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Guest blog - Dr. John Martin

This month, we’re delighted to introduce Dr John Martin as our guest blogger. John’s specialty is neurology, but with a keen interest in sailing amongst other sports, he’s able to apply his specific knowledge to our salt-watery, pre-hospital environment very effectively! Over to Dr John…

In the Beginning

In 1995, I was asked by a local GP for an opinion on types of cervical collars for rugby players. Within a corneal reflex of time thereafter I found myself appointed as medical officer to the team. 


Next came a call to be pitchside with the national team, an association with Resuscitation and Emergency Management Onfield (REMO), providing training courses for the English FA, running immediate care courses for the University of Wales Institute Cardiff (UWIC) in Cardiff (across all sports) and for the medical teams of the professional and semi-professional teams in south Wales. It’s important to note that pre-hospital immediate care presents challenges that elevate pre-hospital care to a speciality of its own. 


I have just completed the Safety at Sea course with South West Maritime Academy and returned from my annual sail off the West Coast of Scotland.  I already have experience of stabilising a casualty whilst awaiting ambulance transfer, which is a matter of minutes usually. But it’s a bit of a different time scale at sea! I am very much looking forward to being on board and being part of the medical team.

What I have learnt over the years

It is said that the best battle plans go completely out of the window when the first bullet is fired and certainly I have seen the medical equivalent. 

Another area, apart from the pre-injury team organisation, is the necessity to ensure that the care and equipment are updated as the recognised standards change. In the training scenarios it is also good to remember that it might be the lead doctor that gets the injury!


Of course, all casualty treatment starts with ABC which is fine for an ‘in-house’ cardiac arrest. But let’s start with ‘S’ for Safety First. 

We need to consider whether the engineer has collapsed due to a build up of noxious gases that could harm us. Or is there a risk of other dangers such as falling debris, floor instability or electrical hazards? Then perhaps we also include haemorrhage control of any obvious heavy external haemorrhage and need to apply a clean dressing and pressure. 


There may be internal haemorrhage from an object that has penetrated (such as a piece of railing etc). Ensure that the piece is somehow secured so it cannot penetrate further (I’d suggest a gate clamp or whatever you have to hand) Don’t ever try to remove a penetrating object!

We would always assume that the unconscious trauma victim has a fractured cervical spine injury until proven otherwise. So now let’s add ‘with cervical spine immobilisation’ to our A for Airway. 


My immediate consideration, that parallels the mantra, is the fact that the unconscious patient is just about to vomit. If the airway is clear, move swiftly onto B for Breathing. If not, it’s worth remembering that any manoeuvres in the mouth may induce vomiting so be prepared on every level! Open the mouth and use a pen-torch to look inside. 


The pen-torch has a larger diameter than the suction tubing, so if the patient clenches their teeth during an epileptic seizure they won’t be biting the end off the suction tube (or your finger if you’ve left it in the wrong place!). Remember to only suck under direct vision and only to suck on the way out. This is also a chance to view the posterior pharyngeal wall (back of the throat). If it is swollen or bruised it may represent a high cervical injury such as an odontoid peg fracture. 


If there are dentures and or other prosthetics visible and they are firmly in place, leave them there. A naso-pharyngeal airway (NPA) is better tolerated than an oropharyngeal airway (OPA) and less likely to initiate a gag reflex (remember that risk of vomiting!). 


The consideration of a skull base fracture is a relative and not an absolute contra-indication. If the patient tolerates an oro-pharyngeal airway readily, then either they are in a deep coma or the airway is too small. If there is now manual in-line spinal immobilisation, how are we to manage vomiting? Suction may be possible, but are we prepared to do either a 4, 3, or 2 man log roll to avoid aspiration of gastric contents? Even a one man roll may be necessary. It’s not ideal but may be the only option to avoid aspiration in a confined space.


These scenarios must be rehearsed. 


Prompt spinal immobilisation will enable the spinal board to be fully tilted by one person kneeling at the side and rotating the board away from them should vomiting occur.  Training sessions that focus on the immediate management of the unconscious patient in a variety of awkward positions, will focus on a team approach as members are designated specific roles. 


This begins with time dedicated to familiarity with all equipment, where to find these pieces in the kit bag and how to assemble them. For instance, flat packed cervical collars can be a source of confusion to the novice.  The well-established spinal board can be used as a ‘sledge’ to slide the patient into a more accessible area. 


Remember to secure the chest straps first, followed by the pelvis, so that if vomiting starts early, the heaviest part is secure and the head can simply be held while the board is rotated. Position your tallest responder opposite the smallest and tallest next to smallest. It sounds complicated, but basically the tallest are diagonally opposite. 


