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1 Model Course 1.14 Medical First Aid2 First published as Medical Emergency - First Aid in 1990 by the INTERNATIONAL MAR...
Model Course 1.14
Medical First Aid
First published as Medical Emergency - First Aid in 1990 by the INTERNATIONAL MARITIME ORGANIZATION 4 Albert Embankment, London SE1 7SR
Revised edition 2000
Printed in the United Kingdom by CPC The Printers, Portsmouth
2 4 6 8 10 9 7 5 3 ISBN 92-801-6118-0
ACKNOWLEDGEMENTS IMO wishes to express its sincere appreciation to the International Labour Organization and the World Health Organization for their assistance and co-operation in the production of this course. In particular, IMO wishes to thank the World Health Organization for permission to utilize relevant parts of the International Medical Guide for Ships as the course compendium.
Copyright © WHO 1988, IMO 2001
All rights reserved.
No part of this publication may, for sales purposes, be produced, stored in a retrieval system or transmitted in any form or by any means, electronic, electrostatic, magnetic tape, mechanical, photocopying or otherwise, without prior permission in writing from the International Maritime Organization.
Course Outline and Timetable
Attachment: Guidance on the implementation of model courses
Foreword Since its inception the International Maritime Organization has recognized the importance of human resources to the development of the maritime industry and has given the highest priority to assisting developing countries in enhancing their maritime training capabilities through the provision or improvement of maritime training facilities at national and regional levels. IMO has also responded to the needs of developing countries for postgraduate training lor senior personnel in administration, ports, shipping companies and maritime training institutes by establishing the World Maritime University in Malmo, Sweden, in 1983. Following the earlier adoption of the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers, 1978, a number of IMO Member Governments had suggested that IMO should develop model training courses to assist in the implementation of the Convention and in achieving a more rapid transfer of information and skills regarding new developments in maritime technology. IMO training advisers and consultants also subsequently determined from their visits to training establishments in developing countries IIaIthe provision of model courses could help instructors improve the quality of their existing courses and enhance their effectiveness in meeting the requirements of the Convention and implementing the associated Conference and IMO Assembly resolutions. In addition, it was appreciated that a comprehensive set of short model courses in various fields of maritime training would supplement the instruction provided by maritime academies and allow administrators and technical specialists already employed in maritime administrations, ports and shipping companies to improve their knowledge and skills in certain specialized fields. IMO has therefore developed the current series of model courses in response to these generally identified needs and with the generous assistance of Norway. These model courses may be used by any training institution and the Organization is prepared to assist developing countries in implementing any course when the requisite financing is available. W. A. O'NEIL Secretary-General
Purpose of the model courses
The purpose of the IMO model courses is to assist maritime training institutes and their leaching staff in organizing and introducing new training courses, or in enhancing, updating or supplementing existing training material where the quality and effectiveness of the training murses may thereby be improved.
It is not the intention of the model course programme to present instructors with a rigid 'eaching package" which they are expected to "follow blindly". Nor is it the intention to substitute audiovisual or "programmed" material for the instructor's presence. As in all training endeavours, the knowledge, skills and dedication of the instructor are the key components in the transfer of knowledge and skills to those being trained through IMO model course material. Because educational systems and the cultural backgrounds of trainees in maritime subjects considerably from country to country, the model course material has been designed to identify the basic entry requirements and trainee target group for each course in universally applicable terms, and the skill necessary to meet the technical intent of IMO conventions and related recommendations . V86'/
Use of the model course
To use the model course the instructor should review the course plan and detailed syllabus, taking into account the information provided under the entry standards specified in the course framework. The actual level of knowledge and skills and prior technical education of the trainees should be kept in mind during this review, and any areas within the detailed syllabus which may cause difficulties because of differences between the actual trainee entry level and that assumed by the course designer should be identified. To compensate for such differences, the instructor is expected to delete from the course, or reduce the emphasis on, items dealing with knowledge or skills already attained by the trainees. He should also identify any academic knowledge, skills or technical training which they may not have acquired. By analysing the detailed syllabus and the academic knowledge required to allow training in the technical area to proceed, the instructor can design an appropriate pre-entry course or, alternatively, insert the elements of academic knowledge required to support the technical training elements concerned at appropriate points within the technical course. Adjustment of the course objectives, scope and content may also be necessary if in your maritime industry the trainees completing the course are to undertake duties which differ from the course objectives specified in the model course. Within the course plan the course designers have indicated their assessment of the time which should be allotted to each learning area. However, it must be appreciated that these allocations are arbitrary and assume that the trainees have fully met all the entry requirements of the course. The instructor should therefore review these assessments and may need to reallocate the time required to achieve each specific learning objective.
MEDICAL FIRST AID
Having adjusted the course content to suit the trainee intake and any revision of the course objectives, the instructor should draw up lesson plans based on the detailed syllabus. The detailed syllabus contains specific references to the textbooks or teaching material proposed to be used in the course. An example of a lesson plan is shown in the instructor manual on page 24. Where no adjustment has been found necessary in the learning objectives of the detailed syllabus, the lesson plans may simply consist of the detailed syllabus with keywords or other reminders added to assist the instructor in making his presentation of the material.
The presentation of concepts and methodologies must be repeated in various ways until the instructor is satisfied, by testing and evaluating the trainee's performance and achievements, that the trainee has attained each specific learning objective or training outcome. The syllabus is laid out in learning objective format and each objective specifies a required performance or, what the trainee must be able to do as the learning or training outcome. Taken as a whole, these objectives aim to meet the knowledge, understanding and proficiency specified in the appropriate tables of the STCW Code.
For the course to run smoothly and to be effective, considerable attention must be paid to the availability and use of:
• • • • •
properly qualified instructors support staff rooms and other spaces equipment textbooks, technical papers other reference material.
Thorough preparation is the key to successful implementation of the course. IMO has produced "Guidance on the implementation of IMO model courses", which deals with this aspect in greater detail and is included as an attachment to this course.
Training and the STCW 1995 Convention
The standards of competence that have to be met by seafarers are defined in Part A of the STCW Code in the Standards of Training, Certification and Watchkeeping for Seafarers Convention, as amended in 1995. This IMO model course has been revised and updated to cover the competences in STCW 1995. It sets out the education and training to achieve those standards set out in Chapter VI Table A-VI/4-1. Part A provides the framework for the course with its aims and objectives and notes on the suggested teaching facilities and equipment. A list of useful teaching aids, IMO references and textbooks is also included.
Part B provides an outline of lectures, demonstrations and exercises for the course. A suggested timetable is included but from the teaching and learning point of view, it is more important that the trainee achieves the minimum standard of competence defined in the STCW Code than that a strict timetable is followed. Depending on their experience and ability, some students will naturally take longer to become proficient in some topics than in others. Also included in this section are guidance notes and additional explanations. A separate IMO model course addresses Assessment of Competence. This course explains the use of various methods for demonstrating competence and criteria for evaluating competence as tabulated in the STCW Code. Part e gives the Detailed Teaching Syllabus. This is based on the theoretical and practical knowledge specified in the STCW Code. It is written as a series of learning objectives, in other words what the trainee is expected to be able to do as a result of the teaching and training. Each of the objectives is expanded to define a required performance of knowledge, understanding and proficiency. IMO references, textbook references and suggested teaching aids are included to assist the teacher in designing lessons. The new training requirements for these competences are addressed in the appropriate parts of the detailed teaching syllabus. The Convention defines the minimum standards to be maintained in Part A of the STCW Code. Mandatory provisions concerning Training and Assessment are given in Section A-I/G of the STCW Code. These provisions cover: qualification of instructors; supervisors as assessors; in-service training; assessment of competence; and training and assessment within an institution. The corresponding Part B of the STeW Code contains non-mandatory guidance on training and assessment. As previously mentioned a separate model course addresses Assessment of Competence and use of the criteria for evaluating competence tabulated in the STCW Code.
The Document for Guidance recommends that seafarers who have completed the more advanced medical training and such other seafarers as may be required by a national administration should undergo refresher courses to maintain and update their knowledge at approximately five-year intervals.
Such refresher training should cover the principal elements of medical first aid, including lifesaving measures, and should also encompass relevant recent developments in medical care and diagnosis.
Medical Care Required for Masters and Chief Mates
In general the competence required of those who provide the medical care on board exceeds that required of the master and chief mate under Regulation 11/2. The competence required in table 11/2is limited to organizing and managing the provision of medical care on board. Masters and chief mates who themselves provide the medical care on board must therefore meet the higher standard in Table VI/4-2.
MEDICAL FIRST AID
Responsibilities of Administrations
Administrations should ensure that training courses delivered by colleges and academies are such as to ensure officers completing training do meet the standards of competence required by STCW Regulation VI/4.
The information contained in this document has been validated by the Sub-Committee on Standards of Training and Watch keeping for use by technical advisors, consultants and experts for the training and certification of seafarers so that the minimum standards implemented may be as uniform as possible. Validation in the context of this document means that the Sub-Committee has found no grounds to object to its content. The Sub-Committee has not granted its approval to the documents, as it considers that this work must not be regarded as an official interpretation of the Convention. In reaching a decision in this regard, the Sub-Committee was guided by the advice of a Validation Group comprised of representatives designated by ILO and IMO.
Objective 1his syllabus covers the requirements of the 1995 STCW Convention Chapter VI, Section AW4, Table A-VI/4-1. On meeting the minimum standard of competence in medical first aid, a trainee will be competent to apply immediate first aid in the event of accident or illness on board.
Entry standards For admission to the course seafarers should have completed IMO Model Course No. 1.13, Elementary First Aid or attained a similar standard in elementary first aid.
Course certificate On successful completion of the course and demonstration of competence, a document may be issued certifying that the holder has met the standard of competence specified in Table AVV4-1 of STCW 1995. A certificate may be issued only by centres approved by the Administration.
Course intake limitations The maximum number of trainees attending each session will depend on the availability of instructors, equipment and facilities available for conducting the training. It should not exceed six trainees per instructor.
Staff requirements The course should preferably be under the control of a qualified medical practitioner assisted by other appropriately trained staff.
Training facilities and equipment Ordinary classroom facilities and an overhead projector are required for the lectures. When making use of audiovisual material such as videos or slides, make sure the appropriate equipment is available. Smaller rooms for practical instruction, demonstration and application should be available. The following equipment should be available: ship's medical chest with contents (no drugs) various splints, braces, etc dressings, bandages life-size dummy for practical resuscitation training resuscitator
MEDICAL FIRST AID
Teaching aids (A) A1
Instructor Manual (Part D of the course)
Videos: First Aid Series: V1 A Matter of Life and Death (Code No. 564) V2 Dealing with Shock (Code No. 565) V3 Bone and Muscle Injuries (Code No. 566) V4 Dealing with the Unexpected (Code No. 567) V5 Oxygen for the Brain - Maintaining the Supply (Code No. 568) V6 After Care of Shock (Code No. 569) V7 After Care of Fractures, Dislocations and Sprains (Code No. 570) V8 Moving Casualties and Dealing with Other Problems (Code No. 571) V9 Cold Water Casualty (Code No. 527) V10 Man Overboard (Code No. 644) Available from:
Videotel Marine International Limited 84 Newman Street London W1 P 3LD, UK Tel: +44 (0)20 72991800 Fax: +44 (0)20 7299 1818 e-mail: [email protected]
All reference material necesary for the course has been incorporated Compendium (T1)
in the Course
IMO and other references (R) R1 R2 R3 R4 R5 R6
The International Convention on Standards of Training, Certification and Watchkeeping for Seafarers, 1995 (STCW 1995), 1998 edition (IMO Sales No. 938E) Medical Section (pages 111 to 148) of International Code of Signals, 1987 edition (IMO Sales No. 994E) Assembly Resolution A.438(XI) - Training and qualification of persons in charge of medical care aboard ship IMO/ILO Document for Guidance, 1985 (IMO Sales No. 935E) ILO/IMO/WHO International Medical Guide for Ships (IMGS), 2nd edition, (Geneva, World Health Organization, 1988) (ISBN 924154231 4) Medical First Aid Guide for use in Accidents Involving Dangerous Goods (MFAG) (IMO Sales No. 251 E)
Details of distributors of IMO publications that maintain a permanent stock of all IMO publications may be found on the IMO website at http://www.imo.org
Textbooks (T) T1
A Course Compendium is provided for use as a textbook. This contains selected extracts from ILO/IMO/WHO International Medical Guide for Ships (Ref R5)
PART B: COURSE OUTLINE
Part B: Course Outline and Timetable Lectures As far as possible, lectures should be presented within a familiar context and should make use of practical examples. They should be well illustrated with diagrams, photographs and charts where appropriate, and be related to matter learned during seagoing time. An effective manner of presentation is to develop a technique of giving information and then reinforcing it. For example, first tell the trainees briefly what you are going to present to them; then cover the topic in detail; and, finally, summarize what you have told them. The use of an overhead projector and the distribution of copies of the transparencies as trainees' handouts contribute to the learning process.
Course Outline The tables that follow list the competencies and areas of knowledge, understanding and proficiency, together with the estimated total hours required for lectures and practical exercises. Teaching staff should note that timings are suggestions only and should be adapted to suit individual groups of trainees depending on their experience, ability, equipment and staff available for training.
MEDICAL FIRST AID
Course Outline Competence:
Apply immediate first aid in the event of accident or illness on board
Course Outline Knowledge,
Approximate time (Hours) and proficiency
demonstrations practical work
Body Structure and Function
Toxicological Hazards aboard Ship
Examination of Patient
Burns, Scalds and Effects of Heat and Cold
Fractures, Dislocations and Muscular Injuries
Medical Care of Rescued Persons, including Distress, Hypothermia and Cold Exposure
Radio Medical Advice
Cardiac Arrest, Drowning and Asphyxia
Review and Assessment
Note: Teaching staff should note that outlines are suggestions only as regards sequence and length of time allocated to each objective. These factors may be adapted by lecturers to suit individual groups of trainees depending on their experience, ability, equipment and staff available for training.
MEDICAL FIRST AID
Part C: Detailed Teaching Syllabus Introduction The detailed teaching syllabus has been written in learning objective format in which the objective describes what the trainee must do to demonstrate that knowledge has been transferred. All objectives are understood to be prefixed by the words, "The expected learning outcome is that the trainee ................... " In order to assist the instructor, references are shown against the learning objectives to indicate IMO references and publications, textbooks, additional technical material and teaching aids, which the instructor may wish to use when preparing course material. The material listed in the course framework has been used to structure the detailed teaching syllabus; in particular, Teaching aids (indicated by A), IMO references (indicated by R), and Textbooks (indicated by T) will provide valuable information to instructors. The abbreviations used are: Ch. Pa. p, pp Pt. Reg.
chapter paragraph page, pages part regulation
The following are examples of the use of references: "R4 - Sect.17, Ap. 2" refers to appendix 2 of Section 17 of IMO/ILO Document for Guidance, 1985. T1 - pp. 4-5 refers to pages 4 and 5 of the Course Compendium .
Throughout the course, safe working practices are to be clearly defined and emphasized with reference to current international requirements and regulations. It is expected that the national institution implementing the course will insert references to national requirements and regulations as necessary.
