Seadrill Annual Summary Topside Support Newsletter 2015

Topside Support
NEWSLETTER
Pre-Hospital Pain Management
I would rather recommend you to focus on keeping it
Introduction
simple and ask the patient “does it hurt”, “does it hurt a
As with many things in medicine, especially those where lot”, is it better after ‘this’” (this being a drug, a manoeuvre
insufficient evidence exists in a particular context for etc.), and “has it gone away now/do you feel much
"best" practice, pain management is sometimes better/back to normal”. Offer to give the patient more
controversial. You are most welcome to disagree with this analgesia; do not make them beg for it. Do not let them
in theory and apply different methods in practice than feel that asking for more pain relief is demanding, selfish,
what is contained in this newsletter. We do require and shows a lack of stoicism.
however that if you are going to practise differently, the Quite apart from making patients more comfortable
principles of safety, efficacy and above all comfort for because it is the right and kind thing to do, leaving them
the patient = with the pain being more than adequately in pain has unwanted effects on their pathophysiology.
treated, are all observed. Apart from pain being psychologically painful, it speeds
up the heart, increases oxygen demand, and produces an
unnecessary excess of circulating catecholamines.
Basic Principles There are really only 2 ways to reduce or eliminate pain.
Before we go into a discussion of the detail let us Remove the source, or block the transmission. If we
remember that for a patient with pain, the pain is not the cannot provide definitive care, such as relocating a
patient's problem alone, it is our problem to resolve. dislocation or opening up a coronary artery, we are left to
block the transmission. In this context, by the way, the
Patients will not be particularly impressed if we can most effective method of pain relief for peripheral
explain to them in great detail what type of Salter-Harris fractures and dislocations is of course nerve blocks. If you
fracture they most likely have or how we have been able can administer, for example, a femoral nerve block for a
to diagnose both the degree of left axis deviation and 2 patient with a leg injury, you do both the patient and
types of eponymous dysrhythmias on their yourself a great service… because the treatment is
electrocardiogram (EKG), if they have a fracture
extremely effective and safe as it is local/focal and not
dislocation of the wrist and cardiac chest pain, systemic, and 100% targeted. If you have not done that
respectively. We are full of information about what has before, we cannot teach you how to do it via a newsletter
gone wrong, but we have left them in pain during our
and a PowerPoint presentation however.
work up. You will all know from your own experience and
observations in hospital practice that what I have just
described, does happen every day.
The 10 Rules of Analgesia
The commonly used pain scale of 1 to 10 is, in my opinion,
a wombat (Waste of Money, Brains and Time). Firstly, it is RULE 1: Be kind to your patients and relieve their pain.
a scale of 11, after all zero means no pain at all. Secondly, RULE 2: Know what you have available and use enough
how does a patient differentiate between 1 and 3 and 5? of it until the patient's pain is well relieved.
Although most importantly, it is a completely subjective
scale that means of course it is not a scale at all to RULE 3: Combinations of different analgesics generally
anyone other than that particular patient at that particular work better than a single analgesic alone.
time. Calling it a scale gives it pseudo-credibility because RULE 4: As always, any drug with an effect has usually
it is going to sound as if it is a comparative measure, such more than 1 side effect. Know the side effects and
as the Glasgow Coma Scale (GCS), which has clinically counter them prophylactically.
predictive value, when it plainly is not and does not.
Topside Newsletter – Pre-Hospital Pain Management

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Pre-Hospital Pain Management – Page 2
RULE 9: While reading this, if you do not have enough

appropriate analgesics in your clinic to treat multiple
injuries and multiple patients for at least 24 to 36 hours, it
is better to discontinue reading the newsletter and
arrange access to appropriate analgesia immediately.
RULE 10: When referring a patient with, for example, an

RULE 5: The appropriate dose of a pain relieving drug is
acute head injury in combination with other trauma or a
that dose which relieves the pain. We are not
surgical acute abdomen to a hospital hours away, please
experiencing pain, the patient is. In an acute case, trust
do not make your patient suffer by inappropriate concerns
the patient if he/she says the pain is not relieved; we have
about what the admitting doctor may say about the
either not given enough, always given an inappropriate
administration of pre-arrival analgesia.
drug, or there is another problem happening we have not
diagnosed.
RULE 6: Use a big enough dose of the best drugs you

Choice of Drugs
have to relieve initial pain, and continue to administer
drugs without waiting for the patient to complain to you As you will see from the attached Seadrill standard list,
again of pain. The vast majority of patients, especially and for those of you not on Seadrill sites will already be
male patients, are slow to complain about unrelieved pain aware of this, we have a good choice of analgesics that
as they do not wish to appear lacking stoicism; waiting are safe, tested over time, and effective.
until the pain builds up again before administering an
effective dose requires a higher dose than achieving
"steady state analgesia".
RULE 7: Intramuscular injection of analgesics 20141205 Seadrill

