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Overboard in Dangerous Seas - A case study

Some time ago, we asked our LinkedIn community about the kind of things they would like to read about with regard to medical care at sea. One comment suggested some scene management around coping with casualty positioning in adverse weather. So, we got in touch for a chat and rather than settle for a generic article, we asked for a scenario to work with! This is what we got…

‘You are on an offshore installation with a man overboard incident, involving a 25m fall and some contact with structure. An Emergency Response Rescue Vessel (standby vessel) in close standby launches a Fast Rescue Craft. The FRC is alongside the casualty and the casualty recovered in 9 minutes with the FRC delivering your casualty onboard in 14 minutes.


The casualty is suffering from the cold, immersion,  and has a deep laceration to their forearm. The sea state is 3m, with a force 4 wind, sea temperature of 12 degrees, and air temperature of 10 degrees. The casualty must be transferred from the FRC to the boat deck. There is the possibility of transferring directly ashore to meet an ambulance to go to a hospital. All standard ERRV equipment is available. The FRC crew have applied direct pressure to the wound but no other treatment. As the ship is manoeuvring out of the platform exclusion zone there is a lot of rolling and you’re on an open steel deck.’


On further investigation you discover some additional information about what the crew member was wearing and an update on his condition. So let’s summarise the main points that will affect your medical response:


  • You have a casualty with a deep laceration to his forearm that is currently having direct pressure applied to it by one of the rescue crew.
  • He spent 9 minutes in the water which was 12 degrees Celsius and he was wearing a boiler suit. Air temperature was 10 degrees with a force 4 wind (13-18mph).
  • He had a lifejacket on and it was deployed, but because of his injured arm he couldn’t get the spray hood in position.
  • The casualty needs transferring from the FRC to the boat deck of the ERRV which is an open steel deck but there is a possibility the casualty can be transferred to the hospital.
  • The casualty appears to be deteriorating as he is now drifting in and out of consciousness.


Ouch, I hear you say! This one’s a tricky situation for sure. And it’s becoming more critical by the minute. So where do your priorities lie? How can we manage a ‘big sick’ casualty and make the right decision, in rough weather, as safely as possible?


We can prioritise. Thinking about the list we made above, we can change it round and set out priorities out:

  • The casualty needs transferring from the FRC to the boat deck of the ERRV which is an open steel deck but there is a possibility the casualty can be transferred to the hospital.
  • The casualty has a deep laceration to his forearm that is currently having direct pressure applied to it by one of the rescue crew. However, the casualty is deteriorating and is drifting in and out of consciousness.
  • He spent 9 minutes in the water which was 12 degrees Celsius and he was wearing a boiler suit. Air temperature was 10 degrees with a force 4 wind (13-18mph).
  • He had a lifejacket on and it was deployed, but because of his injured arm he couldn’t get the spray hood in position.


Next you need to break down each part of this huge dilemma. Remember… when eating big elephants, take small bites! Or simply, break down the points into bite sized chunks that can be managed. 


  • The casualty needs transferring from the FRC to the boat deck of the ERRV which is an open steel deck but there is a possibility the casualty can be transferred to the hospital.


Many ERRV’s have a basket style stretcher available which is a useful way of transferring a casualty from the FRC via the boat deck of the ERRV and then onwards to the hospital. They have a strap system that will allow you to keep the casualty safe during a transfer when the adverse weather makes it hard. This will require a team effort and all team members should be familiar with the use of the stretchers on board.

The casualty has a deep laceration to his forearm that is currently having direct pressure applied to it by one of the rescue crew. However, the casualty is deteriorating and is drifting in and out of consciousness.


How long should you apply direct pressure to the wound? What will affect the blood's ability to clot? So, we normally expect 10 minutes of direct pressure to control most bleeds of this nature but the casualty has been in the water and it was pretty cold! Hypothermia can affect the blood's ability to form a clot so the pressure may need to be held for an extended period of time with thought being given to clotting agents if they are available.


Based on the fact that the casualty is deteriorating, and their conscious level is dropping then we must go back to the beginning of our primary survey and start again. Do you remember what DRS CABC stand for? If you don’t then you need some refresher training ASAP!!

Danger – they have been removed to a place of safety but the ERRV is rolling heavily. Lets make sure that they are well secured in the stretcher and that we have plenty of people to help us manage the manual handling element of the rescue and get them into the hospital.