The team should train in terms of recognising the optimum way to lift a spine board from the round and how to allocate members based on individual height. The patient should be removed from the spinal board as soon as practical (after ABCDE) and managed in a vacuum extraction immobilisation bag. This will not only prevent pressure sores but will also prevent hypothermia whilst awaiting transfer to definitive care.


So where are we now?

The airway is clear and we apply oxygen (but check if it is a safe environment to put on 100% oxygen?), preferably with the use of an oxygen saturation monitor (SpO2). Aim for lower than optimal saturation if the patient has COPD (where 88-92% is considered appropriate in a patient with COPD). Ensure a trauma mask has its rebreathing bag filled before application.


Moving down. Check the trachea is central. But here we have to check the collar again. Even relatively light pressure on the jugular veins can elevate the intracranial pressure - which is a bad thing. Certainly I have treated patients in whom the medical attendants have applied a collar that is a bit on the small side, with the collar subsequently acting as a ‘neck warmer’ rather than an immobiliser. The consequence is raised intracranial pressure. The mistake can arise when sizing a collar, as the collar immobilises the neck by anchoring on the chin superiorly (at the top) and the trapezius muscle inferiorly (at the bottom). So the collar size is measured accordingly. One common mistake is a measurement taken on from the angle of the mandible. The collar won’t fit and subsequently a collar that is much too small is applied in error simply because it was easier and looks effective. 

Moving on to the chest and full exposure. 


Look, feel, listen seems straightforward enough. However make sure you also look at the abdomen. If there is paradoxical breathing (on inspiration the abdomen goes out rather than in and the chest doesn’t expand), there may be a lower cervical spinal fracture. In this scenario, the patient has paralysis of every muscle below the fracture (including the intercostal muscles) except the innervation to the diaphragm, via the phrenic nerve, which originates above the fracture level (the cervical vertebrae numbers 3, 4 and 5). If there is a fracture above that level the patient will not be breathing at all. 


There will be signs of neurogenic shock. This can be seen on occasions when the sympathetic nerve fibres below the fracture are not working and the parasympathetic fibres are unopposed. This means the patient will be very warm below the level of the fracture but also the skin will be very dry. There will be a level of temperature contrast which can be felt on the chest wall. Below the level of fracture the skin will be hot and dry and above the level the skin will be much cooler and very sweaty (clammy). Sometimes an actual line of sweat can be seen circling the chest. There will be associated low blood pressure and bradycardia (slow heart rate). 


The patient is unconscious so you will not be able to discern spinal shock easily. Sucking penetrating wounds need a three-sided adhesive dressing and thoracic decompression (tube) may be required if a tension pneumothorax is suspected when you assess for hyper-resonance on percussion, diminished air entry and a possible deviated trachea. The chest examination is not over until the back is examined (looking for step fractures, penetrating wounds, etc) and this is where, when immobilising the patient initially on the spinal board, we leapt a step out of sequence and examined the back as we log rolled onto the spinal board. 


Then it’s back to the start and if there are no changes (A, B) we get onto C - circulation. 


If possible we would use a wide bore cannula, ideally more than one. There is significant emphasis on intraosseous delivery (drilling into the bone) rather than intravenous for initial fluid therapy and indeed there are some areas of the world where it is the first line of fluid replacement. Warm fluids are best and we ensure urinary output is measured (via a catheter) to assess organ perfusion - how well the blood, with its oxygen and glucose, is circulating to the organs. 


Splinting long bone fractures is part of haemorrhage control. There are lots of different splinting devices to re-align fractures and here again, familiarity from training sessions pays dividends. Practice makes perfect!


Fire is a serious ship hazard and as such burns victims may certainly need significant fluid volume replacement before the helicopter arrives. Tourniquets can be life savers but must be frequently revisited to ensure one problem has not been changed for another. Scalp lacerations are common and can be extensive with significant haemorrhage. But pressure bandages can be difficult to keep in place on heads. I’ve found that large sutures tied tightly are the best primary management to stop haemorrhage even over depressed fracture. If bone is missing, then put saline soaked gauze over the wound and suture around the skin edges if there is a partial avulsion (torn off skin) of the scalp.


When you are handing over to either another crew member or a medical professional, such as a helicopter crew, there are a number of acronyms that are useful and rather universal to aid completeness.


SBARD

Situation

Background

Assessment

Recommendations

Decisions


In other words you have assessed and treated the patient and are now conferring regarding the decisions made, ready for the next line of care.