Standard List V8.0 colour coded.xlsx
ESPECIALLY into the damaged limb is both inappropriate
and practically worthless in terms of relieving the patient's
As we have previously published a number of newsletters
pain.
on the occupational use of analgesics following injuries,
RULE 8: A considerable amount of pain relief can be we are not going to repeat that information here. Please
achieved by the appropriate combination of reassurance, bear in mind however that both International SOS Medical
comfort, splinting, temperature homoeostasis, especially Services and our clients expect appropriate and judicious
to prevent shivering in the presence of trauma use of such drugs in the context of Occupational Safety
(obviously !), and empathy. and Health Administration (OSHA).

The ‘KISS’ principle: Keeping It Simple, Successfully Morphine is the most appropriate parenteral drug and is
very effective. Its use when indicated should not be
Start with the safest, most easily administered drug for the
deferred out of misapplied concerns of respiratory
majority of straightforward and relatively minor (but by no
depression, and so forth. The most effective way to use
means trivial) painful conditions. This is paracetamol; 1 g
morphine is intravenously (of course) and it should not be
orally, hourly, for an adult. Acutely up to 6 g per day (of 24
given intramuscularly; if we do not have intravenous (IV)
hours) is well tolerated. Chronic liver disease is only a
access, our focus needs to be on gaining IV access not
problem with chronic paracetamol use and abuse; this is
on depositing morphine into under perfused muscle tissue
not something that is going to occur on a remote site or
where it is both ineffective and unpredictable.
offshore installation.
The best way to relieve pain especially in trauma with
Aspirin should not be for first-line use. It is both less
morphine is to give an initial bolus of between 2-3 and 7-
effective and has more unwanted side effects than
10 mg (range depends on the age, gender and weight of
paracetamol. (Administration of aspirin with chest pain is
the patient), well flushed into a reasonably sized
given for its blood-thinning ability not for its analgesic
peripheral cannula. This needs to be followed by 1 to 2
effectiveness.)
mg increments at 5-minute intervals until pain is
Next use diclofenac. This is an excellent drug for the appropriately relieved. This is how we start.
short-term treatment of acute, mild to moderately severe
It is common in textbooks to read that the initial dose of
pain, especially that is or may be accompanied by
morphine should be 2 to 3 mg or possibly 5 mg. In my
inflammation, = conditions such as musculoskeletal
opinion, this is a mistake. Large healthy adults with
and/or soft tissue trauma including sprains, wounds,
significant injuries will not have their pain sufficiently
toothache, etc. Analgesia/primary dysmenorrhoea:
relieved by 3 or 5 mg of morphine. If you prefer not to
Starting dose: 50 mg orally 3 times daily. Maximum dose:
administer a large bolus, then make sure that you stay
150 to 200 mg per day in divided doses. In our context,
with the patient for 5 to 10 minutes after your initial
we should not use the sustained release (SR) product.
administration of 5 mg, until you can accurately judge
Paracetamol and diclofenac have different modes/sites of what effect it has had. The basic principle is ‘start high
action. There is no contraindication to using a and titrate down’, not ‘start low and titrate up’. (The
combination of these drugs; and there are well conducted discerning reader will note that this principle is different
studies* that show the combination of these drugs is from OSHA/International Association of Drilling
synergistic (synergistic = when 2 drugs are used in Contractors (IADC) guidelines for drug administration,
combination their combined effect is more than the sum of which is to start low and work up. The information
their independent effects). Therefore, by default in provided is not contradictory; the primary guidance for all
anything other than a very straightforward minor injury or drug administration regardless of OSHA, IADC, FAA and
illness, we recommend their use in combination. IATA is always the principal what is best for the patient.
(* References available upon request.) But we digress…).
Ibuprofen has a similar mode of action to diclofenac, but it The onset of action of morphine is within 5 minutes, the
is not interchangeable or identical. It is chemically peak effect of morphine is after 15 to 20 minutes, and the
different, as diclofenac is an arylalkanoic acid, whereas duration is up to 7 hours.
ibuprofen is an arylpropionic acid, and diclofenac is
We should continue to administer between 2 and 5 mg of
noticeably more effective.
morphine per hour while monitoring the patient's
It may be helpful to know the anti-inflammatory activity of subjective and objective pain levels to ensure we are
nonsteroidal anti-inflammatory drugs (NSAIDs) in getting it right. This is how we continue until we deliver
descending order. Indomethacin is better than diclofenac, the patient to definitive care.
which is better than piroxicam. Piroxicam is better than
The easiest way to measure and administer the dose is to
ketoprofen, which is better than lornoxicam. Lornoxicam is
dilute morphine to 1 mg per ml with normal saline in a 10
better than ketorolac, which is better than acetylsalicylic
ml syringe, label it clearly, and keep it with you so that you
acid (aspirin). Of course anti-inflammatory activity is not
are always aware how much morphine you have given to
the same as nastiness of potential side effects; it is not
the patient. Never forget to write down what you gave,
the same OSHA-acceptability… Ibuprofen is an over-the-
when you gave it, and how the patient reported its effect
counter drug from OSHA's point of view, while diclofenac
and/or how you saw its effect.
is a prescription drug.