Knowledge, understanding and proficiency First-aid kit Body structure and function Toxicological hazards on board, including use of the Medical First Aid Guide for Use in Accidents Involving Dangerous Goods (MFAG) or its national equivalent Examination of casualty or patient Spinal injuries Bums. scalds and effects of heat and cold Fractures, dislocation and muscular injuries Medical care of rescued persons Radio medical advice Pharmacology Sterilization Cardiac arrest, drowning and asphyxia
Objectives are: 1
identification of probable cause, nature and extent of injuries is prompt, complete and conforms to current first-aid practice
risk of harm to self and others is minimized at all times
treatment of injuries and the patient's condition is appropriate, conforms to recognized first-aid practice and international guidelines
A-VI/4 Table A-VI/4-1
5 6 7 8 9 10 11 12 13
MEDICAL FIRST AID
Immediate action (2 hours)
Required performance: .1
R4 - Sect. 17, App.1 R1Table A-VI/4-1
IMO Model Course 1.13
11 - pp. 48,
R4 - Sect. 17 App.2
R4 - Sect. 17 App.2
T1 - pp. 115-122
describes and lists the contents of the first-aid kit required by national regulations
lists location of first-aid kits
describes contents of lifeboat kit
demonstrates use of the first-aid box in appropriate medical situations
Body structure and functions (2.5 hours)
Required performance: .1
uses a chart, dummy, human body or other suitable medium, such as audio-visual aids, to describe and explain the structure of the human body and functions of the important parts and systems; in particular: •
For the skeletal system: - lists the major parts of the skeleton - describes the different kinds of bones - explains the function of the skeleton
For the muscular system: - lists the major muscles of the human body - explains their operation and function
For the cardiovascular system: - states the location of the heart - describes the distribution of arteries and veins - describes the physiological function of blood - describes the heart as a pump - explains how the blood circulatory system operates - states the location of the arterial pressure points and explains how they can be effectively used in an emergency involving bleeding
For the respiratory system: - states the location of the lungs - explains the function of the lungs in terms of gas exchange - states the importance of respiratory rate - explains the importance of the composition of inspired/expired air
11 - pp.
revises, as necessary, important aspects of the Elementary First Aid training course
First-aid kit (1.5 hours)
For the digestive system and abdomen: - describes in simple terms the digestive system and its operation - lists the abdominal organs and describes their function
Toxicological hazards aboard ship (3.5 hours)
R4 - Sect. 17 App.2 R6
T1 - pp. 53-59
R4 - Sect. 17 App.2
T1 - pp. 4-5,61-65, 123-124, 125-126
V4, VB, V10
states that there are important regulations to be observed for the transport of dangerous cargo aboard ship as required by the IMO/IMDG Code
applies first-aid measures in accordance with Medical First Aid Guide for use in Accidents Involving Dangerous Goods (MFAG) or its national equivalent: - TW AITL V levels
uses, in particular, the appropriate First Aid Guide for: - identifying the symptoms and clinical aspects of poisoning - applying first aid in cases of poisoning by ingestion, inhalation, or skin contact! eye injuries - applying therapy in cases of acid and caustic solutions that have been swallowed - identifying the symptoms of and treatment for acid and caustic burns
use of oxygen resuscitator: - parts of the resuscitator - operation of resuscitator - changing cylinders - CPR with resuscitator - after use care and servicing
Examination of patient (1.5 hours)
Required performance: .1
makes detailed observations of a casualty, based on medical precepts
forms a diagnosis from a large variety of individual facts based on: - information derived from medical history - general appearance - answers to specific questions - physical examination
MEDICAL FIRST AID
Knowledge, understanding and proficiency
Teaching Aid V2, V7
Spinal injuries (3 hours)
recognizes the symptoms of spinal injury: - bladder control in spinal injuries
identifies the complications unconsciousness
applies appropriate first aid measures, including: - control of sensitivity in the extremities - appropriate rescue transport and treatment for cases of suspected fracture of the spine
head injuries: - levels of consciousness/unconsciousness
which may be caused by
Burns, scalds and effects of heat and cold (3 hours)
recognises the signs of: - burns - scalds - heatstroke - hypothermia - frostbite
applies appropriate first-aid measures, including the definition, complications and therapy of the general condition of burns
describes the differences between first-degree, seconddegree and third-degree burns
applies the correct first-aid procedures for burns and scalds
states the importance of sterile dressings
describes the effects of heat and states the importance of positioning the patient in the shade, providing the increased fluid requirement and careful cooling of the body
distinguishes between hypothermia and frostbite and applies the correct first aid procedures, including rewarming and attention to possible tissue damage
between burns and scalds
R4 - Sect. 17 App.2
T1 - pp. 8D-82, 95-100
applies practical first-aid procedures for the diagnosis and treatment of fractures, dislocations and muscular injuries
describes types of fracture as: - open (or compound) - closed (or simple) - complicated
describes the treatment for injured parts and explains the importance of immobilization of the injured part
states the importance of immobilization part
describes the special requirements for the treatment of pelvic and spinal injuries
describes the symptoms and therapy of sprains, strains and dislocations
demonstrates the correct procedures to be used in cases of fractures, dislocations and muscular injuries
states the necessary precautions while using pneumatic splints
of the injured
Medical care of rescued persons, including distress, hypothermia and cold exposure (2 hours)
R4 - Sect. 17 App.2
T1 - pp. 103-108
Required performance: .1
applies basic skill in the care of rescued persons
recognizes the special problems in cases of: - hypothermia, applying the correct treatment and taking precautions against heat loss and taking into account the effects of wind and humidity - congelation, applying the correct treatment for cold injury, immersion foot, etc - seasickness, describing the cause and applying the correct therapy - sunburn, describing the cause and applying the correct therapy and prophylaxis - dehydration and nutrition in rescue situations, describing frequent errors and hazards - rewarming
MEDICAL FIRST AID
Radio medical advice (1 hour)
R4 - Sect. 17 App.2
T1 - pp. 103-108
R4 - Sect. 17 App.2
T1 - pp. 109-114
R4 - Sect. 17 App.2
T1 - pp. 127-128
R4 - Sect. 17 App.2
T1 - pp. 3, 6, 14
states that radio medical advice is available using GMDSS BMed 1
describes the methods used to obtain radio medical advice
interprets advice obtained from external sources
Pharmacology (2.5 hours)
Required performance: .1
drug list on board: - usage - dosages - injections sc/im - test dose for penicillin
Sterilization (0.5 hour)
Required performance: .1
disinfection of surgical instruments
Cardiac arrest, drowning and asphyxia (2 hours)
states the cause of and applies the appropriate treatment for: - cardiac arrest - asphyxia - drowning
explains how mouth-to-mouth resuscitation is applied and states under what conditions it cannot be used
explains how cardiac massage is applied and states the limiting factors related to the use of cardiopulmonary resuscitation (CPR) practice on a dummy
demonstrates the correct procedures for mouth-tomouth resuscitation and cardiac massage using a practice dummy
PART C: DETAILED TEACHING SYLLABUS
explains that situational disturbances may be influenced by: - psychological characteristics of seafarers - psychological consequences of separation
states that these may be contributory factors for psychological malfunctioning
Review and Assessment
MEDICAL FIRST AID
Part D: Instructor Manual Introduction The course structure follows the requirements of the STCW 1995 Convention and the recommendations in Section 17 of the IMO/ILO Document for Guidance, 1985. The detailed teaching syllabus has been constructed directly from Appendix 2 of that section. The course should be under the control of a qualified medical doctor, the precise structure and content of the lectures and practical work and the way in which the course work is arranged and developed being left to the discretion of that person. The Document for Guidance advises that the IMGS or the appropriate national medical guide may be used to implement the course. A Course Compendium (T1) has been compiled, making use of extracts from IMGS, and this should be used to implement and support the course, introducing specific national requirements as appropriate. The detailed teaching syllabus is arranged in fourteen main sections, of which the first is a revision of important aspects dealt with in the previous training in Elementary First Aid. This reflects the requirements in the IMO/ILO Document for Guidance, 1985. Where supporting material is available in the course compendium (T1), an appropriate reference to it is indicated in the detailed teaching syllabus. The times allocated to each section are only suggested values, and the instructor should adjust them as necessary: in particular, it may be found to be necessary to increase the times allocated for practical application to ensure that the trainees can properly demonstrate their ability to carry out medical procedures and measures effectively.
PART 0: INSTRUCTOR MANUAL
Guidance Notes 1he training in this course aims to provide seafarers with the knowledge and skill in first aid to be able to take immediate effective action in the case of accident or illness likely to occur on bI&d ship . • should be noted that the competence apply medical first aid on board ship is included in the
I.n:tion Controlling the operation of the ship and care for persons on board at the operational, IeweI for both officers in charge of a navigational watch and for officers in charge of an engineering watch. Although the lectures amplifying and explaining the objectives contained in the detailed leaching syllabus are important in the transfer of knowledge, the instruction involving practical application is of equal importance in establishing that the trainees have also acquired the necessary skills to carry out effective first aid, and as far as is practicable the trainees should demonstrate the procedures involved. To support the syllabus objectives and provide training guidance, a Compendium has been compiled; this should be provided to each trainee taking the course. The compendium consists of Chapters 1, 2, 3, 4, 12, 14 and 17 and Annexes 1, 2, 4 and 5 of IMO/ILO/WHO International Medical Guide for Ships (IMGS). + Although only certain parts of a chapter or annex may relate directly to the syllabus objectives, it was considered preferable to provide the whole chapter or annex rather than unconnected parts of them. Table 1 shows the relevant pages and diagrams from IMGS that can be used to support each section of the syllabus.
+ The compendium is a mainly black-and-white authorized reprint of those parts of IMGS which are relevant to IMO model course 1.14.
MEDICAL FIRST AID
Table 1: Extracts from IMGS used in the Compendium Section of syllabus
Extract used from IMGS*
use Chapter 1, as appropriate, to revise basic level training
Chapter 1, pages 48 and 51; refer also to national regulations for first-aid kit requirements
Body Structure and Functions
Annex 1, use whole annex (pages
Toxicological Hazards Aboard Ship
Chapter 2, use whole chapter (reference is made to MFAG or its national equivalent)
Examination of Patient
Chapter 1, Table 1 (pages 4 and 5) Chapter 3, use whole chapter (pages
61-65) Annexes 2 and 4, use whole annexes (pages 349-350 and 352-353)
7 Burns, Scalds, and Effects of Heat and
Chapter 1, pages 28-31, Figs. 26-29
Chapter 4, pages 80-82, Fig. 76 Chapter 12, pages 263-268
Fractures, Dislocations and Muscular Injuries
Chapter 1, pages 19-39, Figs. 16-39 Chapter 4, pages 82-88, Figs. 77-89
Medical Care of Rescued Persons, including Distress, Hypothermia and Cold Exposure
Chapter 12, use whole chapter (pages 259-269)
10 Radio Medical Advice
Chapter 14, use whole chapter (pages
277-282) 11 Pharmacology
Chapter 17, use whole chapter (pages
303-308) 12 Sterilization
Annex 5, use whole annex (pages
Cardiac Arrest, Drowning and Asphyxia
Chapter 1, pages 3-14, Figs. 1-11
*The page numbers quoted are those used in IMGS.
An important aspect to be noted is that he is exposed to these abnormal and hazardous &:tors throughout the 24 hours of the day and has no respite or period of recovery away from 1hese conditions as happens in an industrial worker ashore. When combinations of these factors interplay along with worry, homesickness and other mental tensions continuously and constantly, a peculiar reaction is set in motion. The deleterious effects of these psychological reactions may prove to be much worse than a single psychological trauma. Hence the basic personality assets of a seafarer become an important factor. However, although unified slringent medical standards for seafarers have been evolved the world over, psychological selection is not yet obligatory or is not yet widely applicable. Hence a background knowledge of psychological aspects of seafarers will go a long way in understanding and capitalizing on the innate strengths and weaknesses of the crew vis-a-vis the particular working conditions of seafarers. General and specific
on board ships
a) Motivation Motivation influences the power of observation at sea and decision making. b) Emotions Emotions affect the capacity for work. Stability and well-balanced emotions are necessary to withstand difficult stress situations. c) Will power d) Intelligence Intellectual factors such as quick appreciation of situation, flexibility, concentration, imagination, faculty to abstract and a retentive memory are of basic importance. Officers especially must be able to recognize inter-relationships in new situations, to find adequate solutions and to verbalize them. Actually we do not yet know the effect of intelligence - whether a higher level produces fewer mistakes, or an average one produces a better capacity for observation and better work output. e) Perception Seamen should realize the limits of their perception under trying conditions at sea. t) Man-machine interface The technical components of the ship demand special capabilities, technical knowledge and know-how, control of precision motions, quick reactions, thoroughness etc. Factors in a ship's environment
which may contribute
A new equilibrium in working and living conditions For most careers ashore, the working and living conditions can be normally separated into i) working environment (when "on duty") ii) social and family environment (when "off duty")
MEDICAL FIRST AID
They have different functions and roles under the two environments. But on board a ship both the environments are inseparable and unchanging. In fact both merge into one single where one aspect constantly influences the other aspect. There is a fixed working hierarchy and schedule, unvarying living conditions and quarters and the ever present and never changing company of other crew members. This means a crew member cannot playa role during working time and play another during leisure time. For example, an officer is an officer in all situations, and during his entire presence on board. However psychological theories propose that for normal mental hygiene and development, change in roles is essential. If a person is denied such a change, it may result in frustration leading to aggression and indifference which may be manifested as accidents, sickness, crime, quarrels, fights, alcoholism etc. Change from a natural to artificial environment Under natural environmental conditions, man reacts as if by an innate instinct to avoid failures. But the modern day ship presents an artificial environment. Hence he cannot rely any more on his innate instincts. He will have to adapt to specific laws and rules to master the technical world. If he continues with his natural pattern of behaviour under the new artificial environment, it may result in more failures. Communication on board Multinational crews have become an accepted feature of seafaring. Hence communication among crew members may not be possible on all vessels to the same extent. Although good communication is indispensable for the safety of the crew and vessels and for smooth operations, it has added necessity from the psychological point of view. i) Communication with other people is necessary if individuals are to be balanced and efficient. Isolation results in changed mental attitudes and abnormal behavior with resultant undesirable consequences. ii) Linguistic competence is essential for achieving versatile personality and development of a broader approach to life. Psychological consequences of separation from family and society Separation from family not only influences the emotional relationships between the partners, but also causes problems in the family management and upbringing of children. Mostly, this results in changing from a patriarchal form of management to matriarchal system during the absence of the seaman father. The mother has to solve the daily problems. Situation changes again during the long vacation stay of the seaman. On board he has to live with other seamen and he has no chance to select his co-workers. He has to come to terms with others whether he likes them or not. His real friends are ashore and far away. He misses the privileges of good friendship - confidence, relaxation, empathy, common interests etc. Added to this separation is the fact that seafarers very often live in isolation regarding information. Unlike the availability of information through press, radio, TV etc. "back home", he has very little accessibility. This can lead to decrease in the fund of knowledge and resultant indifference. Also if one is not well informed, one may not be able to look after one's own affairs. 22
PART D: INSTRUCTOR MANUAL
• Textbooks (1) The detailed teaching syllabus together with the Instructor Manual and the Compendium is all that is required to implement the course. However, if supplementary reading or reference is desired, the following publications may be suitable.
T1 U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General. The Ship's Medicine Chest and Medical Aid at Sea (Washington, D.C., U.S. Government Printing Office, 1984) Available from: Superintendent of Documents Subscription Customer Service Stop. SSOM Washington, D.C. 20402, U.S.A. (DHSS Publication No.(PHS) 84-2024) Tel: 1 202512 1803 Fax: 1 2025122168 E-mail: [email protected]
URL: www.access.gpo.gov T2
W.H.G. Goethe, E.N. Watson, D.T. Jones, ed. Handbook of Nautical Medicine (New York, Springer-Verlag, 1984) (ISBN 0-387-12956-1)
Maritime and Coastguard Agency. The Ship Captain's Medical Guide, 1985 (London, The Stationery Office Ltd) (ISBN 0 11 551658 1)
Available from: The Stationery Office Publications Centre PO Box 276 London 8W8 5DT, UK Tel: 0870 600 5522 Fax: 0870 600 5533 E-mail: [email protected]
URL: www.tsonline.co.uk Secondhand copies of out-of-print books may be available from the Warsash Nautical Bookshop, 6 Dibles Road, Warsash, Southampton 8031 9HZ, UK. Tel: +441489572384 Fax: +44 1489885756 E-mail: [email protected]
GUIDANCE ON THE IMPLEMENTATION OF MODEL COURSES
GUIDANCE ON THE IMPLEMENTATION
OF MODEL COURSES
Contents Part 1
Notes on Teaching Technique
Example of a Model Course syllabus in a subject area
Example of a lesson plan for annex A2
GUIDANCE ON THE IMPLEMENTATION
OF MODEL COURSES
Part 1 - Preparation 1
The success of any enterprise depends heavily on sound and effective preparations.