Response – they are drifting in and out of consciousness. What is our concern with this? If you answered with protecting the airway, then you are on the right path. With decreasing levels of consciousness, the risk of the airway becoming blocked becomes much higher. So, what should we do about this? We could use the recovery position, but we have equipment available to maintain the airway such as suction for fluids and oropharyngeal airways to keep the tongue clear of the airway.


Shout for help – well, you are the help so good luck with that!


Catastrophic Bleeds - these are dealt with as a priority as they are a life threatening injury.


Airway – As mentioned above this is at risk, so basic measures must be taken to maintain the airway as tolerated by the casualty. We could also consider the possibility of Cervical Spine injury at this point, this is based on the mechanism of injury – a whole other articles worth of info needed for that one!


Breathing – well we know that they are breathing but how effectively are they breathing? A basic look, listen and feel along with pulse oximetry will give us a better idea of the casualties breathing efforts. So, let's say that they have a breathing rate of 15, both sides of the chest are rising and falling evenly but the Pulse oximeter is reading 92%. What next? Do we put them on Oxygen? If so, how much? There are various systems available for delivering oxygen to a casualty. We always try to titrate to need so we would start off low using a venturi 24% mask set at 2 litres per minute and up it if necessary until we can achieve oxygen saturation levels above 95%. However, there is an important factor in the information that we have been given. Any idea what it might be? Yes! He was in the water and couldn’t deploy his splash hood. That increases his risk factor for complications from drowning. That will need close monitoring to ensure that his breathing does not deteriorate.


Circulation – So, this person has a deep laceration. Direct pressure is being applied but is that the only source of his bleeding? We know that there was some impact with the vessel when he fell overboard. What assessments should we be doing to work out how hard his heart is having to work? The best place to start is with a pulse. This can be taken at the neck or wrist and should be felt for 30 seconds. Times the result by 2 to get the beats per minute. So, our chap has a pulse of 96. A little high. We should also have assessed the strength and regularity and made a note of any abnormalities. We can do a capillary refill check on all 4 extremities. This will tell us if there is any compromise in the supply of blood to the furthest points in the body. If you are able then you can also do a blood pressure but this is not essential so please don’t worry if you don’t know how to do it.

The casualty is losing blood through his deep laceration but as he was a man overboard, he may well have injured other parts of his body and could even be bleeding internally. The organs of the abdomen, the pelvis and the femurs (thigh bones) are all places that blood can be lost in significant quantities so ensure that you check those thoroughly.


Next…..

I am going to throw in a couple of extra letters for your DRSABC algorithm. Just to keep you on your toes. DE. Arghhhhh….but that is just following the alphabet I hear you say! Well yes, us medics are a simple bunch really and need things to be easy to remember in an emergency. ABCDE is learnt as a child so what better way to remember how to assess our casualty?? So….


Disability – our casualty is drifting in and out of consciousness. He could possibly have a head injury so we ought to check that out. Remember how to check the pupils and what they are supposed to do? Right, well let's do that. His pupils are equal and reacting to light. Is that a good sign? Yes, it is…..for now. We need to check that regularly along with the ABC to make sure we don’t miss a significant change.

He spent 9 minutes in the water which was 12 degrees Celsius and he was wearing a boiler suit. Air temperature was 10 degrees with a force 4 wind (13-18mph). He had a lifejacket on and it was deployed, but because of his injured arm he couldn’t get the spray hood in position.


This leads us onto the final letter in our now extended primary survey. E.


Exposure – The body is designed to operate at between 36 – 37 degrees Celsius. Check out the temperature of the water, air and the wind speed. Combine that with what he was wearing and we are looking at many potential problems. But guess what? Cold shock would’ve got to him way before hypothermia sets in. Familiar with the effects of cold shock? I hope so because that is a whole other article!!


So, let’s take a temperature. Want an accurate one? Go rectal. Not concerned about hypothermia then oral or aural will suffice.

What about these wet clothes? He will continue to lose heat if left in them so lets cut them off and wrap layers of blankets around him. Whilst doing that check his whole body from top to toe for any further deformities, obvious injuries, tender areas or swelling and skin rashes.

Phew! Now what? You are not going to like me for this but…..


Start all over again and recheck your DRSCABCDE’s. Write notes, communicate significant information, recheck all vital signs and most importantly? Keep talking to the casualty. Be reassuring and calm (even if you don’t feel it), don’t discuss your fears in front of them, save that for out of earshot and mostly take comfort in knowing that you are doing your best in a pretty tough environment.

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by Rachel Smith • 03 Jan, 2024
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