Topical analgesia, acupuncture, arnica and aloe vera, liver, has a half life of 90 to 120 minutes; startlingly similar
shiatsu massage, etc… to that of diclofenac whose terminal plasma half life is
6,220 minutes.
There are a number of other alternatives that people often
use when suffering localised pain. These are outside the Consider next the fact that leaving the patient in
scope of this newsletter because they either are self- unnecessary pain to avoid the potential for misguided
administered and of unproven value (acupuncture, aloe criticism by a colleague is wimping out.
vera), or would incur an OSHA trigger without efficiently
If you still remain an unbeliever, do read some of the
relieving a patient's problem (diclofenac jelly).
considerable research that has been done as to whether
Other drugs commonly used in the presence of pain pre-hospital or pre-examination analgesia complicates
diagnosis. A number of well set-up studies assigned
Antispasmodics, e.g. hyoscine (‘Buscopan’)
patients with abdominal pain to randomly (and are
A long-standing yet surprisingly ineffective drug, unknowingly) receive either IV morphine or saline. The
commonly prescribed to people with ‘colicky’ smooth bottom line:
muscle pain. It is not as good as diclofenac for muscle
The presence of peritoneal signs did not change in the
relaxation, a little better than placebo but not much.
group that received morphine.
Anxiolytics, e.g. benzodiazepines
The accuracy of diagnosis did not differ between the 2
This should not be reached for as a first-line drug. The groups of patients.*
best way of reassuring the patient's distress and relieving
The accuracy of diagnosis did not differ between the
their anxiety is to demonstrate to the patient that we are
emergency physicians and the surgeons.
aware of what they are suffering from, we are relieving it,
and we are doing what is necessary to get them * In fact, there was also a trend that examination may be
diagnosed, disembarked and definitively cared for. more reliable after treatment with morphine.
Antidepressants Consider finally the fact that every study of pre-hospital

pain management over decades has shown that it is and
These should never be used for acute pain, although they
remains inadequate. Studies even in "centres of medical
are increasingly used for chronic pain management.
excellence" show that we are very bad at looking after
Other controversies in pre-hospital pain management patients’ pain before they arrive in hospital. Between 1%
As we briefly alluded to above, some people have and 2% of patients with extremity fractures receive pre-
concerns about giving analgesia to a patient with a head hospital analgesia, which means 98% simply do not. Even
injury or surgical abdomen for fear that the administration when patients have proximal - for example hip - fractures,
of this drug will somehow "mask" the symptoms and signs fewer than 20% receive analgesia. (References available
for hospital surgeons when they themselves examine the on request.)
patient. This is absolutely incorrect. It remains Apart from criticism of excessive use of analgesia that we
nonsensical even though some surgeons still believe it have just agreed to, we are going to ignore this because it
themselves, and may criticise the pre-hospital medic for is based on ignorance and myth… Other barriers to good
appropriate administration of drugs required to relieve the pre-hospital pain relief are sometimes attempted to be
patient’s pain. justified by (1) concern about a patient malingering, (2)
Consider first the fact that unless you have a direct concern about giving too much narcotic leading to a
helicopter to hospital ward transfer of 30 or 40 minutes’ concern for potential habituation/addiction, (3) a whimsical
flying/stretcher time, it is vanishingly unlikely that the dose and completely inappropriate belief that pre-hospital our
of the drug you give on the installation is still going to be job is to "take the edge off the pain" but not treat it
circulating at diagnostically difficult levels when the comprehensively, (4) an absurd and completely
surgeon or neurosurgeon turns up to see the patient with unprofessional belief that we want to save our stock of
a head or abdominal trauma some hours later. People analgesia for other imaginary patients “who may need it
who criticise the use of pre-hospital analgesia generally more”, and (5) an even unreasonable and less explicable
cannot tell you anything accurate about the concern that we have such horrible difficulties in getting
pharmacokinetics of drug metabolism and excretion. analgesia through customs that we should use less of it
Morphine, which is relatively rapidly metabolised by the so we have to restock less often. The appropriate
response to that is ‘talk to someone who cares (about

supply difficulties), because we do not adjust our clinical

recommendations in response’.
In closing, let us return to the guiding principle behind

