to speak ❏ coloured ❏ blood in sputum EXAMINATION (First check consciousness, respiration and blood circulation, see Basic vital functions form) Voice Skin Chest Temperature

❏ normal ❏ normal ❏ not tender when pressed ( °C) ❏ hoarse ❏ pale, with cold sweat ❏ tenderness, where? ❏ normal (36–37.5°C) ❏ bluish ❏ fluctuating ❏ yellow Stomach ❏ grey ❏ flushed, reddish ❏ not tender when pressed ❏ signs of injury, what? ❏ tenderness, where? ❏ swelling in legs ❏ equally in both legs ❏ more in one leg If necessary, mark the location of symptoms and ailments on the pictures below

196 VIII Forms VIII Forms

Musculoskeletal diseases and disorders (Specification of symptoms)

Date Name of patient Identity code

SYMPTOMS (Always check patient’s preliminary information, see Preliminary information form)

Pain and swelling Worsens the pain Patient is capable of

❏ painless ❏ touching, pressing ❏ normal walking ❏ morning stiffness ❏ cold, draft, humidity ❏ walking on toes and heels ❏ constant pain ❏ warmth, sauna ❏ straightening knees ❏ radiating pain, where? ❏ movement, which? ❏ squatting down and getting up without support ❏ tender varicose veins ❏ bending the back forward and to the sides ❏ swelling in legs ❏ making a fist and opening it ❏ tender calves ❏ bending and straightening arms ❏ raising arms above shoulders EXAMINATION (First check consciousness, respiration and blood circulation, see Basic vital functions form) General check-up Skin and sense of touch Examination of joints Muscular injury

❏ 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 VIII Forms

Abdominal diseases and gynaecological ailments (Specification of symptoms)

Date Name of patient Identity code

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

❏ no pressure tenderness ❏ no pain when ❏ no lumps ❏ normal ❏ abdominal tenderness abdomen pressed ❏ lump in the abdomen ❏ increased (where?) ❏ pain increases ❏ lumps in the flexure of ❏ absent ❏ soft abdominal wall when abdomen the groin ❏ boardlike tense pressed ❏ lump in the groin, goes abdominal wall ❏ tenderness in away when lying down the back on percussion Body temperature (degrees) Urine tests

❏ normal (36–37.5°C) ❏ nothing specific ❏ fluctuating ❏ protein in urine ❏ glucose in urine ❏ blood in urine ❏ inflammatory cells in urine If necessary, mark the location of symptoms and ailments on the figure below

198 VIII Forms VIII Forms

Conditions of ear, nose and throat (Specification of symptoms)

Date Name of patient Identity code

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

❏ nothing specific ❏ not visible ❏ nothing specific ❏ nothing specific ❏ pain when flap in ❏ light, clear ❏ clear watery discharge ❏ reddish front of ear hole is ❏ reddish, dull ❏ thick, yellow discharge ❏ swollen pressed ❏ hole in eardrum ❏ nosebleed ❏ coated (mouth/ throat) ❏ ear wax ❏ ‘nose blow’ felt in ear ❏ blisters ❏ discharge from ear ❏ ‘nose blow’ hisses ❏ wound passage in ear ❏ cavities in teeth ❏ bleeding gums Neck Body temperature (°C)

❏ nothing specific or abnormal ❏ normal (36–37.5°C) ❏ non-tender lumps in neck ❏ fluctuating ❏ tender lumps in neck, diameter: If necessary, mark the location of symptoms and ailments on the pictures below

199 VIII Forms VIII Forms

Eye diseases, nervous system diseases, vertigo, headache (Specification of symptoms)

Date Name of patient Identity code

SYMPTOMS (Always check patient’s preliminary information, see Preliminary information form) Eyes Nervous system, vertigo, sense of touch Headache

❏ nothing specific ❏ nothing special ❏ no headache ❏ pain ❏ rotation vertigo ❏ pain in neck or back of head ❏ burning ❏ positional vertigo ❏ unilateral pain ❏ itching ❏ nausea, vomiting ❏ pressing pain ❏ discharge ❏ stinging sensation in limbs ❏ stabbing pain ❏ sensitive to light ❏ numbness of skin ❏ stiff neck ❏ pain when moving ❏ weakness or stiffness of limbs eyes ❏ cramps ❏ blurred vision ❏ double vision EXAMINATION (First check consciousness, respiration and blood circulation, see Basic vital functions form) Conjunctiva Eye movement Pupils Nervous system

