Working in Confined Spaces

When we think about working in a confined space, we naturally think of underground scenarios like caves, agricultural environments such as silo’s, or industrial settings like pipelines and tunnels. Every year in the UK alone, around 15 people die from working in a confined space, despite legislation, regulation, information and guidelines. But this is not just a UK problem.

Sometimes an employer may not recognise that the area their team is working in is classed as a confined space. It doesn't have to be small, or have a restricted entrance. It is any space that by virtue of its enclosed nature, there arises a reasonably foreseeable specified risk.

The UKs Health and Safety Executive defines a confined space as:

“A space which is both enclosed or largely enclosed and has a reasonably foreseeable specified risk to workers. It may be small and restrictive for the worker or it could be far larger with hundreds of cubic metres of capacity.” 

The risks specified will vary depending on the location, but underpinning any assessment is the knowledge that confined spaces can kill. A major factor to consider is the ‘potential’ for a risk to arise. This could include: 

• Hazardous Atmosphere: Risks from toxic substances and/or a lack of oxygen (asphyxiation), often undetectable to normal body senses, or a flammable atmosphere. 

• Engulfment: The risk of being trapped or submerged by free-flowing solids, like grain in a silo. 

• Drowning: The risk of suffocation due to a rise in the level of liquid within the space.

• Excessive Heat: The potential for loss of consciousness from high body temperatures. 

Employers have legal duties to identify confined spaces, assess the risks, provide training, and develop emergency plans. 

Ships are full of confined spaces

But how does all this apply to our environment? More importantly, how does it impact on our ability to locate, assess and extricate a patient, whether onboard or ashore? We already know that ships are inherently dangerous, no matter whether it’s a fuel tanker or a superyacht.

Working offshore in any role requires a worker to be medically fit and undertake specialist general safety training, plus additional training specific to their role and in the case of cargo ships, training in relation to what the ship is carrying. 

Thinking about a casualty, it’s easy to imagine all kinds of potentially dramatic situations involving cramped engine rooms, cargo holds and areas with narrow access routes onboard.  The first stage in our algorithm for managing a patient is to look for dangers such as:

• The condition of the space and the air in it, plus other possible contamination.

• Whether the space is, or could become oxygen enriched and increase levels of flammability, or if it could become oxygen depleted leading to unconsciousness and possibly death.

• Physical dimensions, layout, ventilation, access and egress for rescuers, the patient and the kit.

• Additional hazards such as obstructions, chemicals, liquids, electricity, stored energy sources, flammable substances, sources of ignition, equipment.

  
  

If the patient is in a confined space and conscious, you can ask them what’s happened and check for obvious dangers before approaching. Always consider self-rescue where the patient may be able to move themself out of the confined space.

If they are unconscious, the initial assessment may need to slow right down and you’ll need to consider WHY they are unconscious. If it’s something such as toxic fumes, it could also affect rescuers; other actions will be needed and processes followed, before you are able to approach the patient safely. Is there already a rescue plan in place for this kind of incident?

But let’s think about a practicality onboard, and where someone is most likely to go if they feel unwell?

Where do crew go when they feel unwell?

In our experience, you’re most likely to find them in their cabin, or in the toilet! Both of which are normally two of the smallest, most confined spaces onboard! While this may be relatively safe to approach, it raises the question of how are  you going to get in to assess them, with all your kit, and how are you going to get them out, especially if they’re not able to move themselves.

Once you’ve established that it’s safe, you may need to move the patients before you can provide any kind of assistance, and if they’re unconscious this might mean extra hands to lift and carry, or even dragging them out into a bigger space. A blanket lift can be really helpful in this situation if you can get a blanket underneath them. If you’re concerned about a c-spine injury, move them carefully supporting the head and neck, but remember that Airway comes first and c-spine is a consideration. If they don’t have an Airway, we’re not going any further down that algorithm. 

It’s often ignored in the heat of the moment, but remember that you can often make space too - just move anything unfixed that’s in the way such as furniture, belongings or equipment.

In the worst case scenario, you may have no option other than assessing and treating your patient right where they are. Of course this brings challenges. For instance, you might need to think about switching around more often if someone is carrying out CPR in an odd position, or you may need someone just outside the space who is able to hand items from the kit. 

Last month, we wrote about the importance of drills, and that’s certainly something that could help in this instance. A couple of our favourites are listed below:

• Find the smallest space onboard and see if you can assess and treat a patient there, or carry out CPR? Where is the nearest space big enough, and how could you move them there?

• Find a narrow corridor (pretty easy on most vessels!) and work out a plan for a resuscitation. If you’ve only ever practised CPR from the side, how will you manage compressions, breaths, kit and change overs if you’re working from the head?

• Use a crew bunk to start off a scenario for an unconscious patient. If you decide to leave them there to assess, how will you manage a full assessment, the kit you need for each element of the assessment, and completing the relevant paperwork?

• Find a space underneath something like a tender and work out a plan for access and where to move them to, if you’re able to.

• Find the place onboard that is furthest from the area where a patient would be winched off the vessel. Work out how to get them there if they’re conscious or unconscious, using the kit you have available.

• If someone collapses in the shower, how will you get to them and get them out? You can even consider the very real complication that they will be wet and naked - which means a very slippery person and surface, plus you need to think about maintaining their dignity.

  
  

We hope this gives you some inspiration for how to work in and around confined spaces, as well as some ideas to practice. We would love to hear about your experiences onboard and any drills you’re able to develop to help work safely in confined spaces with a patient.

Red Square Medical is a member of The Superyacht Training Group (STG) and we’re delighted to share access to download this White Paper ‘No Room For Error’, from MRS Training and Rescue, a fellow STG member, which takes an in depth look at the complexities of working in confined spaces.