RULE 5. The patient is the one with the pain. We are not
hurting, the patient is. Just because the patient does not
look in obvious pain, does not mean he/she is not
suffering stoically. Just because the patient is very quick
to complain about what we may judge ‘should only’ be
mild-to-moderate pain, does not mean he/she is not
suffering significantly. Judging the patient by his/her
appearance; deciding that a patient is ‘not hurting much’
because he/she is not diaphoretic, tachycardic nor
tachypnoeic; fretting about being criticised for using a
larger-than-average dose of analgesia for a well looking
and acting patient; remembering how much pain we
endured when we had the same or worse problem than
this patient and deciding that he/she is insufficiently
enduring… are all inappropriate professional responses to
a patient who says ‘doc, it really does hurt’.
Post-Christmas/Wish: Methoxyflurane for trauma and

renal colic patients.

Hypovolaemia – Page 6
Chart the same vital signs over time so that we can look
Hypovolaemia - Real and
for trends and monitor the results of fluid, analgesic and
Apparent, and the Patient in other interventions.
"Shock" Not every hypovolaemic patient is shocked, and not every
shocked patient is hypovolaemic. Clinical "shock" means
Shock
different things to different people, so it is best that we
The rapid assessment of a patient in shock is essential to start any discussion by agreeing on a definition of shock.
make sure adequate and applicable treatment is quickly A good working definition relates the patient's condition to
instituted. the underlying problem; hence, shock is best defined as
failure of oxygenated blood to adequately perfuse
When we are faced with a very ill patient, it is best to fall
vital organs.
back on the basics that we know very well. Therefore, A B
C D E. It is useful to differentiate the types of shock depending
on the causative pathology:
A-B-C
 Hypovolaemic shock occurs with blood loss
Check that the patient’s airway is patent, breath sounds
(trauma/bleeding) or fluid loss (e.g. vomiting and
are equal bilaterally, and peripheral and central pulses
diarrhoea).
can be felt.
We need to fix any airway and ventilation problems as we  Cardiogenic shock may be from cardiac tamponade
go; if peripheral and central pulses are weak with a high (injuries above the diaphragm) or from heart disease.
rate, we have a volume deficit that we should start fixing  Neurogenic shock results from extensive injury to the
quickly. central nervous system (CNS) or spinal cord (but
If the blood pressure is low and the pulse pressure is wide virtually never from isolated head injury).
with a rapid weak pulse, we have a significant volume  Septic shock, though rare in our usual evacuation
deficit. circumstances, should always be considered when
D-E treatment has been delayed or infections may be
present.
A brief neurology exam comes next, pupils, and the
Glasgow Coma Scale (GCS), plus looking for the The best treatment for any particular type of shock is to
presence of asymmetrical neurological signs. cure the underlying cause, but pending that cure taking
effect (for example in septic shock) the initial response
Document the patient's systemic neurology as well as
needs to address the lack of vital organ perfusion.
focal neurology at present, and expose the patient so that
Therefore, the common initial treatment pathway is
we do not miss cult injuries (for example, perineal
usually giving volume, plus pharmaceuticals that constrict
bleeding, intra-abdominal organ rupture following high-
the vascular bed and raise organ perfusion pressure.
speed trauma and so forth).
Not all shock patients are created equal. For example:
A shock patient should not be exposed to environment
because he/she is unable to properly thermoregulate;  Older people do not well tolerate hypotension from
therefore, unless there are cogent reasons to call the haemorrhage. Aggressive fluid therapy is often
patient, keep him/her warm. needed to save the patient and prevent serious
complications. That being said, one should be careful
Following the primary survey, it can be necessary to go
not to overload the patient into acute pulmonary
back into a more complete secondary survey interspersed
oedema.
with therapeutic interventions and checking the results of
those interventions. Remember that every patient has 6  Very fit/trained people can compensate substantially
sides that include front, back, left, right, top and bottom. for blood loss; their blood volume may start 1/5 above
We must examine them all and document that we have normal, cardiac output can increase 6 times, stroke
done the examination, especially if he/she is being volume can increase by 1/2 as much again and pulse
referred out of our care. is usually < 50/minute.
 Beta-blockers and calcium channel blockers

significantly alter haemodynamic response by limiting
Topside Newsletter – HYPOVOLAEMIA