❏ no redness ❏ normal, patient able to ❏ contract in light ❏ nothing specific ❏ bloodshot follow object, no double ❏ small ❏ unable to whistle ❏ redness vision ❏ large ❏ stiff neck ❏ twitching ❏ no contraction in light ❏ neck and shoulder muscles feel ❏ double vision ❏ unequal in size, which one hard is larger? ❏ unable to walk on toes ❏ blood in anterior chamber ❏ unable to walk on heels ❏ reduced sense of touch in cheeks ❏ reduced sense of touch in limbs ❏ numbness in anal region If necessary, mark the location of symptoms and ailments on the pictures below

200 VIII Forms VIII Forms

Urinary and sexually transmitted diseases (Specification of symptoms)

Date Name of patient Identity number

SYMPTOMS (always check the patient’s preliminary information, see Preliminary information form) Urinating Leaking from the urethra Skin symptoms Other symptoms

❏ no specific symptoms ❏ no leaking ❏ no skin symptoms ❏ none ❏ stinging sensation when urinating ❏ clear substance leaking ❏ itching in genitals ❏ tender testicles ❏ frequent need to urinate from urethra ❏ ulcer on skin ❏ pain in back ❏ amount of urine per urination ❏ cloudy substance leaking ❏ cysts on skin ❏ pain in groin decreased from urethra ❏ red spots or rash ❏ weak flow of urine on genitals ❏ difficulties in urinating

EXAMINATION (First examine consciousness, respiration and blood circulation, see Basic vital functions form) Pain Tenderness of the stomach Abdominal wall Lumps

❏ none ❏ no tenderness on palpation ❏ soft ❏ lumps can be felt ❏ pain increases when ❏ some tenderness on ❏ board-like ❏ lump in stomach stomach pressed palpation, where? ❏ lump/s in groin, not tender ❏ tenderness in kidney area ❏ top right Intestinal sounds ❏ tender lump/s in groin on percussion ❏ top left ❏ normal ❏ swelling in groin, which ❏ navel area ❏ increased disappears when lying down ❏ bottom right ❏ absent ❏ bottom left Genitals Temperature Urine Sexual contacts

❏ no specific symptoms ( °C) ❏ no specific symptoms ❏ time of contact? ❏ enlarged testicle ❏ normal (36– ❏ blood-red urine ❏ tender testicle 37.5°C) ❏ coffee-coloured urine ❏ clear substance leaking from urethra ❏ fluctuating ❏ country? ❏ cloudy substance leaking from urethra Test strip examination ❏ ulcer on skin ❏ protein in urine ❏ cysts on skin ❏ sugar in urine ❏ red spots or rash on genitals ❏ blood in urine ❏ inflammatory cells in urine If necessary, mark the location of symptoms and ailments on the pictures below

201 VIII Forms VIII Forms

Psychological symptoms (Specification of symptoms)

Date Name of patient Identity code

SYMPTOMS (Always check patient’s preliminary information, see Preliminary information form) Physical symptoms Psychological symptoms

❏ no physical symptoms ❏ nothing specific ❏ vertigo ❏ sleeping difficulties ❏ nausea ❏ nightmares ❏ ache, where? ❏ depression, apathy ❏ sweating ❏ memory problems ❏ tremor ❏ tiredness, exhaustion ❏ anxiety, fears, phobias EXAMINATION / INTERVIEW (First check consciousness, respiration and blood circulation, see Basic vital functions form) Changes in patient Patient’s mood and way of thinking Examination of other systems

❏ not detected ❏ no abnormality Examine the state of different systems and ❏ appearance ❏ obsessions organs on the basis of the symptoms that the ❏ behaviour ❏ estrangement from reality patient has complained about ❏ movement ❏ hallucinations (hearing voices or having (see other examination forms) ❏ speech visions) ❏ social intercourse ❏ confusion ❏ mood ❏ apathy; is patient withdrawn? ❏ level of consciousness ❏ hyperactivity, excessive talkativeness If necessary, mark the location of symptoms and ailments on the figures below

202 VIII Forms VIII Forms

Skin diseases (Specification of symptoms)

Date Name of patient Identity code

SYMPTOMS (always check the patient’s preliminary information, see Preliminary information form) Skin symptoms (where?) General symptoms Symptoms in other organs

❏ skin appears healthy ❏ feeling well see relevant examination forms ❏ reddish ❏ feeling unwell ❏ itching ❏ fever ❏ ulcerations ❏ other symptoms (see relevant examination forms) ❏ scaling ❏ seeping ❏ swelling ❏ pain EXAMINATION (First check consciousness, respiration and blood circulation, see Basic vital functions form) Skin surface Depth of the rash General condition Examination of other organs:

❏ nothing specific ❏ superficial ❏ normal Check the condition of the dif- ❏ reddish ❏ deep ❏ feeling ill, appears ill ferent organs on the basis of the ❏ scratch marks symptoms reported by the patient ❏ elevated spots Extent of the rash Body temperature (degrees) ❏ blisters ❏ ulcers ❏ limited to a certain ❏ normal (36–37.5°C) ❏ scaling of the skin and scalp skin area ❏ fluctuating ❏ seeping skin, pus ❏ covers the whole skin ❏ no rash on the head area If necessary, mark the location of symptoms and ailments on the figures below

203 VIII Forms VIII Forms

59 Treatment on board

(Record dates and times!)

Name of patient Identity code

Radio Medical consultation: no/yes, when: date

Place of consultation:

Name of doctor:

Instructions given:

Medical treatment (take note of possible allergies!)

Name of drug and date of prescription Effectiveness of drug Dosage Duration of medical treatment

Other treatment

Patient unable to work: no/yes

Patient ordered bed rest: no/yes

Further measures

Patient evacuated from ship: no/yes, when, how and where

Patient sent to doctor in port: no/yes, when and where

Patient requested to consult a doctor on return home: no/yes, reason for referral, urgency

Date, signature of nurse, clarification of name

204 VIII Forms VIII Forms

60 Patient follow-up form

Temperature Pulse 12.30 14.00 15.45 o’clock o’clock o’clock o’clock o’clock o’clock o’clock o’clock o’clock Blood pressure p.m. p.m. p.m. 200 42

180

41 V 160 V 40

140 V 39 120 38

100 o x 37 x Λ o o

80 Λ Λ 36 x 60 35 Rate of respiration 20

34 15 ■

10 ■ ■ 5

Notes: Blood pressure V (Systolic) Λ (Diastolic); Pulse x; Temperature (°C) o; Respiration rate ■

205 The drugs mentioned in the book; concentrations, drug forms and treatment equipment

The drugs mentioned in the book; concentrations, drug forms and treatment equipment

1. DRUGS FOR CARDIOVASCULAR DISEASES A Glyceryl nitrate 0.5 mg tablet B Acetylsalicylic acid 100 mg tablet C Furosemide 40 mg tablet 10 mg/ml injection D Metoprolol tartrate 25 mg tablet 2. DRUGS FOR DIGESTIVE DISEASES A Hyperacidity drugs chewing tablet B Omeprazole 20 mg tablet C Metoclopramide hydrochloride 10 mg tablet 20 mg suppository 5 mg/ml injection D Bisacodyl 5 mg tablet E Sodium citrate mini-enema F Loperamide hydrochloride 2 mg capsule G Prednisolone cinchocaine hydrochloride suppository cream 3. ANTIPYRETICS AND PAINKILLERS A Paracetamol 500 mg tablet B Diclofenac 50 mg tablet 100 mg suppository 25 mg/ml injection C Morphine 20 mg/ml injection 4. DRUGS THAT AFFECT THE NERVOUS SYSTEM A Diazepam 5 mg tablet 5 mg/ml injection B Dixyrazine 25 mg tablet C Cyclizine hydrochloride 50 mg tablet 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 6. DRUGS FOR RESPIRATORY AND LUNG DISEASES A Salbutamol 2 mg tablet 0.2 mg inhalation spray B Cough suppressant tablet syrup C Bromhexine 8 mg tablet D Xylometazoline nasal solution 7. ANTI-INFLAMMATORY DRUGS, ANTIBIOTIC DRUGS A Phenoxymethylpenicillin 660 mg tablets B Doxycycline 150 mg tablets C Ciprofloxacin 250 mg tablets D Cefuroxime 750 mg/3 ml injection E Cefadroxil 500 mg tablets