Although the IMO model course "package" has been made as comprehensive as possible, it is nonetheless vital that sufficient time and resources are devoted to preparation. Preparation not only involves matters concerning administration or organization, but also includes the preparation of any course notes, drawings, sketches, overhead transparencies, etc., which may be necessary.
The course "package" should be studied carefully; in particular, the course syllabus and associated material must be attentively and thoroughly studied. This is vital if a clear understanding is to be obtained of what is required, in terms of resources necessary to successfully implement the course.
A "checklist", such as that set out in annex A 1, should be used throughout all stages of preparation to ensure that all necessary actions and activities are being carried out in good time and in an effective manner. The checklist allows the status of the preparation procedures to be monitored, and helps in identifying the remedial actions necessary to meet deadlines. It will be necessary to hold meetings of all those concerned in presenting the course from time to time in order to assess the status of the preparation and ''trouble-shoot" any difficulties.
The course syllabus should be discussed with the teaching staff who are to present the course, and their views received on the particular parts they are to present. A study of the syllabus will determine whether the incoming trainees need preparatory work to meet the entry standard. The detailed teaching syllabus is constructed in "training outcome" format. Each specific outcome states precisely what the trainee must do to show that the outcome has been achieved. An example of a model course syllabus is given in annex A2. Part 3 deals with curriculum development and explains how a syllabus is constructed and used.
The teaching staff who are to present the course should construct notes or lesson plans to achieve these outcomes. A sample lesson plan for one of the areas of the sample syllabus is provided in annex A3.
It is important that the staff who present the course convey, to the person in charge of the course, their assessment of the course as it progresses.
Scope of course In reviewing the scope of the course, the instructor should determine whether it needs any adjustment in order to meet additional local or national requirements (see Part 3).
Course objective 3.2.1 The course objective, as stated in the course material, should be very carefully considered so that its meaning is fully understood. Does the course objective require expansion to encompass any additional task that national or local requirements will impose upon those who successfully complete the course? Conversely, are there elements included which are not validated by national industry requirements?
3.2.2 It is important that any subsequent assessment made of the course should include a review of the course objectives.
GUIDANCE ON THE IMPLEMENTATION
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Entry standards 3.3.1 If the entry standard will not be met by your intended trainee intake, those entering the course should first be required to complete an upgrading course to raise them to the stated entry level. Alternatively, those parts of the course affected could be augmented by inserting course material which will cover the knowledge required. 3.3.2 If the entry standard will be exceeded by your planned trainee intake, you may wish to abridge or omit those parts of the course the teaching of which would be unnecessary, or which could be dealt with as revision. 3.3.3 Study the course material with the above questions in mind and with a view to assessing whether or not it will be necessary for the trainees to carry out preparatory work prior to joining the course. Preparatory material for the trainees can range from refresher notes, selected topics from textbooks and reading of selected technical papers, through to formal courses of instruction. It may be necessary to use a combination of preparatory work and the model course material in modified form. It must be emphasized that where the model course material involves an international requirement, such as a regulation of the International Convention on Standards of Training, Certification and Watchkeeping (STCW) 1978, as amended, the standard must not be relaxed; in many instances, the intention of the Convention is to require review, revision or increased depth of knowledge by candidates undergoing training for higher certificates.
Course certificate, diploma or document Where a certificate, diploma or document is to be issued to trainees who successfully complete the course, ensure that this is available and properly worded and that the industry and all authorities concerned are fully aware of its purpose and intent.
Course intake limitations 3.5.1 The course designers have recommended limitations regarding the numbers of trainees who may participate in the course. As far as possible, these limitations should not be exceeded; otherwise, the quality of the course will be diluted. 3.5.2 It may be necessary to make arrangements for accommodating the trainees and providing facilities for food and transportation. These aspects must be considered at an early stage of the preparations.
Staff requirements 3.6.1 It is important that an experienced person, preferably someone with experience in course and curriculum development, is given the responsibility of implementing the course. 3.6.2 Such a person is often termed a "course co-ordinator" or "course director". Other staff, such as lecturers, instructors, laboratory technicians, workshop instructors, etc., will be needed to implement the course effectively. Staff involved in presenting the course will need to be properly briefed about the course work they will be dealing with, and a system must be set up for checking the material they may be required to prepare. To do this, it will be essential to make a thorough study of the syllabus and apportion the parts of the course work according to the abilities of the staff called upon to present the work. 3.6.3 The person responsible for implementing the course should consider monitoring the quality of teaching in such areas as variety and form of approach, relationship with trainees, and communicative and interactive skills; where necessary, this person should also provide appropriate counselling and support.
Rooms and other services 3.7.1 It is important to make reservations as soon as is practicable for the use of lecture rooms, laboratories, workshops and other spaces.
GUIDANCE ON THE IMPLEMENTATION
OF MODEL COURSES
Equipment 3.7.2 Arrangements must be made at an early stage for the use of equipment needed in the spaces mentioned in 3.7.1 to support and carry through the work of the course. For example: .1
blackboards and writing materials
apparatus in laboratories for any associated demonstrations
machinery and related equipment in workshops
.4 equipment and materials in other spaces (e.g. for demonstrating fire fighting, personal survival, etc.).
Teaching aids Any training aids specified as being essential to the course should be constructed, availability and working order.
or checked for
Audio-visual aids Audio-visual aids (AVA) may be recommended in order to reinforce the learning process in some parts of the course. Such recommendations will be identified in Part A of the model course. The following points should be borne in mind: Overhead projectors .1 Check through any illustrations provided in the course for producing overhead projector (OHP) transparencies, and arrange them in order of presentation. To produce transparencies, a supply of transparency sheets is required; the illustrations can be transferred to these via photocopying. Alternatively, transparencies can be produced by writing or drawing on the sheet. Coloured pens are useful for emphasizing salient points. Ensure that spare projector lamps (bulbs) are available.
Slide projectors If you order slides indicated in the course framework, check through them and arrange them in order of presentation. Slides are usually produced from photographic negatives. If further slides are considered necessary and cannot be produced locally, OHP transparencies should be resorted to.
Cine projector If films are to be used, check their compatibility with the projector (Le. 16 mm, 35 mm, sound, etc.). The films must be test-run to ensure there are no breakages.
Video equipment It is essential to check the type of video tape to be used. The two types commonly used are VHS and Betamax. Although special machines exist which can play either format, the majority of machines play only one or the other type. Note that VHS and Betamax are not compatible; the correct machine type is required to match the tape. Check also that the TV raster format used in the tapes (Le. number of lines, frames/second, scanning order, etc.) is appropriate to the TV equipment available. (Specialist advice may have to be sought on this aspect.) All video tapes should be test-run prior to their use on the course.
Computer equipment If computer-based aids are used, check their compatibility software.
with the projector
and the available
General note .6 The electricity supply must be checked for voltage and whether it is AC or DC, and every precaution must be taken to ensure that the equipment operates properly and safely. It is important to use a proper screen which is correctly positioned; it may be necessary to exclude daylight in some cases. A check must be made to ensure that appropriate screens or blinds are available. All material to be presented should be test-run to eliminate any possible troubles, arranged in the correct sequence in which it is to be shown, and properly identified and cross-referenced in the course timetable and lesson plans.
GUIDANCE ON THE IMPLEMENTATION
OF MODEL COURSES
IMO references The content of the course, and therefore its standard, reflects the requirements of all the relevant IMO international conventions and the provisions of other instruments as indicated in the model course. The relevant publications can be obtained from the Publication Service of IMO, and should be available, at least to those involved in presenting the course, if the indicated extracts are not included in a compendium supplied with the course.
Textbooks The detailed syllabus may refer to a particular textbook or textbooks. It is essential that these books are available to each student taking the course. If supplies of textbooks are limited, a copy should be loaned to each student, who will return it at the end of the course. Again, some courses are provided with a compendium which includes all or part of the training material required to support the course.
Bibliography Any useful supplementary source material is identified by the course designers and listed in the model course. This list should be supplied to the participants so that they are aware where additional information can be obtained, and at least two copies of each book or publication should be available for reference in the training institute library.
Timetable If a timetable presentations mind that any one class and
is provided in a model course, it is for guidance only. It may only take one or two of the course to achieve an optimal timetable. However, even then it must be borne in timetable is subject to variation, depending on the general needs of the trainees in any the availability of instructors and equipment.
GUIDANCE ON THE IMPLEMENTATION
OF MODEL COURSES
Notes on Teaching Technique Preparation Identify the section of the syllabus which is to be dealt with. Read and study thoroughly all the syllabus elements. Obtain the necessary textbooks or reference papers which cover the training area to be presented.
Identify the equipment which will be needed, together with support staff necessary for its operation.
It is essential to use a "lesson plan", which can provide a simplified format for co-ordinating lecture notes and supporting activities. The lesson plan breaks the material down into identifiable steps, making use of brief statements, possibly with keywords added, and indicating suitable allocations of time for each step. The use of audio-visual material should be indexed at the correct point in the lecture with an appropriate allowance of time. The audio-visual material should be test-run prior to its being used in the lecture. An example of a lesson plan is shown in annex A3.
The syllabus is structured in training outcome format and it is thereby relatively straightforward to assess each trainee's grasp of the subject matter presented during the lecture. Such assessment may take the form of further discussion, oral questions, written tests or selection-type tests, such as multiple-choice questions, based on the objectives used in the syllabus. Selection-type tests and short-answer tests can provide an objective assessment independent of any bias on the part of the assessor. For certification purposes, assessors should be appropriately qualified for the particular type of training or assessment. REMEMBER - POOR PREPARATION IS A SURE WAY TO LOSE THE INTEREST OF A GROUP
Check the rooms to be used before the lecture is delivered. Make sure that all the equipment and apparatus are ready for use and that any support staff are also prepared and ready. In particular, check that all blackboards are clean and that a supply of writing and cleaning materials is readily available.
Always face the people you are talking to; never talk with your back to the group.
Talk clearly and sufficiently loudly to reach everyone.
Maintain eye contact with the whole group as a way of securing their interest and maintaining it (Le. do not look continuously at one particular person, nor at a point in space).
People are all different, and they behave and react in different ways. An important function of a lecturer is to maintain interest and interaction between members of a group.
Some pOints or statements are more important than others and should therefore be emphasized. To ensure that such points or statements are remembered, they must be restated a number of times, preferably in different words.
If a blackboard is to be used, any writing on it must be clear and large enough for everyone to see. Use colour to emphasize important points, particularly in sketches.
It is only possible to maintain a high level of interest for a relatively short period of time; therefore, break the lecture up into different periods of activity to keep interest at its highest level. Speaking, writing, sketching, use of audio-visual material, questions, and discussions can all be used to accomplish this. When a group is writing or sketching, walk amongst the group, looking at their work, and provide comment or advice to individual members of the group when necessary.
GUIDANCE ON THE IMPLEMENTATION
OF MODEL COURSES
When holding a discussion, do not allow individual members of the group to monopolize the activity, but ensure that all members have a chance to express opinions or ideas.
If addressing questions to a group, do not ask them collectively; otherwise, the same person may reply each time. Instead, address the questions to individuals in turn, so that everyone is invited to participate.
It is important to be guided by the syllabus content and not to be tempted to introduce material which may be too advanced, or may contribute little to the course objective. There is often competition between instructors to achieve a level which is too advanced. Also, instructors often strongly resist attempts to reduce the level to that required by a syllabus.
Finally, effective preparation makes a major contribution to the success of a lecture. Things often go wrong; preparedness and good planning will contribute to putting things right. Poor teaching cannot be improved by good accommodation or advanced equipment, but good teaching can overcome any disadvantages that poor accommodation and lack of equipment can present.
GUIDANCE ON THE IMPLEMENTATION
OF MODEL COURSES
Part 3 - Curriculum Development 1
Curriculum The dictionary defines curriculum as a "regular course of study", while syllabus is defined as "a concise statement of the subjects forming a course of study". Thus, in general terms, a curriculum is simply a course, while a syllabus can be thought of as a list (traditionally, a "list of things to be taught").
Course content The subjects which are needed to form a training course, and the precise skills and depth of knowledge required in the various subjects, can only be determined through an in-depth assessment of the job functions which the course participants are to be trained to perform Uob analysis). This analysis determines the training needs, thence the purpose of the course (course objective). After ascertaining this, it is possible to define the scope of the course. (NOTE: Determination of whether or not the course objective has been achieved may quite possibly entail assessment, over a period of time, of the "on-the-job performance" of those completing the course. However, the detailed learning objectives are quite specific and immediately assessable.)
Job analysis A job analysis can only be properly carried out by a group whose members are representative of the organizations and bodies involved in the area of work to be covered by the course. The validation of results, via review with persons currently employed in the job concerned, is essential if undertraining and overtraining are to be avoided.
Course plan Following definition of the course objective and scope, a course plan or outline can be drawn up. The potential students for the course (the trainee target group) must then be identified, the entry standard to the course decided and the prerequisites defined.
Syllabus The final step in the process is the preparation of the detailed syllabus with associated time scales; the identification of those parts of textbooks and technical papers which cover the training areas to a sufficient degree to meet, but not exceed, each learning objective; and the drawing up of a bibliography of additional material for supplementary reading.
Syllabus content The material contained in a syllabus is not static; technology is continuously undergoing change and there must therefore be a means for reviewing course material in order to eliminate what is redundant and introduce new material reflecting current practice. As defined above, a syllabus can be though of as a list and, traditionally, there have always been an "examination syllabus" and a "teaching syllabus"; these indicate, respectively, the subject matter contained in an examination paper, and the subject matter a teacher is to use in preparing lessons or lectures.
GUIDANCE ON THE IMPLEMENTATION
OF MODEL COURSES
The prime communication difficulty presented by any syllabus is how to convey the "depth" of knowledge required. A syllabus is usually constructed as a series of "training outcomes" to help resolve this difficulty.
Thus, curriculum development makes use of training outcomes to ensure that a common minimum level and breadth of attainment is achieved by all the trainees following the same course, irrespective of the training institution (Le. teaching/lecturing staff).
Training outcomes are trainee-oriented, in that they describe an end result which is to be achieved by the trainee as a result of a learning process.
In many cases, the learning process is linked to a skill or work activity and, to demonstrate properly the attainment of the objective, the trainee response may have to be based on practical application or use, or on work experience.
The training outcome, although aimed principally at the trainee to ensure achievement of a specific learning step, also provides a framework for the teacher or lecturer upon which lessons or lectures can be constructed.
A training outcome is specific and describes precisely what a trainee must do to demonstrate knowledge, understanding or skill as an end product of a learning process.
The learning process is the "knowledge acquisition" or "skill developmenf that takes place during a course. The outcome of the process is an acquired "knowledge", "understanding", "skill"; but these terms alone are not sufficiently precise for describing a training outcome.
Verbs, such as "calculates", "defines", "explains", "lists", "solves" and "states", must be used when constructing a specific training outcome, so as to define precisely what the trainee will be enabled to do.
In the IMO model course project, the aim is to provide a series of model courses to assist instructors in developing countries to enhance or update the maritime training they provide, and to allow a common minimum standard to be achieved throughout the world. The use of training outcomes is a tangible way of achieving this desired aim.
As an example, a syllabus in training-outcome format for the subject of ship construction appears in annex A2. This is a standard way of structuring this kind of syllabus. Although, in this case, an outcome for each area has been identified - and could be used in an assessment procedure - this stage is often dropped to obtain a more compact syllabus structure.