the heart's ability to speed up in response to low the pulse pressure. If budget allows, for serious cases
volume. we should use mechanical transducer-equipped BP
monitoring.
 Patients suffering from hypothermia and
haemorrhagic shock do not respond as usual to  Normal capillary refill test time is 2 seconds (press
appropriate blood and fluid replacement. The only, hard on the patient’s fingernail and measure time
rare, indication for inotropes (vasopressors) in taken for colour to return). Slow refill means
uncorrected hypovolaemic shock is the hypothermic peripheral circulation is compromised. This test is
patient who suffers a cardiac arrest. going out of favour, but remains a reliable way to
evaluate the presence of severe shock. (And, if our
 The same is true for patients with underlying
pulse oximeter is failing to work, check it is not ‘failing’
(electrical) conduction defects.
just because it is not getting any blood flowing
underneath it.)
 As always, attend to the basics of airway, breathing

and circulation (in this case, control the haemorrhage).
 Give high concentrations of oxygen.
 Insert a nasogastric tube and apply suction; this

reduces the risk of both gastric dilatation (which
compromises ventilation) and aspiration of gastric
contents.
 Insert 2 large (16 gauge) intravenous (IV) needles

(preferred order: forearm or antecubital, femoral
jugular, saphenous cutdown).
Haemorrhagic shock
This is likely to be the most common type of shock one

deals with on a remote site or offshore.
 Tachycardia is the earliest sign of shock - any injured

Crystalloids versus colloids
patient who is cool (reduced peripheral circulation)
and has a fast beating heart is in shock until proven This is controversial, but the fundamental rules apply:
otherwise.
1. Use what you have.
 Due to compensatory mechanisms, systolic pressure 2. Use enough volume of whichever fluid you have, to
may not fall until up to 30% of volume is lost, whereas perfuse the vital organs.
narrowing of the pulse pressure occurs much earlier
(refer to standard texts for more detail). We cannot 3. Crystalloids are cheaper, faster to administer, and
wait until blood pressure (BP) falls to diagnose and easier to get and store.
treat hypovolaemia. We are sometimes tempted to 4. There are no well-controlled randomised trials that
record only systolic pressures if monitoring in flight by have proven crystalloids to be superior or inferior to
palpation and not able to hear the diastolic colloids in terms of patient outcome*, so let us talk
sounds. This will make it difficult to assess changes in about something else.

 Replace volume with crystalloids at a ratio of about filters are not helpful in preventing allergic
4:1 (i.e. for each 100 ml blood lost, give 400 ml reactions. Blood is a very poor volume resuscitation
Hartmann’s solution/Ringer's lactate – better than option – to start with (but not to end with), even if you can
normal saline). Give the initial bolus of fluid as rapidly get blood fast, the bags are too small and the fluid is too
as possible (1 to 2 litres in an adult or 20 ml/kg in a cold.
child). The response to the bolus guides further fluid
If frozen blood or plasma is to be used, one needs to be
administration:
sure there is a mechanism for warming it on the
o Rapid response - Those who respond rapidly and aircraft. To prevent hypothermia, crystalloids should also
remain stable have usually lost less than 15% of be warmed to body temperature (particularly if large
blood volume (approximately the same as a amounts are given); the easiest way to do this is between
blood donor). No further fluid replacement is our thighs or inside our shirt.
needed.
o Transient response - Indicates a loss of 20% to

Cardiogenic shock
40% of blood volume or continued bleeding. The
bleeding needs to be stopped; that is the solution,  In trauma victims, cardiogenic shock can occur from
not ongoing fluid replacement. cardiac tamponade due to chest injury, usually a
penetrating wound. This is part of the resuscitation
o Minimal or no response - Usually indicates
algorithm for obvious reasons, in case it is overlooked,
severe continuing haemorrhage requiring
and it is a staple of advanced trauma life support
extremely urgent surgical intervention.
(ATLS) scenarios. History and primary survey should
Do not use hypotonic fluids (e.g. dextrose) for pick up the possibility. Again, the diagnosis is
haemorrhagic shock. Watch for pulmonary oedema during traditionally supposed to be suggested by “muffled
fluid therapy, especially in older patients. It will be difficult heart sounds and engorged neck veins associated
to detect crepitations in lungs due to fluid overload in flight with hypotension and tachycardia that is
or en route, so we need to look at other ways to diagnose unresponsive to fluid therapy”, - but hearing muffled
this, such as engorged neck veins (a ‘textbook’ heart sounds and spotting engorged neck veins are
suggestion that in practice shows only as a very late sign), difficult during air transport.
increasing shortness of breath and desaturation.
 Tension pneumothorax can produce a similar picture
to tamponade and again, history and primary survey
should pick up the possibility.
 While these are standard ‘bread and butter’ cases in