SAMPLE

Signs and Symptoms

Allergies

Medications

Past Medical History

Last Eaten


Useful for a medical (rather than trauma) handover to cover other aspects that may be pertinent.


RSVP

Reason (Injury is usually the reason and this is basically the nature of it)

Story (History so far)

Vitals (BP etc)

Plans (extrication)


MIST

Mechanism

Injuries

Symptoms and Signs

Treatment(s)


Similar to SBARD. This is my personal preference really.


Note from the Red Square Medical team - we love this one too, and normally add AT at the beginning to make it ATMIST. So starting with the patients AGE and gender, then the TIME of the incident. 


We hope you’ve enjoyed this insight into John’s advice for treating onboard and what we’ve taken from it is the need for familiarity with kit, with the crew onboard, and to carry out regular drills to make sure everyone knows their role and how to work together in the best interest of the patient. 

Guest blog: Jordan Lin

by Rachel Smith • 08 May, 2024
At Red Square Medical, we’re keen to support those who have a passion for maritime medicine. While we can’t provide placements for everyone, occasionally a request pops up at just the right time and we can provide some experience and insight into our unique and specialised world. Last year we were contacted by Jordan Lin, a medical student with a love of the ocean. This is his story… When I was a boy, my dad and I used to go fishing with a local fisherman off the Norfolk coast. I absolutely loved being on the sea and so for quite a long time, I wanted to be a fisherman. When I got a bit older I kind of forgot about this and think I may have been slightly put off by watching the TV series ‘World’s Deadliest Catch’! But I have always loved being on the water and spent a lot of time sailing dinghies; I was also a swimming teacher for children back in high school and college. Later, I decided to study medicine and I’m now a final year medical student at the University of Bristol where I completed an intercalated degree; a Masters in Health Sciences Research. I’m now looking forward to starting work as a qualified Doctor in August. Though having spent 6 years training, my next 2 years will be spent working for the required two foundation training years that must be completed before being able to work independently as a Doctor in the UK. At university, I joined the VITA network which is a group dedicated to developing a health and public health approach at the heart of any response to human trafficking and exploitation. I became the blog coordinator for the organisation and you can read the blogs, including those that I have written, here: https://vita-network.com/blog/ In my spare time, I have been involved with the Bristol University Hot Air Ballooning Society and trained through the society to get my Balloon pilots licence. So, I often spend weekends during the summer flying in a leisurely fashion over Bristol and the surrounding area!

That Lightbulb Moment!

by Rachel Smith • 24 Apr, 2024
At Red Square Medical, we’re fascinated by the learning process - it’s key to our business after all. But we often wonder what happens when our students leave the classroom. Do they remember what they’ve learnt? What if they’re faced with a real emergency, will they know what to do? Is there a lightbulb moment when it all clicks into place? Skill fade is a very real issue, as we wrote about in this blog , and we know that setting up drills and practice scenarios when you’re back in your environment, with your kit and crew, can make a massive difference. It’s great to get some feedback from our students too. Last year, we received photos from the Southern Ocean from a solo round the world sailor who was able to successfully steri-strip a cut eyebrow closed. Or the Captain who recognised a heart attack in a crew member because they looked just like the guy he saw in the video on one of our courses.

Worse Things Happen at Sea… a salty tale of dysentery, haemorrhoids, accidents, depression and death!

by Rachel Smith • 03 Apr, 2024
You might wonder about the title of this month’s guest blog, as Worse Things Happen at Sea is also the name of our monthly newsletter. But this month, we’re delighted to introduce Andrew Edwards as our Guest Blogger, and we felt his amazing story about life at sea really deserved a dramatic headline… Dysentery... In the summer of 1966, I was a cadet on a cargo ship that loaded in the UK for 9 ports in West, South and East Africa. Our first port of call was Luanda, the capital of Angola – which was then a colony of Portugal. Next, 300 miles down the coast we called in to Lobito – also in Angola. In Lobito two of the ship's company contracted dysentery; myself and a big Irishman called Reg. The shoreside Doctor we saw simply diagnosed the condition (amoebic dysentery) and said, ‘sorry but I have no antibiotics for this!’. Thankfully the ship’s purser stood our corner and demanded that the Doctor find some. The following day the antibiotics were flown in from the Belgian Congo. The Doctor gave us no advice as to how to deal with the condition, not a word about how contagious it was, not a word as to the importance of thoroughly washing our hands and maintaining scrupulous personal hygiene. Thankfully both Reg and I were quartered just a short sprint from the heads, and we were left to get on with it by our shipmates. It took about a week to get over the dysentery, by which time I had lost several stone in weight and was as weak as a kitten. By the time we arrived in Walvis Bay, South West Africa (now known as Namibia), a further 1000 miles south, I was just about fit enough to play football for the ship against a local team. Their football ground had a main road going right through the middle of it which made for some challenging moments, but they still beat us comfortably and they were playing in bare feet!