206 The drugs mentioned in the book; concentrations, drug forms and treatment equipment

8. DRUGS FOR RESUSCITATION, AND CASES OF POISONING A Adrenaline 1 mg/ml injection B Insulin (short-acting) 100 IU/ml injection C Glucagon 1 mg/ml injection D Medicinal charcoal 50 g granules E Basic infusion solution solution 9. SUBSTANCES FOR SKIN AND WOUND CARE A Polyvidone iodine solution 10% solution B Chlorhexidine hydrocortisone cream C Miconazole emulsion cream powder D Neomycin-bacitracin ointment E Vaseline dressings dressings F Hydrocortisone 1% emulsion cream G Methylrosanilinium 0.5% solution H Permethrin 5% cream I Malathion 1% shampoo 10. OPHTHALMOLOGIC DRUGS A Tetrahydrozoline hydrochloride 0.5 mg/ml eye drops B Chloramphenicol 5 mg/ml eye drops 1mg/ml eye ointment C Oxybuprocain hydrochloride 4 mg/ml eye drops D Pilocarpine hydrochloride 20 mg/ml eye drops 11. OTORHINOLARYNGOLOGIC DRUGS A Flumethasone-clioquinol 0.2 mg + 10 mg/ml ear drops B Pain-relieving ear drops ear drops C Earwax removal drops drops 12. MOUTH AND LARYNX DISINFECTANTS A Mouthwash solution B Larynx disinfectant tablets 13. LOCAL ANAESTHETICS A Lidocaine 1% injection B Lidocaine 2% gel 14. DENTAL CARE PRODUCT A Dental cement

15. TOPICAL GYNAECOLOGICAL MEDICATION A Miconazole 400 mg vagitory B Methylergometrine maleate 0.125 mg tablet 16. RINSING AND CLEANSING SOLUTIONS A Chlorhexidine acetate 0.5 mg/ml solution B Disinfection solution for instruments and general use solution C Saline solution (0.9% NaCl®) solution 17. DIAGNOSTIC PRODUCTS A Strip for indicating sugar, proteins, blood, pH and leukocytes in urine B Strip for determining sugar level in blood

207 The drugs mentioned in the book; concentrations, drug forms and treatment equipment

Treatment equipment

1. Resuscitation and intubation equipment Batteries for laryngoscope Binding tape Disposable face mask First aid guide book Hand-operated resuscitation device + face mask In-leader for intubation tube Intubation tube Laryngoscope Magill’s clamp, for adults Middle piece for intubation tube Mucus catheter Oxygen mask + oxygen bottle + spare oxygen bottle Pharyngeal tube Protective gloves Resuscitation mask for mouth-to-mouth respiration Suction device and suction catheter Thermal sheet 10 ml syringe

2. Dressing and suture materials Adhesive plaster Adhesive support bandage Cover bandage Elastic bandage Elastic fixative bandage Eye shields First aid bandage Medicated dressing Sterile gauze Stitch cutter Suture needle and thread Suture strips Triangular bandage Tubular gauze Tubular net Wound bandage Wound wipe 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 The drugs mentioned in the book; concentrations, drug forms and treatment equipment

4. Examination and follow-up equipment Cotton swab Ear lamp Ear lamp funnel Examination gloves Kidney bowl Magnifying glass Protective bed cover Protective gloves Sphygmomanometer Stethoscope Thermometer Tourniquet Wooden spatula 5. Injection, perfusion, puncture and catheterization equipment Aural syringe Catheterization kit Hypodermic syringe 1 ml, 2 ml, 5 ml Infusion apparatus Infusion apparatus bottle holder Injection needle Skin cleansing pads Urine catheter Vein cannula 6. Splinting and supporting equipment Neck support Splints Stretcher, suitable for transporting the patient in stairs and ladders 7. General treatment equipment Bedpan Condoms Ice bag – warm bag Paper bag Sanitary napkin

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

ear wax in the external ear 63 gonorrhoea 95 ear; itching 63 groin; rash 104 ear; structure and functions 179, 187 gums, infected 66 ecstasy 115 gynaecological disorders 84 ectopic pregnancy 86 haemorrhoids 78 eczema 99 hallucinogens 117 eczema, fungal 101 hand hygiene 156 electric shock 40 hashish 115 emergency first aid 8 headache 52 endocrine system 180 heart attack 67 epididymitis 92 heart rhythm; disorders 68 epidural bleeding 23 heart; structure and functions 172 erysipelas 101 heat exhaustion 39 ethylene glycol 49 heat spasm 39 evacuation 155 heat stroke 39 examining the patient 181 heat-induced illness 38 extrauterine pregnancy 86 hepatitis 120 eye burns 27 Hepatitis A 120 eye diseases 60 hernia incarceration 83 eye drops 137 heroin 115 eye injury 24 herpes 86 eye ointment 138 high blood pressure 68 eye, removing a foreign object from 24 high blood sugar 123 eye; bleeding 26 HIV 96 eye; corrosion wound 27 hoarseness of the voice 62 eye; penetration wound 27 human body; structure and functions 172 eye; radiation injury 26 hydrochloric acid 49 eye; structure and functions 179, 187 hydrofluoric acid 50 eyelid injuries 26 hydrogen cyanide 50 face; structure and functions 186 hyperglycaemia 123 fainting 58 hypertension 68 fainting due to heat 39 hypoglycaemia 122 fallopian tubes; infection/inflammation 86 hypotension 69 fever 75 hypothermia 41 fluid balance 80 ileus 83 folliculitis 101 impetigo 99 food poisoning 77 infection; see respective organ or body part foreskin, tight 92 infectious diseases 118 fracture; see respective body part inflammation; see respective organ or body part frost injury 38 influenza 73 fungal infection of the feet/toes 101 inguinal flexure; rash 104 gall bladder; inflammation 82 injections of medications 135 gall stones; attack 82 inoculations 161 gastric ulcer 83 instruments; cleaning and disinfection 156 gastrointestinal tract; structure and intestinal obstruction 83 functions 176 intraocular pressure; rise 61 Glasgow Coma Scale 184 intravenous (IV) infusion therapy 139