Training outcomes describe an outcome which is to be achieved by the trainee. Of equal importance is the fact that such an achievement can be measured OBJECTIVEL Y through an evaluation which will not be influenced by the personal opinions and judgements of the examiner. Objective testing or evaluation provides a sound base on which to make reliable judgements concerning the levels of understanding and knowledge achieved, thus allowing an effective evaluation to be made of the progress of trainees in a course.
GUIDANCE ON THE IMPLEMENTATION OF MODEL COURSES
Annex A2 - Example of a Model Course syllabus in a subject area Subject area:
Have a broad understanding of shipyard practice
Have knowledge of materials used in shipbuilding, specification of shipbuilding steel and process of approval
No specific textbook has been used to construct the syllabus, but the instructor would be assisted in preparation of lecture notes by referring to suitable books on ship construction, such as Ship Construction by Eyres (T12) and Merchant Ship Construction by Taylor (T58)
GUIDANCE ON THE IMPLEMENTATION OF MODEL COURSES
Part C3: Detailed Teaching Syllabus Introduction The detailed teaching syllabus is presented as a series of learning objectives. The objective, therefore, describes what the trainee must do to demonstrate that the specified knowledge or skill has been transferred. Thus each training outcome is supported by a number of related performance elements in which the trainee is required to be proficient. The teaching syllabus shows the Required performance expected of the trainee in the tables that follow. In order to assist the instructor, references are shown to indicate IMO references and publications, textbooks and teaching aids that instructors may wish to use in preparing and presenting their lessons. The material listed in the course framework has been used to structure the detailed teaching syllabus; in particular, Teaching aids (indicated by A) IMO references (indicated by R) and Textbooks (indicated by T) will provide valuable information to instructors. Explanation of information contained in the syllabus tables The information on each table is systematically organized in the following way. The line at the head of the table describes the FUNCTION with which the training is concerned. A function means a group of tasks, duties and responsibilities as specified in the STCW Code. It describes related activities which make up a professional discipline or traditional departmental responsibility on board. The header of the first column denotes the COMPETENCE concerned. Each function comprises a number of competences. For example, the Function 3, Controlling the Operation of the Ship and Care for Persons on board at the Management Level, comprises a number of COMPETENCES. Each competence is uniquely and consistently numbered in this model course. In this function the competence is Control trim, stability and stress. It is numbered 3.1, that is the first competence in Function 3. The term "competence" should be understood as the application of knowledge, understanding, proficiency, skills, experience for an individual to perform a task, duty or responsibility on board in a safe, efficient and timely manner. Shown next is the required The training outcomes are the areas of knowledge, understanding and proficiency in which the trainee must be able to demonstrate knowledge and understanding. Each COMPETENCE comprises a number of training outcomes. For example, the above competence comprises thrj3e trC1i~ing..()utc()mes~ The first is conce.r.~ed with the fundamental ~.rir1~!~le~i8!il~rslE>IMlirslJll;giRINI!i~e:S.·.·.··~Ei.SlileC~NSTRUITIQN,·. TRIM If';,IE>SJIB!lJlmI. Each training outcome is uniquely and consistently numbered in this model course. That concerned with fundamental principles of Ship
GUIDANCE ON THE IMPLEMENTATION OF MODEL COURSES
Construction, Trim And Stability is uniquely numbered~:1:1:~PLc:I~:lJity, outcomes are printed in black type on grey, for example Jif'it~lllliQ~JiCQMJ;.
Finally, each training outcome embodies a variable number of Required performances - as evidence of competence. The instruction, training and learning should lead to the trainee meeting the specified Required performance. For the training outcome concerned with fundamental principles of ship construction, trim and stability there are three areas of performance. These are:
18.104.22.168 Shipbuilding materials 22.214.171.124 Welding 126.96.36.199 Bulkheads Following each numbered area of Required performance there is a list of activities that the trainee should complete and which collectively specify the standard of competence that the trainee must meet. These are for the guidance of teachers and instructors in designing lessons, lectures, tests and exercises for use in the teaching process. For example, under the topic 188.8.131.52, to meet the Required performance, the trainee should be able to: -
state that steels are alloys of iron, with properties dependent upon the type and amounts of alloying materials used state that the specifications of shipbuilding steels are laid down by classification societies state that shipbuilding steel is tested and graded by classification society surveyors who stamp it with approval marks
and so on. IMO references (Rx) are listed in the column to the right-hand side. Teaching aids (Ax), videos (Vx) and textbooks (Tx) relevant to the!~.ini~98~t~8m2.a.~ required performances are placed immediately following the JiAJllliirQ~I.QMJ; title. It is not intended that lessons are organized to follow the sequence of Required performances listed in the Tables. The Syllabus Tables are organized to match with the competence in the STCW Code Table A-II/2. Lessons and teaching should follow college practices. It is not necessary, for example, for ship building materials to be studied before stability. What is necessary is that _allof the material is covered and that teaching is effective to allow trainees to meet the standard of the Required performance.
Textbooks:T11, T12,T35,T58,T69 Teaching aids: A1, A4, V5, V6, V7 Required performance:
Shipbuilding materials (3 hours) -
states that steels are alloys of iron, with properties dependent upon the type and amounts of alloying materials used
states that the specifications of shipbuilding steels are laid down by classification societies
states that shipbuilding steel is tested and graded by classification society surveyors, who stamp it with approval marks
explains that mild steel, graded A to E, is used for most parts of the ship
states why higher tensile steel may be used in areas of high stress, such as the sheer strake
explains that the use of higher tensile steel in place of mild steel results in a saving of weight for the same strength
explains what is meant by: • tensile strength • ductility • hardness • toughness
defines strain as extension divided by original length
sketches a stress-strain curve for mild steel
explains: • yield point • ultimate tensile stress • modulus of elasticity
explains that toughness is related to the tendency to brittle fracture
explains that stress fracture may be initiated by a small crack or notch in a plate
states that cold conditions increase the chances of brittle fracture
states why mild steel is unsuitable for the very low temperatures involved in the containment of liquefied gases
lists examples where castings or forgings are used in ship construction
explains the advantages of the use of aluminium alloys in the construction of superstructures
states that aluminium alloys are tested and graded by classification society surveyors
explains how strength is preserved in aluminium superstructures in the event of fire
describes the special precautions against corrosion that are needed where aluminium allov is connected to steelwork
Compendium for model course 1.14
Medical First Aid
ACKNOWLEDGEMENTS IMO expresses its sincere appreciation to the International Labour Organization and to the World Health Organization for their assistance and co-operation in the production of this compendium
Page Extracts from International Medical Guide for Ships
Chapter 1: First aid
Chapter 2: Toxic hazards of chemicals, including poisoning
Chapter 3: Examination of the patient
Chapter 4: Care of the injured
Chapter 12: Medical care of castaways and rescued persons
Chapter 14: External assistance
Chapter 17: Advice on medicines
Annex 1: Anatomy and physiology
Annex 2: Regions of the body
Annex 4: Medical report form for seafarers
Annex 5: Disinfection procedures
First aid is the emergency treatment given to the ill or injured before professional medical services can be obtained. It is given to prevent death or further injury, to counteract shock, and to relieve pain. Certain conditions, such as severe bleeding or asphyxiation, require immediate treatment if the patient is to survive. In such cases, even a few seconds' delay might mean the difference between life and death. However, the treatment of most injuries or other medical emergencies may be safely postponed for the few .minutes required to locate a' crew-member skilled in first aid, or to locate suitable medical supplies and equipment.
Contents Priorities General principles of first aid aboard ship Unconsciouscasualti.es Basic life support: artificial respiration and heart compression Severe bleeding Shock Clothing on fire Heat burns and scalds Electrical burns and electrocution Chemical splashes Fractures Dislocations Head injuries Blast injuries Internal bleeding Choking Suffocation Strangulation Standarddressing Transporting a casualty First aid satchels or boxes Oxygenadministration (oxygen therapy)
1 2 3
6 14 17 18 19 19 19 19 37 39 39 40 42 43 43 44 44 48 51
All crew-members should be prepared to administer first aid. They should have sufficient knowledge of first aid to be able to apply true emergency measures and decide when treatment can be safely delayed until more skilled personnel arrive. Those not properly trained must recognize their limitations. Procedures and techniques beyond the rescuer's ability should not be attempted. More harm than good might result.
Priorities On finding a casualty: • look to your own safety: do not become the next casualty; • if necessary, remove the casualty from danger or remove danger from the casualty (but see observation below on a casualty in an enclosed space). If there is only one unconscious or bleeding casualty (irrespective of the total number of casualties), give immediate treatment to that casualty only, and then send for help. If there is more than one unconscious or bleeding casualty: • send for help; • then start giving appropriate treatment to the worst casualty in the following order of priority: severe bleeding; stopped breathing/heatt; unconscIOusness. If the casualty is in an enclosed space, do not enter the enclosed space unless you are a trained
MEDICAL FIRST AID: COMPENDIUM
member of a rescue team acting under instructions. Send for help and inform the master. It must be assumed that the atmosphere in the space is hostile. The rescue team MUST NOT enter unless wearing breathing apparatus which must also be fitted to the casualty as soon as possible. The casua.lty must be removed quickly to the nearest safe adjacent area outside the enclosed space unless his injuries and the likely time of evacuation make some treatment essential before he can be moved.
General principles of first aid aboard ship First aid must be administered • • • •
restore control remove prevent stance, carbon
breathing and heart-beat; bleeding; pOisons; further injury to the patient (for inhis removal from a room containing monoxide or smoke).
A rapid, emergency evaluation of the patient should be made immediately at the scene of the injury to determine the type and extent of the trauma. Because every second may count, only the essential pieces of the patient's clothing should -be removed. In the case of an injured limb, get the sound limb out of the clothing first, and then peel the clothes off the injured limb. If necessary, cut clothes to expose the injured part. Keep workers from crowding round. The patient's pulse should be taken. If it cannot be felt at the wrist, it should be felt at the carotid artery at the side of the neck (see Fig. 2). If there is no pulse, heart compression and artificial respiration must be started (see Basic life support, page 6). The patient should be treated for shock if the pulse is weak and rapid, or the skin pale, cold, and possibly moist, with an increased rate of shallow, irregular breathing. Remember that shock can be a great danger to life, and its prevention is one of the main objectives of first aid (see Shock, page 17).
The patient should be kept in the position that best provides relief from his injuries. Usually this is a lying-down position, which increases circulation of the blood to the head. The patient should be observed for type of breathing and possible bleeding. If he is not breathing, mouth-to-mouth or mouth-to-nose artificial respiration must be given (seepages 8-9). Severe bleeding must be controlled. During this time, the patient, if conscious, should be reassured and told that all possible help is being given. The rescuer should ask about the location of any painful areas. The patient should be kept in a lying-down position and moved only when absolutely necessary. The general appearance of the patient should be obseryed, including any signs and symptoms that may indicate a specific injury or illness. The patient sho.uld not be moved if injuries of the neck or spine are suspected. Fractures should be splinted before moving a patient (see pages 19-22). No attempt should be made to set a fracture. Wounds and most burns should be covered to prevent infection. The treatment of specific injuries will be discussed more fully in the rest of this chapter, and in the next chapter. Once life-saving measures have been started or deemed not necessary, the patient should be examined more thoroughly for other injuries. The patient should be covered to preverit loss of body heat. Ifnecessary, protect him also from heat, remembering that in the tropics, the open steel deck on .which he may be lying will usually be very hot. The patient should not be given alcohol in any form. Never underestimate inJUrIes:
and do not treat as minor
• unconsciousness (page 3); • suspected internal bleeding (page 40);
• • • •
stab or puncture wounds (page 68); wounds near joints (see Fractures, page 19); possible fractures (page 19); eye injuries.(page 76).
Note. Never consider anyone to be dead, until you and others agree that: • no pulse can be felt, and no sounds are heard when the examiner's ear is put to the chest; • breathing has stopped; • the eyes are glazed and sunken; • there is progressive cooling of the body (this may not apply if the surrounding air temperature is close to normal body temper:ature). Unconscious casualties '1 respIratIOn .. (8 ee a so: B·aSIClie l'~ support: artI'fi CIa
and heart compression, page 6; General nursing care, Unconscious patients, page 104.) . The causes of unconSCIOusnessare many and are often difficult to determine (see Table 1). Treatment varies with the cause, but in first aid it is usually not possible to make a diagnosis of the cause, let alone undertake treatment. '" The ImmedIate threat to lIfe may be: • breathing obstructed by the tongue falling back and blocking the throat; • stopped heart.
With an unconscious patient, first listen for breathing. To relieve obstructed breathing, tilt the head firmly backwards as far as it will go (see F
Ig.. Listen and feel for any movement of air, because the chest and abdomen may move in the presence of an obstructed airway, without moving air. The rescuer's face should be placed within 2-3 cm of the patient's nose and mouth so that any exhaled air may be felt against his cheek. Also, the rise and fall of the chest can be observed and the exhaled breath heard (see Fig. 1). Remove patient's dentures, if any.
Heart Next, listen for heart sounds. Feel pulse at wrist (see page 94) and neck (carotid pulse, see Fig. 2), Quickly check the carotid (neck) pulse by placing the tips of the two fingers of one hand into the groove between the windpipe and the large muscle at the side of the neck. The carotid pulse is normally a strong one; if it cannot be felt or is feeble, there is insufficient circulation. Check the pupils of the eyes to see if they are dilated or constricted. When the heart stops
beating, the pupils will begin to dilate within 45-60 seconds. They will stay dilated and will not react to light (see Physical examination (eyes), p. 63).
If the heart is beating and breathing restored, and the casualty is still unconscious, place the casualty in the UNCONSCIOUS POSITION (see Fig. 3).
The examination for breathing and heart action should be done as quickly as possible. The rescuer must immediately establish if the casualty . • ISno t b rea th mg an d th e h ear t h as st oppe d , or . • ISno t b rea th mg b u t th e h ear t h as no t st oppe d ..
Turn casualty face down, head to one side or the other (Fig. 3). No pillows should be used under the head. Now pull up the leg and the arm on the side to which the head is facing. Then pull up the . chm. Stretch the other arm out as shown. The subsequent treatment of an unconscIous person is described in Chapter 5.
Not breathing, heart stopped A trained first-aider must begin heart compression at once. Unless circulation is restored, the brain will be without oxygen and the person will die within 4-6 minutes. • Lay casualty on a hard surface. • Start heart compression at once (see page 9). • Give ~rtificial respiration (see page 8), since breathmg stops when the heart stops. The necessary aid can be given by one person alternately compressing the heart and then filling the lungs with air, or - better still- by two · peop Ie wor k mg t oge th er ( see page 11- 12)...
Not breathing heart not stopped
, • Open mouth and ensure the airway is clear (see Airway, page 7). • Begin ARTIFICIAL RESPIRATION at once (see page 8).
Follow other general principles of first aid (see page 2).