How does the Easter Bunny avoid Diabetes?

by Rachel Smith • 20 Mar, 2024
As it’s Easter, we thought that it would be a very appropriate time, what with all that chocolate around, to take a closer look at the subject of Diabetes and why it’s such a huge problem in the UK and across the world. The Easter Bunny always looks so cute and cuddly, but is he a diabetes case waiting to happen? Or does his diet of grass and all that hopping around for the rest of the year make an important difference? According to the WHO, diabetes is a chronic, metabolic disease which is characterised by elevated levels of blood glucose (or blood sugar). Over time, this leads to serious damage to the heart, blood vessels, eyes, kidneys and nerves. The most common is type 2 diabetes, and it usually develops with a late onset in adults. It occurs when the body becomes resistant to insulin or doesn't make enough insulin. Worryingly, in the past 3 decades the prevalence of type 2 diabetes has risen dramatically in countries of all income levels and is closely linked to obesity, poor diet, and an unhealthy lifestyle. Symptoms for type 2 diabetes are generally similar to those of type 1 diabetes (need to urinate often, thirst, constant hunger, weight loss, vision changes and fatigue), but are often less marked. As a result, the disease may be diagnosed several years after onset, after complications have already arisen. For this reason, it is important to be aware of risk factors. Effective approaches are available to prevent type 2 diabetes and to prevent the complications and premature death that can result from all types of diabetes. These include policies and practices across whole populations and within specific settings (school, home, workplace) that contribute to good health for everyone, regardless of whether they have diabetes, such as exercising regularly, eating healthily, avoiding smoking, and controlling blood pressure and lipids. Type 1 diabetes, once known as juvenile diabetes or insulin-dependent diabetes, is a chronic condition in which the pancreas produces little or no insulin by itself. Normal onset is in younger people, but can also be in adults. Symptoms of type 1 diabetes include the need to urinate often, thirst, constant hunger, weight loss, vision changes and fatigue. These symptoms may occur suddenly. Type 1 diabetes cannot currently be prevented. It’s thought to be caused by an autoimmune reaction which destroys the cells in the pancreas that make insulin. It can also be caused by genetics, viruses, trauma, tumours, removal of the pancreas or other damage to the pancreas. About 422 million people worldwide have diabetes, the majority living in low-and middle-income countries, and 1.5 million deaths are directly attributed to diabetes each year. But the number of cases and the prevalence of diabetes have been steadily increasing over the past few decades. The starting point for living well with type one or type 2 diabetes is an early diagnosis – the longer a person lives with undiagnosed and untreated diabetes, the worse their health outcomes are likely to be. Easy access to basic diagnostics, such as blood glucose testing, should therefore be available in primary health care settings. Patients will need periodic specialist assessment or treatment for complications. A series of cost-effective interventions can improve patient outcomes, regardless of what type of diabetes they may have. These interventions include blood glucose control through a combination of diet, physical activity and, if necessary, medication; control of blood pressure and lipids to reduce cardiovascular risk and other complications; and regular screening for damage to the eyes, kidneys and feet to facilitate early treatment.

Reflective Practice and why it’s so important

by Rachel Smith • 21 Feb, 2024
Well, we’ve made it to February! How are your goals for the year going so far? As you’ll know, we do love a bit of goal setting at Red Square Medical HQ. But, we also understand the importance of Reflective Practice too. Especially in relation to setting goals. Want to know more? Please read on…

Guest Blog - Sam Kelly MSA

by Rachel Smith • 07 Feb, 2024
Today we start the first in a series of blogs in conjunction with our friends at the Maritime Skills Academy, and kicking it all off is a Guest Blog from MSAs Head of Training, Sam Kelly. Sam is 37 and lives in southeast Kent, in the quaint seaside town of Deal with with his wife, two children and a ‘Golden Doodle’ called Pringle. He has lived in the area ever since his father, a serving Royal Marine at the Deal Depot, and mother decided this was the place to raise their family. And it is, quite frankly, an excellent place to live. Here is his story… I’m the Head of Training for the Maritime Skills Academy, based in our head office in Dover. I oversee a team of Maritime Safety Instructors who deliver all STCW training for seafarers. Outside the Dover base, we have MSA Gibraltar. This location is operated in partnership with the University of Gibraltar and delivers Basic Safety Training and most recently Operational Firefighting, We are actually in the process of building a state-of-the-art Fire Training Module on ‘the Rock’.