211 Index

intubation 127 panic disorder 110 iris; infection 61 paraphimosis 92 jaundice 120 patient information, recording 194 joint injuries 33 patient placed on his/her side 10 joint pain 107 patient; positioning 153 khat 115 personality disorder 111 large intestine; inflammation 84 pharyngeal tube 126 liver; rupture 30 pharynx; structure and functions 188 liver; structure and functions 176 phenol 50 low blood pressure 69 phlebitis 69 low blood sugar 122 pleural sack; inflammation 71 lumbago 108 pneumonia 71, 73 lymphatic system; structure and functions 175 pneumothorax 71 lymphatic tissue; structure and functions 175 poisoning 45 malaria 119 positioning a patient 153 mania 112 post-traumatic stress disorder 111 marijuana 115 priority classification 19 maxillary sinusitis 64 prostatitis 92 medicines 133 protective gloves 106 mental disorder 109 protective ointments 106 methanol 49 psychosis 112 migraine 53 pulmonary embolism 69 miscarriage 87 pulse 10, 185 moles 105 Radio Medical 166 morphine 115 rash 98 motion sickness 55 rash in the inguinal flexure (groin) 104 mouth problems 65 reproductive system; structure and mouth; structure and functions 188 functions 177 muscle injuries 35 respiration 184 muscle pain 107 respiratory arrest 9 muscles; structure and functions 172 respiratory diseases 72 nausea 75 respiratory system; structure and neck and shoulder pain 107 functions 175 neck; structure and functions 188 resuscitation 9 nervous system; structure and functions 178 resuscitation drugs 13 nevus 105 rib, fractured 32 nitric acid 49 ruptured liver 30 nose; structure and functions 188 ruptured spleen 29 nosebleed 64 salmonella 77 obstetrics 84 SARS 74 opiates 115 scabies 104 opium 115 sciatica 108 orchitis 92 sea sickness 55 ovaries; infection/inflammation 81 seizures 59 pain; see respective organ or body part self-protection 160 pancreas; inflammation 81 Severe acute respiratory syndrome (SARS) 74 pancreas; structure and functions 176 sexually transmitted diseases (STD) 93

212 Index

shigella 77 testicles; inflammation 92 shock 16 thermoregulation of organs 41 shoulder pain 109 throat, sore 62 sinus pain 64 tooth, broken 65 skeletal system; structure and functions 172 tooth, detached 65 skin neoplasm 105 toothache 65 skin temperature 186 triage 19 skin, dry 97 tuberculosis 74 skin, itchy 98 unconsciousness 56 skin; structure and functions 180, 186 urinary retention 92, 152 skull fracture 23 urinary stone 91 skull injuries 22 urinary system; structure and functions 177 spinal fracture 32 urinary tract infection 91 spleen; rupture 29 urolith 91 sprain, strain 33 uterus; infection 86 STD 93 vaccinations 161 stomach 189 venereal diseases 93 stomach ache 79 venous thrombosis 69 stopping bleeding 15, 35, 145 vertigo 55 stye 60 voice; hoarseness 62 subdural bleeding 23 vomiting 75 sulphuric acid 49 wound; anaesthetizing 148 sunstroke 38 wound; closing with stitches, suturing 148 superficial venous inflammation 69 wounds 144 suturing a wound 148 yeast infection 85 syphilis 95 yellow fever 121 teeth, problems with 65 yersinia 78 tendinitis 109 tension headache 53

213