Basic life support: artificial r~spiration and heart compression Basic life support is an emergency life-saving procedure that consists of recognizing and correcting failure of the respiratory or cardiovascular systems. .. , . Oxygen, which ISpresent m the atmosphere m a , concentratIOn of about 21%, ISessential for the life o~all ce.lls. The brain,. t~e prin~ipal organ for conscIous hfe, starts to die If depnved of oxygen for as little as four minutes. In the delivery of oxygen from the atmosphere to the brain cells, there are two necessary actions: breathing (taking in oxygen through the body's air pas-
sages) and the circulation of oxygen-enriched blood. Any profound disturbance of the airway, the breathing, or the circulation can promptly produce brain death. Basic life support comprises the "ABC" steps, which concern the airway, breathing, and circulation respectively. Its prompt application is indicated for: A. Airway obstruction B. Breathing (respiratory) arrest C. Circulatory or Cardiac (heart) arrest. Basic life support requires no instruments or supplies, and the correct application of the steps for dealing with the above three problems can maintain life until the patient recovers sufficiently to be transported to a hospital, where he can be provided with advanced life support. The latter consists of the use of certain equipment, cardiac monitoring, defibrillation, the maintenance of an intravenous lifeline, and the infusion of appropriate drugs. Basic life support must be undertaken with the maximum sense of urgency. Ideally, only seconds should intervene between recognizing the need and starting the treatment. Any inadequacy or absence of breathing or circulation must be determined immediately. If breathing alone is inadequate or absent, all that is necessary is either to open the AIRWAY or to apply ARTIFICIAL RESPIRATION. If circulation is also absent, artificial circulation must be instituted through HEART COMPRESSION, in combination with artificial respiration. If breathing stops before the heart stops, enough oxygen will be available in the lungs to maintain life for several minutes. However, if heart arrest occurs first, delivery of oxygen to the brain ceases immediately. Brain damage is possible if the brain is deprived of oxygen for 4-6 minutes. Beyond 6 minutes without oxygen, brain damage is very likely.
1: FIRST AID
It is thus clear why speed is essential in determining the need for basic life support and instituting the necessary measures. Once you have started basic life support, do not interrupt it for more than 5 seconds for any reason, except when it is necessary to move the patient; even in that case, interruptions should not exceed IS seconds each.
Airway (Step A) ESTABLISHING AN OPEN AIRWAY IS THE MOST IMPORTANT STEP IN ARTIFICIAL RESPIRATION. Spontaneous breathing may occur as a result of this simple measure. Place the patient in a face-up position on a hard surface. Put one hand beneath the patient's neck and the other hand on his forehead. Lift the neck with the one hand, and apply pressure to the forehead with the other to tilt the head backward (see Fig. 4). This extends the neck and moves the base of the tongue away from the back of the throat. The head should be maintained in this position during the entire artificial respiration and heart compression procedure. If the airway is still obstructed, any foreign material in the mouth or throat should be removed immediately with the fingers. Once the airway has been opened, the patient mayor may not start to breathe again. To assess whether breathing has returned, the person providing the basic life support must place his ear about 2-3 cm above the nose and mouth of the patient. If the rescuer can feel and hear the movement of air, and can see the patient's chest and abdomen move, breathing has returned. Feeling and hearing are far more important than seeing. With airway obstruction, it is possible that there will be no ~ir 'movement even though the chest and abdomen rise and fall with the patient's attempts to breathe. Also, observing chest and abdominal movement is difficult when the patient is fully clothed.
Breathing (Step B) If the patient does not resume adequate, spontaneous breathing promptly after. his head has
been tilted backward. artificial respiration should be given by the mouth-to-mouth or mouth-to-nose method or other techniques. Regardless of the method used, preservation of an open airway is essential.
Mou th - to-mou th reSp/f8 tIon • Keep the patient's head at a maximum backward tilt with one hand under the neck (see Fig.4b). • Place the heel of the other hand on the forehead, with the thumb and index finger toward the nose. Pinch together the patient's nostrils with the thumb and index finger to prevent air from escaping.
Continue to exert pressure on the forehead with the palm of the hand to maintain the backward tilt of the head. Take a deep breath, then form a tight seal with your mouth over and around the patient's mouth (see Fig. 5). Blow four quick, full breaths in first without allowing the lungs to deflate fully. Watch the patient's chest while inflating the lungs. If adequate respiration is taking place, the chest should rise and fall. Remove your mouth and allow the patient to exhale passively. If you are in the right position, the patient's exhalation will be felt on your cheek (see Fig. 6).
• Take another deep breath, form a tight seal around the patient's mouth, and blow into the mouth again. Repeat this procedure 10-12 times a minute (once every five seconds) for adults and children over four years of age. • If there is no air exchange and an airway obstruction exists reach into the patient's, ' ~. mou th an d th roa t t0 remove any loreign matt 'th fi th .. er ~I . you ~r n~ers' en resu m artificial e respua t Ion. Aloreignb 0d y sh ou ld ebsuspectd 'f bl t . fI hId . e I you ar~ .un~ e 0 10 a~e t e. ungs esplte proper posltIonmg and a tight au-seal round the mouth or nose.
Mouth-to-nose respiration The mouth-to-nose technique should be used when it is impossible to open the patient's mouth, when the mouth is severely injured, or when a tight seal round the lips cannot be obtaine~ (see Fig. 7).
• Keep the patient's head tilted ~ack with hand. Use the other hand to 11ft up the tient's lower jaw to seal the lips. • Take a deep breath, seal your lips round patient's nose, and blow in forcefully smoothly until the patient's chest rises. peat quickly four times.
one pathe and Re-
• Remove your mouth and allow the patient to exhale passively. • Repeat the cycle 10-12 times per minute. "
Alternative method of artificial respiration (Silvester method) . ", In some mstances, mouth-to-mouth respuatlOn · ., cannot b e use d ; For mstance, certam tOXICand caustic materials constitute a hazard for the res. ., ... cuer, or f:aCIaI mJunes may prohibIt the use of the mouth-to-mouth or mouth-to-nose technique. An alternative method of artificial respiration (shown in Fig. 8) should then be applied. However, this method is much less effective than those previously described and it should be used only when the mouth-to-mouth technique cannot be used. .' ... ArtIficIal resplfatlOn should be contmued as long as there are signs of life; it may be necessary to carry on for up to two hours, or longer.
Heart compression (Step C) In attempting to bring back to life a non-breathing person whose heart has stopped beating, heart compression (external cardiac compression) should be applied along with artificial respiration.
Artificial respiration will bring oxygen-containing air to the lungs of the victim. From there, oxygen is transported with circulating blood to the brain and to other organs. Effective heart compression will - for some time - artificially restore the blood circulation, until the heart starts beating.
Technique for heart compression Compression of the sternum produces some artificial ventilation, but not enough for adequate oxygenation of the blood. For this reason, artificial respiration is always required whenever heart compression is used. Effective heart compression requires sufficient pressure to depress the patient's lower sternum about 4-5 cm (in an adult). For chest compression to be effective, the patient must be on a firm surface. If he is in bed, a board or improvised support should be placed under his back. However, chest compression must not be delayed by a search for a firmer support.
Kneel close to the side of the patient and place the heel of one hand over the lower half of the sternum. Avoid placing the hand over the tip (xiphoid process) of the breastbone, which extends down over the upper abdomen. Pressure on the xiphoid process may tear the liver and lead to severe internal bleeding. Feel the tip of the sternum and place the heel of the. hand ab~ut 4 cm nearer the head of the patIent (se~ FIg. 9~. Your.fingers must !lever.rest on the patIent's rIbs dUrIng compreSSion,Since this increases the possibility of rib fractures. • Place the heel of the other hand on top of the first one. • Rock f?rward so that your. sh~ulders are almost dIrectly above the patIent s chest. • Keep your arms straight and exert adequate pressure almost directly downwards to depress an adult's lower sternum 4-5 em. • Depress the sternum 60 times per minute for an adult (if someone else is available to give artificial respiration). This is usually enough to maintain blood flow, and slow enough to allow the heart to fill with blood. The com-
pression should be regular, smooth, and uninterrupted, compression and relaxation being of equal duration. Under no circumstances should compression be interrupted for more than five seconds (see page 7).
It is preferable to have two rescuers because artificial circulation must be combined with arti-
ficial respiration (see Fig. 10).The most effective artificial respiration and heart compression are achieved by giving one lung inflation quickly after each five heart compressions (5: I ratio). The compression rate should be 60 per minute if two rescuers are operating. One rescuer performs
heart compression, while the other remains at the patient's head, keeps it tilted back, and
continues rescue breathing (artificial respiration). It is important to supply the breaths without any pauses in heart compression, because every Interruption in this compression results in a drop of blood flow and blood pressure to zero. A single rescuer must perform both artificial respiration and artificial circulation using a 15: 2 ratio (see Fig. II). Two very quick lung inflations should be delivered after each 15 chest compressions, without waiting for full exhalation of the patient's breath. A rate equivalent to 80 chest compressions per minute must be maintained by a single rescuer in order to achieve 50--60 actual compressions per minute, because of the interruptions for the lung inflations.
Checking effectiveness of heart compression: pupils and pulse Check the reaction of the pupils. If the pupils contract when exposed to light, this is a sign that
the brain is receiving adequate oxygen and blood. If the pupils remain widely dilated and do not react to light, serious brain damage is likely to occur soon or has occurred already. Dilated but reactive pupils are a less serious sign. ..• The carolld (neck) pulse (see Fig. 2, page 3) .• should be felt after the first mmute of heart . · · " compressIOn an d artl ficia 1 respiratIOn, an d every
Other indicators of this effectiveness are: • expansion of the chest each time the operator blows air into the lungs; • a pulse that can be felt each time the chest is compressed; return of colour to the skin; t" ' a spon t aneous gasp lor b reath , • re t urn 0f a spon t aneous heartbeat .
five minutes thereafter. The pulse will indicate the effectiveness of the heart compression or the return of a spontaneous effective heartbeat.
Summary of points to be remembered. when applying artificial respiration and heart compression Don't delay
Place victim on his back on a hard surface.
Step A. Airway - If patient is unconscious, open the airway; thereafter make sure it stays open. • Lift up neck. • Push forehead back. • Clear out mouth with fingers. Step B. Breathing - If patient is not breathing, begin artificial respiration. Mouth-to-mouth or mouth-to-nose respiration. • Before beginning artificial respiration, check carotid pulse in neck. It should be felt again after the first minute and checked every five minutes thereafter. • Give four quick breaths and continue at a rate of 12 inflations per minute. • Chest should rise and fall. If it does not, check to make sure the victim's head is tilted as far back as possible. • If necessary, use fingers to clear the airway. Step C. Circulation - If pulse is absent, begin heart compression. If possible, use two rescuers. Don't delay. One rescuer can do the job. • • • •
Locate pressure point (lower half of sternum). Depress sternum 4-5 cm, 60 to 80 times per minute. If one rescuer - 15 compressions and two quick inflations. If two rescuers - 5 compressions and one inflation. Pupils of eyes should be checked during heart compression. Constriction of a pupil on exposure to light shows that the brain is getting adequate blood and oxygen.
Do not cut off the circulation. A pulse should be felt on the side of the injured part away from the heart. If the bandage has been applied properly, it should be allowed to remain in place undisturbed for at least 24 hours. If the dressings are not soaked with blood and the circulation beyond the pressure dressing is adequate, they need not be changed for several days.
Elevation When there is a severely bleeding wound of an extremity or the head, direct pressure should be applied on a dressing over the wound with the affected part elevated. This elevation lowers the blood pressure in the affected part and the flow of blood is lessened.
Pressure points When direct pressure and elevation cannot contro) severe bleeding, pressure should be applied to the artery that supplies the area. Because this
technique reduces the circulation to the wounded part below the pressure point, it should be applied only when absolutely necessary and only until the severe bleeding has lessened. There are a large number of sites where the fingers may be applied to help control bleeding (see Fig. 14). However, the brachial artery in the upper arm and the femoral artery in the groin are those where pressure can be most effective. The pres~ure point for the brachial artery is l~ated ml~way between the elbow and the armpit on the Inner arm between the large muscles. To ap~ly ~ressure,. one hand should be rou.nd the pattent s arm with the thum~ o~ the outside ~f the ~rm and the fingers on the Instde. Pressure ISapplted by moving the flattened fingers and the thumb towards one an~ther. The pressure point for the femora) artery tS located on the front of the upper leg just below the middle of the crease of the groin. Before pressure is applied, the patient should be turned on his back. Pressure
should be applied with the heel of the hand while keeping the arm straight.
Tourniquet A tourniquet should be applied to control bleeding only when all other means have failed. Unlike direct hand pressure, a tourniquet shuts off all normal blood circulation beyond the site of application. Lack of oxygen and blood may lead to the destruction of tissue, possibly requiring amputation of a limb. Releasing the tourniquet periodically will result in loss of blood and danger of shock. If the tourniquet is too tight or too narrow, it will damage the muscles, nerves, and blood vessels;if too loose, it may increase blood loss. Also, there have been cases where tourniquets have been applied and forgotten. If a tourniquet is applied to save a life, immediate RADIO MEDICAL ADVICE must be obtained. A tourniquet must be improvised from a wide band of cloth. An improvised tourniquet may be made from folded triangular bandages, clothing, or similar material. Fig. 15 shows how to apply a tourniquet, and how to secure it with a piece of wood. Record the time the tourniquet was applied. If you are sending the casualty to hospital, attach a sheet of paper to his clothing or an extremity, indicating this time. Note
• Never cover the tourniquet with clothing or bandages, or hide it in any way. • Never loosen the tourniquet, unless a physician advises it.
Shock Shock following an injury is the result of a decrease in the vital functions of the various organs of the body. These functions are depressed because of inadequate circulation of blood or an oxygen deficiency. Shock usually follows severe injuries such as extensive burns, major crushing injuries (particularly of the chest and abdomen), fractures of large bones, and other extensive or extremely
MEDICAL FIRST AID: COMPENDIUM
painful injuries. Shock follows the loss of large quantities of blood; allergic reactions; poisoning from drugs, gases, and other chemicals; alcohol intoxication; and the rupture of a stomach ulcer. It also may be associated with many severe illnesses such as infections, strokes, and heart attacks. In some individuals t~e emotional response to trivial injuries or even to the mere sight of blood is so great that they feel weak and nauseated and may faint. This reaction may be considered to be an extremely mild form of shock which is not serious and will disappear quickly if the patient lies down. Severe shock seriously threatens the life of the patient. Signs and symptoms of shock are: • Paleness. The skin is pale, cold, and often
moist. Later it may develop a bluish, ashen colour. If the patient has dark skin, the colour of mucous membranes and nail beds should be examined. • Rapid and shallow respirations. Alternatively breathing could be irregular and deep. • Thirst, nausea, and vomiting. These frequently occur in a haemorrhaging patient in shock. • Weak and rapid pulse. Usually the pulse rate is over 100. • Restlessness, excitement, and anxiety. These occur early, later giving way to mental dull. ness, and siilliater to unconsciousness. In this late stage the pupils are dilated, giving the patient a vacant, glassy stare. Although these symptoms may not be evident, all seriously injured persons should be treated for shock to prevent its possible development.
and head. The legs should not be elevated if there is injury to the head, pelvis, spine, or chest, or difficulty in breathing. • Keep the patient warm, but not hot. Too much
heat raises the surface temperature of the body and diverts the blood supply away from vital organs to the skin. • Relieve pain as quickly as possible. If pain is
severe, 10mg of morphine sulfate may be given by intramuscular injection. If the blood pressure is low, morphine sulfate should not be given because it may cause an additional drop in the pressure. Also, it should not be given to injured patients unless pain is severe. The dosage should be repeated only after obtaining RADIO MEDICAL ADVICE. • Administer fluids. Liquids should not be given
by mouth if the patient is unconscious, drowsy, convulsing, or about to have surgery. Also, fluids should not be given if there is a puncture or crush wound to the abdomen, or a brain injury. If none of the above conditions is present, give the patient a solution of oral rehydration salts (half a glass every 15 minutes). Alcohol should NEVER be given. The intravenous administration of fluids is preferable in the treatment of shock, if a person trained to administer them is available (see page 117). Dextran (60 gjlitre, 6%) and sodium chloride (9 gjlitre, 0.9%) solution (injection) may be given intravenously. In a case of suspected shock, get RADIO MEDICAL ADVICE. Clothing on fire
Treatment • Eliminate the causes of shock. This includes
controlling bleeding, restoring breathing, and relieving severe pain. • Have the injured person lie down. The patient
should be placed in a horizontal position. The patient's legs may be elevated approximately 30 cm to assist the flow of blood to the heart
If someone's clothing is on fire, by far the best way to put the fire out is to use a dry-powder fire extinguisher at once. If a dry-powder extinguisher is not available, then lay the person down and smother the flames by wrapping him in any available material, or throw bucketfuls of water over him, or use a hose, if available. Make sure that all smouldering clothing is extinguished.
