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Soft tissue injury or potential fracture??
So is it a soft tissue injury or potential fracture? A sprained ankle can be a tricky one to navigate. Check out our guide to assessing severity when onboard a ship.
In the medical world, we use a tool called the Ottowa Ankle Rules to decide whether an x-ray is needed for an ankle injury. The tool was developed to meet a need for a rapid and accurate way to assess severity and avoid unnecessary x-rays. Of course if there’s a bone sticking out, or some dodgy looking deformity, then your decision may be a quick one!
Ankle sprains are a common injury in the general population and certainly not uncommon onboard vessels of all kinds. According to NICE Guidelines, lateral ankle sprains are the most prevalent form of musculoskeletal injury in physically active populations and an Australian study found that up to 70% of people reported having an ankle injury during their lifetime. Other studies indicate a higher incidence in females compared to males and that the risk is greater the younger you are.
Historically, ankle injuries are seen frequently in emergency departments, but only 15% have significant fractures. The Ottowa Ankle Rules were developed as a tool for identifying ankle and mid-foot fractures. Less than 1.7% of patients presenting with no symptoms are likely to be suffering a fracture. This figure reduces the sooner after the injury that the assessment can be made.
So how do the Ottowa Ankle Rules work and is it possible for an onboard medic to use them? Let’s start with a diagram…
This diagram shows the key areas of the foot and ankle that the rules apply to. Don’t worry about the big words, we’ll keep it simple! This short video might help too:
There are 5 components to test to assess whether your patient is positive for the Ottowa Ankle Rules. Always make sure you palpate areas thoroughly.
- Find the lateral (outside) malleolus at points A or B. Is there bony tenderness on palpation of 6 cm above the tip of the lateral malleolus?
- Find the medial (inside) malleolus at points A or B. Is there bony tenderness on palpation of the 6 cm above the tip of the medial malleolus?
- Is there bony tenderness at the base of the 5th metatarsal?
- Is there bony tenderness at the navicular bone?
- Was the patient unable to bear weight immediately after the injury and for 4 steps during your assessment?
If there is pain in the malleolar zone, or the mid foot zone, or if the patient ticks the box for any of the above points, an ankle and/or foot x-ray is indicated.
Certain patient groups are excluded, for instance someone who happens to be intoxicated, if there is another reason that they lack ability to follow the test, or if the patient is pregnant.
If you, or in conjunction with your Telemedicine provider, decide that your patient does need an x-ray, you will need to follow your vessel procedures for disembarkation or medevac, depending on your circumstances and location.
But how would you treat an ankle injury if a fracture isn’t suspected?
On medical courses over the years, you’re likely to have come across mnemonics such as RICE, PRICE and POLICE in relation to the management of acute soft tissue injuries. We’ve listed them in full at the end of the blog for information.
But hey, we’re now moving on to
PEACE and LOVE! Far out man!
The aim of PEACE and LOVE, is to optimise recovery and healing as part of the soft tissue injury management from the first point of care. It takes into consideration some important factors to aid recovery, but also highlights the potentially harmful effects of using anti-inflammatory medication as part of the process. Wowsa! So does this mean that taking anti-inflammatories isn’t the right thing to do any more? Let’s look into this PEACE and LOVE a bit more…
P - PROTECT
- Unload or restrict movement for the first 1-3 days.
- This reduces bleeding.
- It prevents distension of any injured fibres.
- It reduces the risk of aggravating the injury.
- Minimise rest - prolonged rest actually compromises the tissue strength and quality.
- Let the patient's level of pain guide the removal of protection and gradual reloading.
E - ELEVATE
- Elevate the injured limb higher than the heart. This helps to keep interstitial (in the spaces between the cells) fluid flowing out of the injured tissue. Although the evidence of its benefit is poor, there’s a low risk to benefit ratio and it may help some patients.
A - AVOID ANTI-INFLAMMATORY MODALITIES (medications and treatments)
- Anti-inflammatory medications may negatively impact long term healing, so don’t use them! This is because the inflammatory process actually supports optimal soft tissue regeneration. Using medications to inhibit this process can impair the healing process.
- Avoid ice. The benefit of ice is mainly for pain relief and although it's used widely, there’s little high quality evidence to support its use in healing soft tissue injuries. Ice could also disrupt inflammation, the restoration of blood flow to the injured area and formation of new blood vessels. It can delay the infiltration of neutrophils and macrophages to fight infection, and potentially increase immature microfibres, resulting in impaired tissue regeneration.
C - COMPRESS
- Joint swelling and internal bleeding may be limited by external compression such as taping or bandaging. But, it must allow full range of movement at the joint.
E - EDUCATE
- Contrary to popular belief, there are many benefits to an active rather than passive approach to recovery.
- Many passive therapies (e.g. electrotherapy, manual therapy, acupuncture) have minimal effects on pain and function compared to an active approach.
- Load management will avoid over treatment. Over treatment can increase the likelihood of injections and surgery.
- Dependence on therapies such as physiotherapy can actually contribute to persistent symptoms.
- Set realistic expectations about recovery times.
L - LOAD
- Evidence shows that an active approach with movement and exercises is beneficial, so normal activities should start as soon as symptoms allow.
- To provide optimal loading without increasing pain is indicated. It promotes repair and builds tissue tolerance and the capacity of tendons, muscles and ligaments.
O - OPTIMISM
- Our brains can play a significant role in rehabilitation interventions. Research shows that these factors may explain differences in symptoms and limitations better than the degree of injury.
- Barriers to recovery include many psychological factors, such as catastrophisation, depression and fear.
- Pessimistic patient expectations can negatively influence the outcomes and prognosis of an injury.
- It’s important to stay realistic and encourage optimism to improve chances of optimal recovery.
V - VASCULARISATION
- Cardiovascular physical activity is needed to manage musculoskeletal injuries.
- While more research is needed, evidence suggests that pain free cardiovascular activity increases blood flow to injuries and is a motivation booster.
- Benefits of early mobilisation and aerobic exercise improves function and work status and reduces the need for pain relief.
E - EXERCISE
- Evidence shows that exercise therapy can reduce the risk of a recurring injury.
- Exercise can restore mobility, strength and proprioception (sense of self-movement, force and body position) after an injury.
- Avoiding pain can help to promote optimal repair initially, and pain can be used as a guide to progress the difficulty of exercises gradually.
This short film might help to explain it too:
https://www.youtube.com/watch?v=HGTabgG7GIU&t=1s
So what does PEACE and LOVE mean onboard. Nope, it’s not a cue to smoke weed and hug each other while wearing flowers in our hair!
What it does mean is that crew with ankle injuries where a fracture isn’t suspected, can take pain relief (but not anti-inflammatories), use compression and elevation initially and keep the joint moving gently. As the pain allows, they should be encouraged to start to weight bear and exercise the joint.
Of course if you’re managing a crew member with a musculoskeletal injury and you aren’t sure what to do, please remember to contact your telemedicine provider.
Previous mnemonics used in the treatment of soft tissue injuries:
RICE - Rest, Ice, Compression, Elevation.
PRICE - Protect, Rest, Ice, Compression, Elevation.
POLICE - Protection, Optimal Loading, Rest, Ice, Compression, Elevation.
Resources used for this blog:
https://cks.nice.org.uk/topics/sprains-strains/background-information/prevalence/
We love this blog, it is so informative.....why not share the peace and love.....
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!
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.
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!
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.
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…
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’.
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!
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.
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!
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.