Dry January!

by Rachel Smith • 17 Jan, 2024
So Christmas seems like years ago, and we’re all well into the New Year now. Did you make any resolutions? Some love to, some don’t. At Red Square Medical HQ, we love a goal or two and think the turn of the years can be a good prompt to make some positive changes. But, it’s well known that New Year resolutions don’t last. Forbes magazine tells us that 21% don’t make their resolution stick for even a month. While 34% state that it lasted for between one and three months. Is that a failure though? Or could it be all it takes to make some small changes that have a lasting impact? We thought it would be good to take a closer look at one of the most popular resolutions… Dry January! Now, let’s get one thing straight, the Red Square Medical team are not averse to a tipple or two! But as medics, we’re very aware of the short and long term benefits of giving our livers a little breather every so often. Of course, everyone responds differently to stopping drinking for a month, so the timeline below is just a guide. But it might help you to decide whether it’s a good idea to give the booze a break for a while, or work towards reducing your intake - we know it’s easy for it to creep up over time!

12 months since I left the NHS

by Rachel Smith • 03 Jan, 2024
What I miss most about the Ambulance Service… It’s been 12 months since I left the Ambulance service after 8 years of working frontline, and to be honest it’s flown by. A few weeks ago the team at Red Square Medical HQ were chatting about how life has changed in that time and what, if anything, I was missing from my former life! The list might just surprise you… Most of all, I miss my old colleagues and I definitely miss the patient contact. And driving on blue lights… that was one of the best parts of the job! Working in the ambulance service with regular partners who you get on well with really does create friendships for life. Or even doing a tricky job with someone you don’t know well provides a common bond forever. Every day you’re facing stressful situations and sometimes split second, life changing decisions. You rely on each other totally and make sure you keep each other safe in some difficult and challenging situations. I worked with 3 very different partners most of the time for my last few years and I miss them all. Happily though, I have some great new colleagues at Red Square Medical and Outreach Rescue, the other company that I work for.

Guest Blog - Rachel Smith

by Rachel Smith • 03 Jan, 2024
I was born in a tiny village in Northamptonshire but had a fairly nomadic childhood, eventually settling in the industrial town of St Helens in the north west. As a child I was horse mad, so boats never got a look in. Apparently ‘horse’ was the first word I said and despite the fact that we could never afford a horse, my dream was always to ride and work with horses. It’s perhaps an early indication of my goal-oriented side that I got a Saturday job as soon as I could. At the age of 13, I’d cycle a 12 mile round trip, twice a day, just to go and ‘muck out’ at a local farm where they bred Welsh ponies and Arab horses! There wasn’t even any riding. Later, I found myself working for the family of a young girl who would go on to represent Great Britain in dressage at the Olympics. The work was physically hard and the standards high. No corners were cut and I learnt the skills I needed the old fashioned way. I got to travel all over the UK in the branded horsebox which was pretty exciting for a teenager. But I think I will always be grateful for the solid work ethic and sense of responsibility that this job instilled in me. I always planned to leave school at 16 and go to ride racehorses. But I got quite reasonable exam results and a new degree course was announced in Equine Science and Business which changed the plan. So, after taking the required year out, when I worked in an eventing yard in Yorkshire, I started the 3 year course. For the two work placements, I opted to go abroad, to Italy and the USA, which supercharged my desire to travel. I continued working in the equestrian world for a couple more years, but the poor pay and prospects, plus a dose of pneumonia pushed me onto a different path. I got a job in telemarketing for a bank, and after putting forward the idea of finance for horses, I found myself transferred to Marketing for 6 months. 16 years later, I was still there!

Are they wearing a beer jacket??

by Rachel Smith • 20 Dec, 2023
Christmas is coming and the season of parties is upon us. Of course this means that most of us will overindulge in large amounts of luscious food and, of course, a tipple or two. At Red Square Medical HQ, we have a method of categorising drunk people. During our combined careers, we’ve dealt with more drunks than we can remember; it’s easily running into several hundred. What we’ve learnt, amongst other things, is that most people who are drunk fall into one of these categories. Now please don’t judge as it is purely observation and also makes for an interesting chat when delivering the STCW Medical training, because we all know at least one person from each category and sometimes… a person can be in multiple categories depending on many other factors, or, we might even have been there ourselves! Once we have established these categories there is a serious note to this blog so please do keep reading.
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