[Note: page 117 of IMGS has not been included in this compendium]
Note. The powder from a fire extinguisher will
not cause much, if any, eye damage. Most people shut their eyes tightly if sprayed with powder. Any powder in the eye should be washed out immediately after the fire has been extinguished and while burns are being cooled. Heat burns and scalds All heat burns should be cooled as quickly as possible with running cold water (sea or fresh), applied for at least ten minutes, or by immersion in basins of cold water. If it is not possible to cool a burn on the spot, the casualty should be taken to a place where cooling can be carried out. Try to remove clothing gently but do not tear off any that adheres to the skin. Then cover the burned areas with a dry, non-fluffy dressing larger than the burns, and bandage in place. For further advice on classification, treatment, and prognosis in burns, see Burns and scalds (page 80). In cases of severe burns followed by shock (see page 17), obtain RADIO MEDICAL ADVICE as soon as possible. Electrical burns and electrocution Make sure you do not become the next casualty when approaching any person who is in contact with electricity. If possible, switch off the current. Otherwise insulate yourself before approaching and touching the casualty, by using rubber gloves, wearing rubber boots, or standing on an insulating rubber mat. Electrical lines may be removed from the casualty with a wooden pole, a chair, an insulated cord, or other non-metal object. Then check casualty immediately for breathing and heartbeat. If casualty is not breathing, give artificial respiration (see page 8). If heart has stopped, apply heart compression (see page 9).
1: FIRST AID
Send for help. When the casualty is breathing, cool any burnt areas with cold water and apply a clean, dry, non-fluffy covering to these areas. The treatment for electrical burns is the same as for thermal burns (see page 80). It includes relief of pain, prevention and treatment of shock, and control of infection. Electrical burns may be followed by paralysis of the respiratory centre, unconsciousness, and instant death. Chemical splashes Remove contaminated clothing. Drench casualty with water to wash the chemical from the eyes and skin. Give priority to washing the eyes which are particularly vulnerable to chemical splashes. If only one eye is affected, incline the head to the side of the affected eye to prevent the chemical from running across into the other eye. For further advice on treatment, see Skin contact and Eye contact (page 56) in Chapter 2, Toxic hazards of chemicals. Fractures A fracture is a broken bone. The bone may be broken into two or more pieces or it may have a linear crack. Fractures are described as closed if the skin remains unbroken. If there is a wound at or near the break, it is said to be an open fracture (see Fig. 16). Careless handling of a patient may change a simple fracture into a compound one, by forcing jagged bone-ends through intact overlying skin. Compound fractures accompanied by serious bleeding are likely to give rise to shock (see page 17), especially if a large bone is involved. The following are indications that a bone is very probably broken: • The fact that a heavy blow or other force has been applied to the body or limbs. • The casualty himself, or other people, may have heard the bone break. • Intense pain, especially on pressure or movement at the site.
MEDICAL FIRST AID: COMPENDIUM
Swelling almost always occurs immediately, and discoloration of the skin may follow.
General treatment RADIO MEDICAL ADVICE shoula Desought early in the case of a compound fracture or a severe type of fracture (skull, femur, pelvis, spine) because it might be necessary to evacuate the patient from the ship. Unless there is an immediate danger of further injury, the patient should not be moved until bleeding is controlled and all fractures are immobilized by splinting.
• Distortion. Compare good with injured limb
or side of the body to see if the affected part . is swollen, bent, twisted, or shortened. • Irregularity. The irregular edges of a broken bone can sometimes be seen in an open fracture. They may be seen or felt under the skin in a closed fracture. • Loss of use. The casualty may be unable or unwilling to use the injured part because of the pain. He may also experience severe pain if an attempt, even a very gentle one, is made to help him move it. Watch his face for signs of pain. Occasionally, if the broken ends of a bone are impacted together, the patient may be able to use the affected part but usually only with a fair amount of pain. • Unnatural movement and grating of bone-ends.
Neither of these symptoms should be sought deliberately. A limb may feel limp and wobbly, and grating may be felt when an attempt is made to apply support to the limb. Either of these indicates that the bone is certainly broken .. • Swelling. The site may be swollen and/or bruised. This may be due to internal bleeding.
Bleedingfrom open fractures should be stopped in the normal way by pressing the area the blood comes from and applying a dressing. Blood will not come from the broken bone-end but from around the break. Care must be exercised in lifting up the affected part if it is broken, but it should always be elevated if bleeding is severe. People can die from loss of blood; they will not die from a broken bone, although moving it may be painful. Rest is very important to prevent further bleeding, to prevent further damage, and to relieve pain. If bleeding is well controlled, the wound can be treated. The area round it should be cleansed thoroughly with soap and water and then disinfected with 1% (lOg/litre) cetrimide solution. Surface washings should not be allowed to spill into the wound. The wound itself should not be washed. It should be covered with a sterile dressing. Particles of dirt and pieces of clothing, wood, etc. should be gently removed from the wound with sterilized forceps. Blood clots should not be disturbed, as this may cause fresh bleeding. The wound should not be sutured. Dressings on it should be allowed to remain in place 4-5 days (if there is no wound infection).
Pain If the patient is in severe pain, 10mg of morphine sulfate may be given by intramuscular injection. Before repeating the dosage, RADIO MEDICAL ADVICE should be obtained.
Car~ should be taken no~ to agg~ayate pain by movmg or roughly handhng the mjured part. . lnata rfl ble splmts are a useful method for tem-
Inflatable splints may be used when a patient is being transported about the ship or during removal to hospital. They shouldnot be left i~ place for more than a few hours. Other means of immobilizing the fracture should be used after that period.
porarily immobilizing limb fractures but are unsuitable for fractures that are more than a short dista~ce abov~ th~ knee or elbow, as they cannot provIde.su~cIent !mmobilization in these places. The splInt ISapplIed to the limb and inflated by mouth (see Fig. 17). Other methods of inflation can make the splint too tight and thus slow down or stop the circulation. Inflatable splints can be applied over wound dressings. The splints are made of clear plastic through which any bleeding from the wound can easily be seen. All sharp objects and sharp edges must be kept well clear of inflatable splints to avoid puncture. . .. . To provIde adequate stabIlIty, the splInt should be long enough to extend beyond the joints at the end of the fractured bone.
Immobi.1izea limb in the position in which it is found, If it is comfort~le. If ~t does become necess~ry to ~ove an mjured lImb because of poor cIrcul~tIon or fo~ any ot~er reason, first apply tractIOn by pullmg the lImb gently and firmly.away from the body before attempting to move It. If a long bone in the arm or leg has been fract~red, it should be ~traightened carefully. Tracbon shoul~ be applIed on th~ hand o~ the foot, a~d the lImb moved back mto. ~osItion (see FIg. 18). Compound fractures of jomts, such as the elbow or knee, should not be manipulated . They should be placed gently into a proper position for splinting. The knee should be splinted straight. The elbow should be splinted at a right angle.
Fractures of specific body areas Skull A fracture of the skull may be caused by a fall, a direct blow, a crushing injury, or a penetrating injury such as a bullet wound. The patient may be conscious, unconscious, or dizzy, and have a headache or nausea. Bleeding from the nose, ears, or mouth may be present; and there may be paralysis and signs of shock.
Circulation of the blood Check and re-check the circulation of blood in a fractured limb by pressing on a nail. When circulation is normal, the nail becomes white when pressed and pink when released. Continue until you are satsified that all is well. Danger signs are: • blueness or whiteness of fingers and toes; • coldness of the parts below the fracture; • loss of feeling below the injury (test for this by touching casualty lightly on fingers or toes and asking him if he can feel anything); • absence of pulse. If there is any doubt at all about the circulation, loosen all tight and limb-encircling dressings at once and straighten out the limb, remembering to use traction when doing so. Check the circulation again. If the limb does not become pink and
warm and you cannot detect a pulse, then medi-
Treatment. The patient with a head injury should receive immediate attention to prevent additional damage to the brain. The patient should be kept lying down. If the face is flushed, the head and shoulders should be elevated slightly. If the face is pale, the head should be kept level with the body or slightly lower. Bleeding can be controlled by direct pressure on the temporal or carotid arteries. The patient should be moved carefully with the head supported on each side with a sandbag.
Morphine sulfate should never be given . Upper jaw I~ all injuries of the face, ens~ring .an adequ~te airway must be the first consideration (see AIrway, page 7). Treatment. If there are wounds, bleeding should be controlled. Loose teeth should not be removed.w.ithout RADIO ME~ICAL ADVICE, unless It IS ~eared that they will be swallowed or block the airway. .
cal help is probably urgently necessary if amputation is to be avoided. Get RADIO MEDICAL ADVICE.
A fracture may cause a deformity of the jaw, missing or uneven teeth, bleeding from the gums, swelling, and difficulty in swallowing.
Remember that fractures may cause serious blood loss internally. Check and take the appropriate action (see Internal bleeding, page 40, and Severe bleeding, page 14).
Treatment. The injured jaw may interfere with breathing. If this occurs, the jaw and tongue should be pulled forward and maintained in that position. A problem arises when both sides of the
jaw are broken. In this case the jaw and tongue may move backwards and obstruct the air passages. Hook a finger - yours or the casualty's - over and behind the lower front teeth and pull the jaw, and with it the tongue, forward. Then, if possible, arrange for the casualty to sit up with his head forward. Clenching the teeth may also stop further slippage. If the casualty cannot be put in a sitting position on account of other injuries, he must be placed in the unconscious position and another person must stay with him, keeping the jaw pulled forward, if necessary, and watching carefully for any sign of obstructed breathing. Normally, jaw fractures give little trouble because the casualty sits with the teeth clenched, often refusing to speak much on account of pain. The spasm in the jaw muscles which is caused by pain keeps the teeth clenched and the jaw immobilized. Application of cold compresses may reduce the swelling and pain. The patient's jaw must be immobilized not only by closing his mouth as much as possible but also by applying a bandage (see Fig. 19). If the patient is unconscious or bleeding from the mouth, or if there is danger of vomiting, an attendant must be present at all times to loosen the bandage if necessary. Treat for pain (see page 20).
Collar bone, shoulder blade, and shoulder Fractures in these areas are often the result either of a fall on t~e outs!retched hand or a fall on the shoulder. Direct violence to the affected parts is a less c?mmon ca';lse. Place lo~se padding about the size of a fist mto the a~plt. Then tie the arm to the body. A convement way of doing this is to use a tri~n~ular sling (s~e Fig. 20). Keep the ca~ualt~ Slttll~ up as he will be most comfortable 10 this posItion.
Upper arm (humerus) and the elbow Complications may occur in fractures of the humerus because of the closeness of the nerves and blood vessels to the bone. There is pain and
tenderness at the fracture site, and an obvious deformity may be present. The patient may be unable to lift his arm or to bend his elbow. A full-arm, inflatable air splint should be applied to the fracture (see Fig. 17). If inflatable splints are not available, the arm should be placed in a sling, with the sling and arm secured to the body by a wide cravat bandage (see Fig. 20). A short padded splint, applied to the outer surface of the arm, may also be used (see Fig. 21). The elbow should not be ~nt, if it does not bend easily. Long, padded sphnts should be applied, one to the outer surface and another to the inner surface of !h~ arm. If.there is any possibility that the elbow ISmvolved 10 the fracture, the joint should be immobilized with a splint (see Fig. 22). Treatment.
Treat for pain (see page 20).
Lower arm (radius and ulna) or forearm There are two large bones in the forearm, and either one or both of these may be broken. When onl.y one bone is broken~ the other acts a~ a splInt and there may be lIttle or no deformIty. However, a marked deformity may be present in a fracture near the wrist. When both bones are broken, the arm usually appears deformed. 7' r. . .I. reatment. Th e Jrac t ure sh ou Id b e st ralg ht ene d carefully by applying traction on the hand (see Fig. 18, page 22). . . · A h a If-arm, Infla t a bl e aIr sp IInt sh ou Id b e applied to the fracture (see Fig. 17). If inflatable splints are not available, two well-padded splints should be applied to the forearm, one at the top and one at the bottom (see Fig. 23). The splints should be long enough to extend from beyond the elbow to the middle of the fingers. The hand should be raised about 10 cm higher than the elbow, and the arm supported in a sling (see
Fig. 23). If necessary, a splint may be improvised using, e.g., a magazine. Treat for pain (see page 20).
Wrist and hand A broken wrist is usually the result of a fall with the hand outstretched. Usually there is a lumplike deformity on the back of the wrist, along with pain, tenderness, and swelling . A fracture of the wrist should not be manipulated or straightened. In general, it should be managed like a fracture of the forearm. The hand may be fractured by a direct blow or may receive a crushing injury. There may be pain, swelling, loss of motion, open wounds, and broken bones. The hand should be placed on a padded splint which extends from the middle of the lower arm to beyond the tips of the fingers. A firm ball of gauze should be placed under the fingers to hold the hand in a cupped position. I
Roller gauze or elastic bandage may be used to secure the hand to the splint (see Fig. 24). The ar:mand hand should be supported in a sling (see FIg. 20). Often, further treatment is urgent, regardless of the severity of the injury, to preserve as much of the function of the hand as possible. RADIO MEDICAL ADVICE should be obtained. . Treat for pam (see page 20).
Finger Only the frac~red finger should be immobilized, an~ th~ moblhty of the other fingers should be mamtam.ed. The fi.nger.should be straightened ~y grasp~ng the WristwIth one hand and applymg tractIon to the fingertip with the other. The finger should be immobilized with a splint (see Fig. 25). The patient should be examined by a physician as soon as possible.
Falls from a height are ,the likeliest cause of spinal injury at sea. Always suspect a fracture of the spine if a person has fallen a distance of over two metres. Ask if there is any pain in the back. Most people with fractures of the spine have pain, but a very few do not. So, check carefully how the injury happened and, if in doubt, treat it as a fractured spine. First ask the casualty to move his toes to check whether or not he has paralysis and check also that he can feel you touching his toes. A casualty who has a fractured spine must be kept still and straight. He must never be bent or jackknifed by being picked up under the knees and armpits. He can, however, be safely rolled over
Spine A FRACTURED SPINE IS POTENTIALLY A VERY SERIOUS INJURY IF YOU SUSPECT A FRACTURED SPINE TELL THE CASUALTY TO LIE STILL AND DO NOT ALLOW ANYONE TO MOVE HIM UNTIL HE IS SUPPORTED ON A HARD FLAT SU RFACE . Any care 1ess movement 0f a casua Ity WI'th a frac t ure d· spme cou Id d amage or 'I cor d , resu 1tmg ' . permanent sever t he spma m paralysis and loss of feeling in the legs and double'incontinence for life.
(see Fig. 26) on to one side or the other, because, if this is done gently, there is very little movement of the spine. The aim in first aid will be to place the casualty on a hard flat surface where his spine will be fully supported and to keep him like that until X-rays can be taken. .... Tell the casualty to .he still Immedl~tely you suspect a fractured spme. If you drag him about " or move him ·unskllfully you could cause permanen t para 1YSlS. Tie the feet and ankles together with a figure-ofeight bandage and get the casualty lying still and
straight. Use traction on the head and on the feet to straighten him out. Do not fold him. Take your time. He can now lie safely in this position for as long as is necessary. So do not be in a hurry to move him. Prepare a stiff supporting stretcher, A Neil-Robertson or basket stretcher will do. A canvas stretcher will not do unless it has stiff wooden boards laid transversely over the canvas to provide a rigid support for the back. There may be a need to stiffen some models of the Neil-Robertson stretcher. ... If a Ned-Robertson stretcher ISnot available, a wide wooden board may be used for immobiliza'F' Ig..27 Th'IS t'Ion ' 0 f th e pa t'lent , as sh own In .. · ' ' Improvised meth 0d 0f Immo bIIIzat'Ion may a Iso . a case 0 f suspected pelvIc ' fracture. be used In Another method of lifting a patient with a spine injury is shown in Fig. 28. First, roll the casualty
very carefully (see Fig.26) on to a blanket spread out flat. Then roll up both edges of the blanket very tightly and as close as possible to the casualty. Prepare a stretcher, stiffened with wooden boards. Two pads must be provided to support and fill the hollows of the spine, which are in the small of the back and behind the neck. The back pad should be larger than the neck pad (see Fig, 28). Now prepare to lift the casualty, Have at least two people grasping each side of the blanket, d t th h d d t th fI t t an one pe~son a e ~a. an one a e ee 0 apply tractIon. Those IIftmg . the blanket "1 should be spaced so th at more II·titIng power ISaval a bl ·the d wh·ICh' IS heavy compare d WI a t th e b0dy en . . the end beanng th e Iegs. A tiur th er person IS required to push the prepared stretcher under the casualty when he is lifted.