ATLS examinations, in our daily working environment
they remain a rarity.
 The treatment of cardiac tamponade in the

emergency situation is needle aspiration. It can be
Blood replacement in haemorrhagic shock conducted anywhere at any time, once we conclude it
We mention this to dismiss it. Fully crossmatched blood is must be done.
rarely (almost never) available for primary emergency  Non-traumatic cases of cardiogenic shock are usually
medical transports. If the situation is dire and specialist due to acute myocardial infarction or end-stage
advice is that blood should be carried and given, type- progressive congestive heart failure. We may
specific blood is preferable to type O. It is often stated that transport such a patient, but not generally on our own.
type O (preferable Rhesus factor (Rh) negative) can be
‘freely’ given for life-threatening haemorrhage cases when  We are better off to have this type of patient intubated
type-specific blood is not available; however, this is less prior to an elective flight, if in doubt about how the
than accurate. patient will cope with changes in circulation dynamics,
position and oxygenation.
‘O’ is less likely to result in group incompatibility reactions,
but other antigen reactions and general transfusion  The exact choice of inotrope is not very important;
reactions remain a distinct possibility. Micropore blood however, titrating the inotrope carefully to the
patient's condition is important; we are after all

“thrashing” a diseased heart, using both chronotropic  Initial treatment is the same. Use sufficient volume to
and inotropic effects of the drug(s) to increase the pump up the BP, thereby increasing the perfusion
speed and force of contraction of failing heart muscle. pressure to vital organs.
 It is always best to use drugs we are familiar with,  If this is unsuccessful after good volume attempts,
especially outside the hospital/clinic setting. Small use an inotrope.
advantages from novel drugs will not offset the
 By all means, use broad-spectrum IV antibiotics early.
disadvantage of using a drug with which we have no
BUT one should take blood cultures, at least 2 sets,
prior experience in a difficult situation.
to help the treating doctor in intensive care unit (ICU)
 If we are convinced that fluid overload is present, we to which we are delivering the patient make a
can give IV furosemide (Lasix), starting with an initial microbiological diagnosis and target antibiotics more
dose of 20 mg and follow-up if there is no response in effectively.
30 to 45 minutes, with more up to 40 to 80
 While it remains common in many countries to give
mg. However, let us not commit ‘frusemidicide’ -
high-dose corticosteroids, there is no evidence that it
draining off sufficient circulatory volume with diuretics
alters the outcome except for the worse.
to drop preload below what is appropriate for an
already malfunctioning heart.
 We should use vasodilators, i.e. nitroglycerine, * A recent Cochrane report has analysed a significant
carefully if hypotension is present. number of relevant studies and the ‘bottom line’: There is
no evidence from randomised controlled trials that
 We need a defibrillator (preferably manual) ready for
resuscitation with colloids reduces the risk of death,
immediate use.
compared to resuscitation with crystalloids, in patients
with trauma, burns or following a surgery. Additionally, the
use of hydroxyethyl starch might increase mortality. As
Neurogenic (spinal) shock
colloids are not associated with an improvement in
Spinal cord injuries can cause hypotension due to loss of survival and are considerably more expensive than
sympathetic tone. Remember: crystalloids, it is hard to see how their continued use in
 Isolated head injury does not produce shock. clinical practice can be justified.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0010743/
 Hypovolaemia and loss of sympathetic tone
compound each other’s effects.
 The classic signs of spinal shock are hypotension

without tachycardia or peripheral vasoconstriction
(initial treatment is the same as for hypovolaemia;
best to avoid an inotrope until (some) volume has
been restored).
Septic shock
 Septic shock is more likely when patients are brought

to us from outside our remote site, when it is clear
treatment has been delayed, especially in cases of
penetrating abdominal injuries or peritonitis.
 Signs of septic shock include modest tachycardia,

warm normal-coloured skin, near-normal systolic
pressure and wide pulse pressure. However, if a
septic patient is also hypovolaemic, it may be difficult
to distinguish sepsis from low-volume shock.

Taking and Sending Clinical Pictures – Page 10
SOS’ doctors and staff who are all bound to medical

Taking and Sending Clinical
confidentiality.)
Pictures
3. Store the pictures only for as long as is necessary to
This month we are reviewing a skill that is mandatory for make sure they have been well received in the
all remote and offshore health professionals - the ability to Assistance Centre. Delete the pictures from the
take and transmit clinically useful pictures of patients’ camera and store copies of those pictures only on the
visible conditions. This would be done with appropriate hard drive of an International SOS secure computer.
respect for patients’ privacy, observing confidentiality and Additionally, delete those pictures from that secure
working with patients’ informed consent. computer’s hard drive once the file is closed.
You may have heard the expression “A Picture is Worth a 4. E-mail the pictures only to the Assistance Centre at
Thousand Words”. When it comes to making diagnoses of an International SOS e-mail address. You must not
visible problems, even 1,000 words will never be as good use Yahoo, Gmail, Google or any other e-mail service
as an appropriate set of pictures. to send these pictures. You must not send the
pictures to anyone else, including the offshore
The International SOS group promises our clients that all
installation manager (OIM) or rig manager (RM).
our remote site medical staff have access to (at least*) a
Should they ask for this, citing their company’s wish,
second opinion service through the Assistance Centres
politely decline and call your MS operations manager
on a 24-hour basis. (*Occasionally, further opinions may
day or night. Breaching confidentiality is a serious
be sought by the Assistance Centres’ doctors with the
medicolegal issue and we want to support you when
relevant specialist. In order to provide the best support to
you have to say “no”, because you have to say no.
you, our colleague, and to your patient and our clients).
It is understandably difficult either on the phone or in

writing to describe something well enough, so that the
Getting the Right View
topside doctor can visualise exactly what you are seeing.
Therefore each medic on every installation, whether 1. Every lesion, rash, swelling, deformity, puncture,
offshore or onshore, has a digital camera and laceration, cyst, vesicle, ulcer, burn, etc. should have
understands how to take quality pictures and e-mail them at least 2 pictures taken thereof, usually at right
to the topside support as part of case notification. angles. Frequently, it is useful to take pictures of the
unaffected side for comparison purposes. (The
If you do not have a digital camera or access to one, or
anatomy of every patient has 6 sides - top and bottom,
you do not understand anything about downloading,
left and right, front and back, as you will remember
editing and sending pictures, or do not have e-mail
from your advanced trauma life support training, yes?)
access or your communications are down, do not read
any further; pick up the telephone and call your Medical
Services (MS) manager right now (unless it is after
midnight! In which case you should call at 0700).
Consent and Confidentiality
1. Always get the patient's consent and document it in

writing with date and signature. If the patient is
unconscious and incapable of giving consent, the
duty medical director in the Assistance Centre will Figure 1 Measure the lesion in 3 planes
waive consent once the situation is communicated by
you. (This happens rarely, but it does happen.)
2. It may take a number of attempts to get the distance,
2. Explain to the patient why you are taking the pictures
orientation and lighting to reproduce a view in a digital
and to whom you are sending them. (You are sending
file, to as close as what you are seeing with Mk I
them only to the topside support via the Assistance
human eyeball. Take the time and trouble to get it
Centre, where they will be seen only by International
right. Digital film is free.
Topside Newsletter – Taking and Sending Clinical Pictures

3. A basic digital camera is all you need. A good setting

for close-up photos with a sharp focus is the macro
function (very common in most digital cameras). The
universal symbol for this setting is a flower . Use

the same settings every time you take photos
with the same camera. Also, avoid using the zoom
lens. Just about every camera will reset the digital
and/or lens zoom when it is switched off; however, we
need the same magnification at all times to get the
same result in the 1st and subsequent shots when a
condition is monitored over hours or days.
Figure 3 This is a mole
Figure 2 Focus on right part of the scene
Figure 4 This is also a mole

4. When taking pictures of the face, unless it is essential,
6. We have already mentioned taking symmetrical
avoid including the patient's eyes in your photo. If
pictures for comparison purposes. This is especially
you have to do so, then black the eyes out with an
necessary with limbs, especially if you are trying to
easily available software tool, such as Microsoft Paint highlight and monitor swelling or discolouration. A
(installed by default on every Windows computer). variation of this, which is difficult to get right when you
Patients may be reassured about the degree of
start but becomes more straightforward with practice,
security set-up in International SOS’ NewCase is photographing capillary refill after you have applied
software and servers where their pictures are stored
the initial pressure. Press with one thumb and click
in their case file, but as always there is no need to
the shutter with the other. Make sure the timing of the
pass on extraneous/unnecessary information that
comparison photos is exact.
does not serve a clinical purpose. If you are taking
pictures of an injured or ill patient, there is no need to 7. With illnesses that show themselves on the skin, e.g.
show the face of the patient unless the face has rashes, infections, etc., pictures can be very helpful
clinically significant injuries or markings. when tracking the progress of skin/superficial
infections. Draw a circle on the skin with washable
5. Should the patient have an unusual identifying (or marker to encircle the extent of the infection on the 1st
indeed any) tattoo, this should not be
day and take a picture under the same lighting
photographed unless the tattoo is located on the conditions at the same time every day and from the
skin’s surface where the clinical problem is manifest.
same distance, for 2 or 3 days.