Begin by applying traction to the head and feet. Pull under the jaw, under the back of the head , and around the ankles. When firm traction is being applied, lifting can commence slowly. Lift the casualty very slowly and carefully to a height of about half a metre, i.e., just enough to slip the stretcher under the casualty. Be careful, take time, and keep the casualty straight. Slide the stretcher between the legs of the person who is applying traction to the ankles. Then move the stretcher in the direction of the head, continuing until it is exactly underneath the casualty. Adjust the position of the pads to fit exactly under the curves in the small of the back and neck. Now lower the casualty very, very slowly on to the stretcher. Maintain traction until he is resting firmly on the stretcher. The casualty is now ready for removal. Ifhe has to be placed on any other surface, that surface must be hard and firm and removal precautions must be as described above, with plenty of people to help and with traction on the head and feet during removal. As there will be so many people helping and it is ~mportant to handle the casualty with great care, It may be useful to have someone read out the relevant instructions before each operation is carried out. See Stroke and paralysis (page 231) for further advice on how to treat a patient with an injury to the spinal cord. Neck Injuries to the neck are often in the form of compression fractures of the vertebrae due for example to the victim standing up suddenly and bumping his head violently or to something falling on his head. Falls from a height can also produce neck injuries. Treatment is similar to that described above for fractures of the spine, because the neck is the upper part of the spine. The casualty should be laid flat, if not already in this position, and should be kept still and
straight. A neck collar should then be applied gently to stop movement of the neck while an assistant steadies the head. An improvised neck collar can be made quite easily from a .new~paper. Fold the newspaper so that the width IS about 10 cm at t.hefront. Fold the top edge ov~r to. produce a shghtly !1arrower back. Then tie thl.saround the neck with the top edge under the chm and the b~ttom edge over the top of t~e collar bones. Tie a bandage, scarf, or necktie over the newspaper to hold it in place. This will keep the neck still (Fig. 29).
[Note: page 231 of IMGS has not been included in this compendium]
mouth or nose, use a sucker, if possible, or mop out the blood to keep the air passages clear.
Pelvis A fracture of the pelvis is usually due either to a fall from a height or to direct violence in the pelvic area. The casualty will complain of pain in . the hip, groin, and peJvic areas and perhaps also of pain in the lower back and buttock areas. The ring compression test is useful. Press gently on the front of both hip bones in a downward and inward direction so as to compress the pelvic ring. This will give rise to sharp pain if the pelvis is broken. Some movement of the pelvic bones may also be felt if there is a fracture. If you think that the pelvis may be fractured, tell the casualty not to pass urine. If he has to pass urine, keep the specimen and examine it for the presence of blood .. If the bladder or urethra (the channel from the bladder to the tip of the penis) is damaged, urine can leak into the tissues. Pelvic fractures can cause severe and even lifethreatening bleeding into the peJvic and lower abdominal cavities. So, start a pulse chart (Fig. 41, page 41) immediately and check for concealed internal bleeding (page 40).
Casualties with a fractured pelvis should be ber to keep checking for concealed internal lifted with great care (see Fig. 33). If the patient bleeding (page 40). has a lot of pain, ., with a fractured pelvISmay " ' use' the same ~ technique' as for A patient be m shock a frac tured spme (F Ig, 28) belore pu tt mg th e. (see page 17), If necessary, treat him ' for shock, casua ' m , a shock positIOn. ,, Ity on a stretcher or on 'a woo . den boar d but do not place him (F'Ig..27) Keep th e casua Ity Iymg m wh a tever position is most comfortable to him - on the A long wooden board (see Fig. 27) or rigid back, on one side, or face downwards. Remem- stretcher will provide the necessary support
during transportation. The patient should not be rolled, because this may cause additional internal damage. A pad should be placed between the patient's thighs, and the knees and ankles bandaged together, as shown in Fig. 27. Treat for pain (see page 20).
Hip to knee A broken thigh bone is a potentially serious
injury and will cause significant blood loss. If it is combined with other fractures and/or injuries, then the loss may easily reach a level at which blood replacement will become necessary. There is severe pain in the groin area, and the patient may not be able to lift the injured leg. The leg may appear shortened and be rotated, causing the toes to point abnormally outward. Shock will generally accompany this type of fracture.
Get RADIO MEDICAL ADVICE. A fracture of the neck of the thigh bone will produce shortening of the injured leg and cause the casualty to lie with the whole lower limb and foot flopped outwards. Fractures of the shaft of the thigh bone are usually fairly easy to diagnose. If you think that the thigh is broken, first pad between the thighs, knees, legs, and ankles with folded blankets or any other suitable soft material. Then bring the good leg to the broken leg. Do this slowly and carefully. Next, bring the feet together. If the attempt to do this causes pain, apply traction gently and slowly and then bring the feet together. Now tie a figure-of-eight bandage around the feet and ankles to keep the feet together. Next, prepare the splints to immobilize the hip. A well-padded board splint should be placed from the armpit to beyond the foot. Another well-padded splint should be placed on the inner side of the leg from the groin to beyond the foot. The splints .should be secured in place with an adequate number of ties, and both legs tied together to provide additional support (see Fig. 34). The patient should be transported on a stretcher or a long board to a bed in his quarters or sick-bay. Treat for pain (see page 20).
Knee A fracture of the knee is generally the result of a fall or a direct blow. Besides the usual signs of a fracture, a groove in the kneecap may be felt. There will be inability to kick the leg forward, and the leg will drag if an attempt is made to walk. Treatment. The leg should be straightened carefully (see Fig. 18).A full-leg, inflatable air splint should be applied. If other types of splint are used, a well-padded board splint should be applied, with padding under the knee and below the ankle. The splint should be secured in place with ties (see Fig. 35). Treat for pain (see page 20).
IMGS CHAPTER 1: FIRST AID
Lower leg (tibia and fibula) Fractures of the lower leg are common and occur as a result of various accidents. There is a marked deformity of the leg when both bones are broken. When only one bone is broken, the other acts as a splint and little deformity may be present. When the tibia (the bone in the front of the leg) is broken, a compound fracture is likely to occur. Swelling may be present, and the pain is usually severe enough to require administration of morphine sulfate. Treatment. The leg should be straightened carefully, using slight traction (see Fig. 18). A fullleg, inflatable air splint may be applied, if available (see Fig. 17). The air splint will assist in controlling the bleeding, if there is a compound fracture. If other types of splint are used, a wellpadded splint should be applied to each side of the leg, and another should be placed under the leg. The splints should extend from the middle of the thigh to beyond the heel (see Fig. 36). Treat for pain (see page 20).
Both legs There may be considerable blood loss if both legs are broken. Look for signs of shock (see page 17), and if necessary, give appropriate treatment. Prepare well-padded stiffish supports reaching from the thigh to the ankles for below-the-knee
fractures, and from the armpit to the ankles for above-the-knee fractures. Pad between the thighs, knees, legs, and ankles. Then bring both feet together as gently as you can, using traction if necessary (page 21) .. Now tie a figure-of-eight bandage round the feet and ankles to keep the feet together. The padded splints should now be applied to the outside of both legs. Tie with enough encircling bandages to keep the splints and the legs secured firmly together. Avoid making any ties over the site of any break. Then check circulation and feeling in the toes as described on page 22. The casualty should be moved while remaining straight and flat on a stretcher (Fig. 37). Treat for pain (page 20).
Ankle and foot A fracture of the ankle or foot is usually caused by a fall, a twist, or a blow. Pain and swelling will be present, along with marked disability. Treatment. If available, a half-leg, inflatable air splint should be applied. If conventional splints are applied, the ankle should be well-padded with dressings or a pillow. The splints, applied to each side of the leg, should extend from mid-calf to beyond the foot (see Fig. 38). Treat for pain (page 20).
Dislocations A dislocation is present 'when a bone has been displaced from its normal position at a joint (Fig. 39). It may be diagnosed when an injury occurs at or near a joint and the joint cannot be used normally. Movement is limited. There is pain, often quite severe. The pain is made worse by attempts to move the joint. The affected area is misshapen both by the dislocation and by swelling(bleeding) which occurs around the dislocation. Except that there is no grating of boneends, the evidence for a dislocation is very similar to that for a fracture (page 19). Always remember that fractures and dislocations can occur together.
First aid Dislocations can be closed or open. If a wound is present at or near a dislocation, the wound should be covered both to stop bleeding and to help prevent infection. Do not attempt to reduce a dislocation. A fracture may also be present, in
which case attempted manipulation to reduce the dislocation can make matters worse. Prevent movement in the affected area by suitable immobilization. The techniques for immobilization are exactly the same as for fractures of the same area(s) (pages 19-37). Look out for impaired circulation and loss of feeling (see page 22). If these are present, and if you cannot feel a pulse at the wrist or ankle, try to move the limb gently into a position in which circulation can return, and keep the limb in this position. Look then for a change in colour of the fingers or toes, from white or blue to pink. Transport the casualty in the most comfortable position. This is usually sitting up for upperlimb injuries and lying down for lower-limb injuries. For further treatment of dislocations, see Chapter 4, page 82. .••
Head injuries Head injuries commonly result from blows to the head and from falls, often from a height.
.. , the edge of the dressIng, and the pad IS held In place by a bandage. The pad should press on the blood vessels but not on the foreign body or the fracture. A ring-pad can be made by passing a narrow bandage twice around the fingers, of one hand to form a ring and then wrapping the remainder of the bandage around the ring to form a doughnut-shaped pad (Fig. 40).
Most preventable deaths from serious head injuries are the result of obstructed breatbing and breathing difficulties, not brain damage. Apart from covering serious head wounds, your attention should be concentrated on the life-saving measures that support normal breathing and prevent obstructed breathing (see Airway, page 7). This will ensure that the brain gets sufficient oxygen. In this way, you have a good chance of keeping the casualty alive until he can have skilled medical aid in a hospital. Get RADIO MEDICAL ADVICE.
... ExplosIOns pr?duce sudden and vIolent dlsturbances of t~e. au. As a res~lt men may be throw~ ~own or Injured b~ ~alhng wreck~ge. In addIh~n, the bla.st of au Itself may strIke the body ~Ith suc~ .vI?lence as to cause seve~e .or. fatal Internal InJUrIes. There may be blast InJurIe~ to ~ore th~n. o~e part of the bo~y; a~y combInahon of InjUrIes to the folloWIng sItes may be found ..
See the section on assessing the significance of a head injury (page 73) for a fuller discussion of the subject . In the case of some head injuries or where a foreign body or a fracture is directly below an open wound, it may not be possible to control bleeding by pressure. In such circumstances a ring-pad should be used. A paraffin gauze dressing is placed over the wound, a suitably sized ring-pad is placed around the wound and over
Blast can damage th~ small blood ves~el~ of the lungs so that bleedIng takes place InsIde the lungs. The patient will be shocked and he will have difficulty in getting his breath, together with a feeling of tightness or pain in the chest; his face will usually be blue, and there may be blood-stained froth in his mouth. Carry the patient into the fresh air, if this is reasonably possible. Support him in a half-sitting position (see Fig. 31, page 33). Loosen tight clothing.
MEDICAL FIRST AID: COMPENDIUM
Keep him warm. Encourage him to cough and spitout any phlegm. Morphine must not be given. Artificial respiration by the mouth-to-mouth method should be given if breathing fails.
Head Blast injuries to the head are rather like concussion (page 74). In some cases there may be paralysis of the limbs due to damage to the spinal cord. The patient may be completely unconscious or extremely dazed. In the latter case people may be found sitting about, incapable of moving and taking no notice of what is going on. Although often to all outward appearances uninjured, they have no energy or will to move. They are momentarily "knocked silly" and may behave very foolishly. For example, although there may be an easy way of escape from a sinking snip, they may be too dazed to take it, or, if one of them should fall, he might drown from immersion in only 20 cm of oil or water because he has not the sense to get up. If patients are unconscious, ingly (page 3).
treat them accord-
If they are dazed, take them by the hand and lead them to safety. Tell them firmly everything that they must do. Think of them as very small children. By acting in this manner you may save many lives. For example, you may prevent men going down with the ship when they have not the sense to abandon it.
Abdomen Bleeding is caused inside the abdomen by blast damage to the organs there. Such damage is usually due to the effects of underwater explosions on men in the sea. Shock and pain in the abdomen are the chief signs; they may appear some time after the explosion. For treatment, see Injury to the abdomen (Internal injuries, page 73) and Internal bleeding (below).
Internal bleeding can be concealed or visible. Bleeding round a broken limb may be concealed but may be detectable because it causes a swelling, the size of which shows the amount of the bleeding. Bleeding into the chest or abdominal cavities may be revealed if blood is coughed up or is vomited. Stab and puncture wounds can cause serious internal bleeding. The casualty will be shocked. At first he will be pale, giddy, faint, and sweating. His pulse rate and respiration rate will rise. Later his skin will become cold and his extremities will become slightly blue. The pulse will become difficult to feel and very rapid (Fig. 41). The breathing will be very shallow. He will complain of thirst and nausea, become restless, and complain that he cannot breathe properly ("air hunger"). These three signs show that bleeding is still occurring. Later he will cease to complain, lose interest in his surroundings, and become unconscious. The most important indication of continuing bleeding is a rising pulse and falling blood pressure. Anyone in whom internal bleeding is suspected must therefore have his pulse rate and blood pressure recorded at fixed and frequent intervals, say, every 5-10 minutes. After about an hour of such recording it should be clear whether or not he is bleeding internally. If the patient's blood pressure remains about normal, and the pulse rate falls or remains steady, he is not bleeding. People who have concealed internal bleeding may need a blood transfusion. Get RADIO MEDICAL ADVICE. It is important to keep what blood is available circulating around the lungs and brain. Lay the casualty down with a slight head-down tilt. Raise the legs to divert the blood out of the legs . towards the brain and lungs. Maintain this position when transporting the casualty to the ship's hospital or to a cabin. Ifhe is restless or in severe pain, morphine may be given (page 1~ 1).
Internal bleeding Internal bleeding may result from a direct blow to the body, from strains, and from diseases such as peptic ulcer.
Bleeding from the nose Pinch the soft part of the nose firmly for 10 minutes while keeping the head well forward
over a basin or bowl. The pinching is most easily done by the casualty himself. At the end of to minutes, slowly release the pressure and look for drips of blood in the basin or bowl. Absence of drips will show that bleeding has stopped (Fig. 42).
Instruct the casualty not to blow his nose for the next four hours and to refrain from violent noseblowing over the next two days. If bleeding has not stopped, continue pressure on the soft part of the nose for a further 10 I
each side to help maintain pressure and stop the fingers slipping. Pressing is usually most easily done by the casualty himself under the direction of another person or with the aid of a mirror (Fig. 43).
Bleeding from a tooth socket See Dental emergencies, page 184.
Bleeding from the ear passage This is usually caused by a head injury or by blast. Place a large pad over the ear and bandage it in position. Keep the affected ear downwards. If the casualty is unconscious, place him in the unconscious position (see Fig. 3, page 6) with the affected ear downwards. Never plug the ear passage with cotton wool or other material. Get RADIO MEDICAL ADVICE. Choking Choking is usually caused by a large lump of food that sticks at the back of the throat and thus stops the person concerned from breathing. The person then becomes unconscious very quickly and will die in 4-6 minutes unless the obstruction is removed. Choking can be mistaken for a heart attack. The distinguishing features are:
minutes and release slowly again. If bleeding has not stopped after 20 minutes, it may be necessary to pack the affected side of the nose with strip-gauze.
Bleeding from the lip cheek and tongue ' , Press on both sides of the lip, cheek, or tongue to stop bleeding. Use a piece of gauze or a swab on
• the person who is choking may have been seen to be eating; • the person who is choking usually cannot speak or breathe; this is not the case if the person is having a heart attack; • the person who is choking will turn blue and lose consciousness quickly because of lack of oxygen; • the victim of a choking incident can signal his distress (he cannot speak) by graspin~ h~s neck between .?ng~r .and .th?,mb. ~hl~ ~s known as the HeimlIch sign . an~ If It IS !lnderst?od by all personnel the nsks mvolved m chokmg should be reduced. If the casualty is conscious, stand behind him, place ~our closed fist (thumb side) agai~st t~e place m the upper abdomen where the nbs dlvide. Grasp the fist with your other hand. Press suddenly and sharply into the casualty's
[Note: page 184 of IMGS has not been included in this compendium]
abdomen with a hard quick upward thrust. Repeat several times if necessary (Fig. 44). For self-treatment, try to cough forcibly while using your own fist as described above; alternatively, use the back of a chair, the corner of a table or sink, or any other projection that can be used to produce a quick upward thrust to the upper abdomen. If the casualty is unconscious, place him on his
back and turn the face to one side. Kneel astride him and place one hand over the other with the heel of the lower hand at the place where the ribs divide. Press suddenly and sharply into the abdomen with a hard quick upward thrust. Repeat several times if necessary (Fig. 45). When the food is dislodged, remove it from the mouth and place the casualty in the unconscious position (see Fig. 3, page 6). Suffocation (See also: Ventilation, Chapter 15"page 283.) Suffocation is usually caused by gases or smoke. Remember that dangerous gases may have no smell to warn you of their presence. Do not enter enclosed spaces without the proper precautions. Do not forget the risks of fire and/or explosion when dealing with inflammable gases or vapours. Fi rst aid Get the casualty into the fresh air. If necessary, give artificial respiration and heart compression and place in the unconscious position (see Fig. 3, page 6). Administer oxygen (see page 51). Strangulation . Hanging is one form of strangulation and is fortunately rare on board ship. It is not always deliberate, but can be an accident. It is important to have a clear mental picture of the scene, so that your evidence is helpful at any later inquiry. The face in hanging is dark blue from interference with blood supply to the head, the eyes protrude, and the face and the neck are swollen. [Note: page 283 of IMGS has not been included in this compendium]
In a narrow space, the simplefore-and-aji carry may be best. One helper supports the patient under his arms, and the other under his knees. Other methods of manhandling strated in Fig. 47-55.
shoulders and his spare hand to hold the casualty's thighs. If conscious, the casualty may help to support himself with his hands on the sh ou Iders 0 f th e h e Ipers .. The simple pick-a-back method is useful only where the casualty is conscious and able to hold on by putting his arms round the carrier's neck.
One advantage of the three-handed seat (Fig. 50 and 51) is that one of the helpers has a free arm and hand that can be used either to support a.n injured limb or as a back support for the casualty. Which of the two helpers has the free arm will depend on the nature of the injury. As a last resort, the drag-carry method may have ' to be used In narrow spaces, partIcularly where there is wreckage following an explosion and where it may be possible for only one man to reach a trapped patient and rescue him. After
the initial rescue, two men may be able to undertake further movement through a narrow space. The method is demonstrated in Fig. 53 and Fig. 54. Ensure that the tied wrists do not interfere with any breathing apparatus the rescuer may be wearing.
Neil-Robertson stretcher (Fig. 56)
A number of modifications of this type of stretcher exist under various names. A good general-purpose stretcher for use on board ship, it is easily carried, gives firm support to the patient, and is particularly useful in narrow spaces, when difficult comers have to be negotiated, or when the patient has to be hoisted. I
The stretcher is made of stout canvas stiffened by sewn-on bamboo slats. The upper portion takes the head and neck, which are steadied by a canvas strap passing over the forehead. The middle portion is wrapped round the chest and has notches on which the armpits rest. This part has three canvas straps which are used for fastening the stretcher round the chest. The lower portion folds round the hips and legs down to the ankles.
If the patient is unconscious, place him on his back and tie his ankles and feet together with a figure-of-eight bandage, and his knees with a broad-fold bandage; also his wrists (Fig. 57).
with one hand and, with the other, slides the stretcher under the patient, at the same time opening out the flaps, When the stretcher is in position, No. I gives the order to lower and all lower together,
Three persons are required to carry out the lift. No: I, takes ~harg~; .he stands astride the pattent s le~s, with his nght hand un~er the ~eft calf and his left hand under the nght thigh (Fig. 57~. No.2 stands astride the .chest and clasps his hands underneath the patient. No.3 places the patient's wrists (tied together) round No. 2's neck. If the patient is conscious he may himself be able to clasp his hands round the neck of No.2. The stretcher, with all straps unfastened, should be positioned close to the head of the patient. If spinal injury is suspected, extreme . , .. care should be exercised 10 movmg the casualty (see page 28). No. 1 now gives the order to lift, while No.3 supports the head of the unconscious patient
The stretcher is now strapped up and the patient is ready for removal (Fig. 59); this can be done most conveniently with four bearers (Fig. 60), The Neil-Robertson stretcher can also be used to remove casualties vertically (Fi ,61). g First aid satchels or boxes These should contain iodine solution, a large standard dressing, 2 medium standard dressings, 4 small standard dressings, 8 triangular bandages, some cotton wool, safety pins, sticking plaster, scissors, and a pencil and paper. · ' " · 0ne box shOU Id be mcIu ded 10 th e shIp s med 1. &' ' &'. · cme Iocker lor SWIfit t ransler t0 th e Sl te 0 f an 'd ' .. acci ent. 0t hers pIaced at strategic positions, particularly in a large ship, can be an aid to prompt action if the crew are made aware of
their location and contents. These extra boxes are, however, liable to be thoughtlessly used for minor unreported casualties and, in some instances, are subject to pilfering. Routine checking of their contents is therefore essential.
Emergency medical outfits There is a special need on merchant vessels, and on medium-sized and large fishing vessels with crews numbering over 20, for an emergency medical outfit readily accessible for use if the medical cabinet should be destroyed or made inaccessible by fire. The emergency outfit should be sited well away from the ship's medical cabinet or the ship's hospital.
Oxygen administration (oxygen therapy) Oxygen is essential to life. It is given for treatment when the body is unable to get enough oxygen from the air because of damage to the lungs or for other reasons, such as suffocation (see page 43) or carbon monoxide poisoning (page 58). Oxygen must be given with care since it can be dangerous to patients who have had breathing difficulties for a number of years due to lung disease, particularly chronic bronchitis. Oxygen should be given only where advised in this guide. Usually, it is given to a patient who is breathing without assistance but is unconscious or cyanotic (has bluish skin); also, oxygen should be given to all patients suffering from carbon monoxide or other toxic gas poisoning even when they are conscious. There are two stages at which a patient may require oxygen: (1) during rescue from the place of an accident, and (2) when the patient is in the ship's sick-bay.
During . rescue from the place of an accident During this time the patient should be connected to the portable oxygen apparatus through a
. face. The oxygen valve mask placed over his should be turned on and oxygen admjnistered until the patient is transferred to the ship's sickbay.
MEDICAL FIRST AID: COMPENDIUM
When the patient is in the ship's sick-bay
The procedure set out below should be followed.
The unconscious patient 1. 2.
Ensure that a clear airway has been established (see page 7) and an airway (see page 104) has been inserted. Place over the nose and mouth a disposable mask designed to give 35% oxygen to the patient. Ensure that it remains securely in place. Check that the equipment is correctly assembled according to the manufacturer's instructions and that the cylinder contains sufficient oxygen. Connect the mask to the flowmeter, using the tubing provided, and set the flowmeter to 4 litres per minute. Administration of oxygen should continue until the patient no longer has difficulty in breathing and has a healthy colour.
The conscious patient 1.
3. 4. 5.
All other patients should be given 35% oxygen, using an appropriately designed mask, with the flowmeter set at 41itres per minute. The mask should be placed over the patient's mouth and nose and secured in place. The patient should be placed in the high sitting-up position (see Fig. 31, page 33). Check that the equipment is correctly assembled according to the manufacturer's instructions and that the cylinder contains sufficient oxygen. Turn on the oxygen flowmeter at 4 litres per minute.
Oxygen therapy should be continued until the patient no longer has difficulty in breathing and has a healthy colour. If the patient has difficulty in breathing, or the face, hands, and lips remain blue for longer than 15-20 minutes, he probably has one of the following complications: bronchitis (see page 177), pneumonia (see page 221), circulatory collapse in congestive heart failure (see page 205), or pulmonary oedema. In such a case, seek RADIO MEDICAL ADVICE.
Ask the patient whether he usually suffers from severe difficulty in breathing and a chronic cough, i.e., chronic bronchitis (see page 178). If the patient has severe chronic bronchitis, then he should be given only 24% oxygen, using an appropriately designed WARNING. Smoking, naked lights, or fires mask, with the flowmeter set at 41itres per must not be allowed in a room where oxygen is minute. being administered, because of the risk of fire.
[Note: pages 104, 178, 177, 221 and 205 of IMGS have not been included in this compendium]
Toxic hazards of chemicals, including poisoning
Ships carry a number of substances in addition to cargo that are potentially toxic. For instance, medicines are not generally poisonous but can become so if taken other than as prescribed. Then there are substances like cleaners, degreasers, and disinfectants that can give rise to toxic hazards through misuse. For instance, emptying a bucket of bleaching solution into a lavatory bowl containing a proprietary caustic cleaner may result in the release of poisonous gas in a confined space. Notes on specific toxic substances are given at the end of this chapter (pages 57-59). Toxic substances can affect the body in various ways: • through the lungs by inhalation of toxic gases and fumes; • through the mouth and digestive system, if swallowed; • thr.ough skin contact; • through eye contact.
Contents Diagnosis of poisoning Inhaled poisons Swallowed poisons Skin contact Eye contact Special considerations Specific toxic substances Prevention of poisoning
54 54 55 56 56 56 57 58
Note. More detailed
information on the treatment of the effects of specific chemicals is given in the Chemicals Supplement to the present guide, Le., the Medical first aid guide for
Breathing in is the most co.mmon route of poisoning in the shipping industry and the toxic substance may consist of vapour, gas, mist, spray, dust, or fumes. Swallowing of a poison occurs less frequently and is usually the result of an accident. Absorption through the skin and by inhalation may have a delayed effect. The substances that cause harm do so by burning, or causing local damage to, the skin, eyes, or other tissue, or by general poisoning after absorption. Allergic reactions are also possible. The effects may be sudden and dramatic, or gradual and cumulative. The damage may be temporary or permanent. Suspect every chemical to be dangerous until you know otherwise. Whatever the cause of the poisoning, treatment must be prompt. Complications of poisoning can be avoided by rapid emergency treatment.
use in accidents involving dangerous goods.' Medical first aid guide for use in accidents involving dangerousgoods. London, International Maritime Organi-
MEDICAL FIRST AID: COMPENDIUM
Diagnosis of poisoning
The general symptoms of poisoning include:
• headache • nausea and vomiting ~ drowsiness • changes in mental behaviour • unconsciousness • convulsions • pam. Signs of severe poisoning are:
The diagnosis of poisoning may be simplified if one or more of the following factors point to the probable cause: • the circumstances of the incident, e.g., a leakage of chemicals; • the nature of the illness, and its relationship in time to recent exposure to chemicals; • the epidemiological aspects, e.g., if more than one person is involved and all develop a similar illness. It must be realized however that: • the effects of some poisons resemble those of natural illness, e.g., vomiting and diarrhoea, or collapse; • because a ship is carrying a cargo of chemicals it does not follow that the cargo is responsible for the illness (this is, in fact, unlikely unless there is evidence of a leakage); • different individuals may be exposed to the poison at different times, or to a different extent during a single episode, and they may as a result become ill at different times or to differing degrees; • individuals react differently to poisons according to their health, their constitution, and the extent of their exposure to the poison. In a typical case of poisoning, three stages of illness may be distinguished, namely latent, active, and late.
The latent stage This is the interval between the moment of entry of a poison into the body and the appearance of the first symptoms (feelings) or signs. These usually occur rapidly after exposure, but in some cases there may be a delay of several hours before they develop.
The active stage' This is the stage at which the signs and symptoms of the poisoning are apparent. Often there are a great many different chemicals that could produce these signs and symptoms and they therefore have to be treated in a general way.
• • • •
a rapid and weak pulse grey or blue colour of the skin severe difficulty in breathing a prolonged period of unconsciousness.
The late stage The signs and symptoms usually resolve after a few hours in the majority of incidents, particularly if the degree of exposure is small. If a greater amount of chemical has been absorbed, or the period of exposure prolonged, or the chemical is very toxic, symptoms may persist for some hours or even days. The patient's condition may deteriorate as a result of complications, the most common of which are: suffocation (page 43), bronchitis (page 177),pneumonia (page 221), pulmonary oedema, heart failure, circulatory collapse, liver failure, and kidney failure. For details regarding various toxins, the signs and symptoms of poisoning by them, and the appropriate first aid and follow-up treatment, refer to Medical first aid guide for use in accidents involving dangerous goods,l the Chemicals Supplement to the present guide. Inhaled poisons Many chemicals produce fumes that can irritate the lungs and cause difficulty in breathing. They also produce such symptoms as cough and burning sensation in the chest.
Medical first aid guide for use in accidents involving dangerousgoods. London, International Maritime Organi-
[Note: pages 177 and 221 of IMGS have not been included in this compendium]
2: TOXIC HAZARDS OF CHEMICALS
Gases such as carbon dioxide (page 57) and carbon monoxide (page 58) may also be poisonous, particularly in a confined space, because they replace oxygen in the air and blood. The main symptoms are: ... • difficulty m .br~athmg • headach~, dlzzm~ss, and nausea • unconsciousness m some cases.
vomiting (sometimes the vomit IS bloodstained), abdominal pain, colic, and later diarrhoea. Examples of such poisons are arsenic, lead, poisonous fungi, berries, and contaminated or decomposed food (see Food-borne diseases, page 199). Particularly severe symptoms are caused by corrosives, strong acid, alkalis, or disinfectants, which bum the lips and mouth and cause intense pain.
Always remembe~ t~at some poisonou~ gases, such as ~arbon dIOxide, carbon monoxide, and some ~efngerant gases, hav~ n~ smell to warn you of theIr presence (see VentIlatiOn! page 283, for. rescue from an enclosed contammated space). Remember that the presence of certain gases, e.g., hydrogen, may make it necessary to take precautions against fire and explosion.
Other poisons produce general toxic effects without irritation of the gastrointestinal tract. After ingestion, the onset will be gradual, following their absorption into the blood stream and their effect on the nervous system, which may cause uncnsciousness and ~eath. Exampies .a~e the vafl~us t!,pes of sedatlv~ tablets. or medlcmes for pam rehef, when taken m excessive amounts. Alcohol taken to excess may likewise act as an acute poison .
Treatment • Remove the casualty at once into the fresh air. Loosen tight clothing and ensure a free airway
(page 7)..... • Start artIficial ~esplratI