11. If you have enough time and required skill set, use
picture editing software to indicate with arrows and
circles the point of maximum tenderness, puncture
wound you are concerned with or angle of entry of a
penetrating object, to describe the depth of a visibly
incised wound and so forth.
Figure 6 The gold standard for wound measurement
12. The camera is often very helpful in documenting

dental cases and other problems in the oral cavity.
However due to the lack of light and access inside the
Figure 5 Close-ups without context are useless mouth, when you are taking pictures of a tooth injury
or sore/infected throat, your 1st case is not the time to
learn how to use a mirror and lighting to see
8. While the most obvious uses of a digital picture may pathology inside the mouth. Using your pen torch to
appear to be those related to skin and surface shine into the mouth with one hand and holding the
conditions, in other words for dermatological camera with the other hand can often give better light
problems, for every injury case, a picture is (and therefore picture quality) than flash. Again,
essential. Pictures can be extremely helpful in practise early.
communicating the severity and extent of injuries,
13. When you are taking pictures of a “surgical
especially injuries that involve incised or lacerated
abdomen” to highlight the point of maximum
wounds, obvious fractures, amputations of extremities,
tenderness and there is a scar seen in the visual field,
eye injuries, burns, etc.
annotate the picture and/or be 100% sure to note in
9. When a patient has a laceration, place (next to the your history the cause of the scar. Was it surgical or
wound/in the same orientation as the wound) a ruler accidental?
or tape measure so that other reviewers can
accurately gauge the size of the wound. If no ruler or The priority remains of course patient care, not digital
tape measure is immediately available, then use a image manipulation.
“standard” object like a pen/5-ml or 10-ml syringe, etc.
against which size can be determined. It is often
difficult to tell how big something is especially with
closer images. Managing the Picture File
10. If a patient has burns, then rather than attempting to 14. Always date- and time-stamp the picture; this should
assess the extent of the burns solely by the ‘Rule of be done electronically when you set up the camera. If
Nines’ or other algorithm, you should photograph you are taking a close-up, set the camera on macro
each of the burnt areas up close and then in the or close-up mode. Use the built-in flash or additional
context of the whole body. Also, indicate in your background lighting, but not both at the same time.
summary (see below) the depth you believe those The time to learn how to get the lighting right is not
areas have sustained thermal injury to. These when an emergency has happened and you are in a
pictures will be sent ahead by the Assistance Centre hurry. So if you have not got a lot of experience with
to the future treating doctor and/or the burns unit, so operating a digital camera for other than family and
that they also have a visual understanding of the tourist-type photos, make sure you acquire that
problem. experience before you need it in earnest. Read the
camera manual and experiment/practise on yourself -

a good place to start is taking photos of your hands To repeat, because this is most important, once you have
and feet, both close-up (the hands) and further off sent the pictures and you are sure they have been
(the feet). received, delete them from the camera. If you are using a
shared computer, delete them from the computer; but you
should be using an International SOS computer that is
Remember the History, Examination Findings, secured against unauthorised access.
Functional Enquiry, etc…
These pictures are part of the patient's medical
15. A picture alone is never enough. We have to records and are subject to exactly the same
take/have a good history and for an injury, it has to be confidentiality and access restrictions as the rest of
made clear in the history how the injury happened, the patient's medical record. No one else on board/on
what were the likely impact forces and whether the the site should be viewing these pictures. No one
item that caused the injury penetrated clothing or else* on board is allowed a copy of these pictures.
safety gear and, therefore, may have left the wound *The patient himself/herself is the ONLY exception.
contaminated with fabric, fibres, plastic, glass, etc. It
is especially necessary that when there is a possibility
of a high-pressure injection injury, the examination
Note for the camera aficionados: If you have a high-tech
and pictures follow potential tracking paths of the air,
camera and the equivalent amount of knowledge, the
grease, paint or other substances, along the path of
following settings are recommended by medical
least resistance.
photographers for adjustable cameras:
Include what you think the diagnosis is. Always  Auto white balance or florescent daylight (trial and
remember, without a history and differential error) (daylight for strobes)
diagnosis, a clinical picture alone is not worth much.
 Supplementary lighting to ISO 800 standard (=
constant output lights)
 Focus set to centre spot (not multiple areas)

Sending the File
 Manual mode
16. When you download the picture, unless you have set
the camera to take small file-sized pictures (which is  Shutter speed 1/125 sec.
recommended as the default setting in most cases,  Lens opening (f-stop) 5.6 (change to lighten or darken
so that you do not have to manipulate every image photos)
that takes time), you will need to resize all pictures
before sending them. Pictures larger than 2 MB will
frequently not go through a single e-mail and a
Appendix
couple such files may quickly fill up your or others’
mailboxes. Download and use a free picture resize With regards to the size of the digital images, we usually
programme; picture quality will not suffer unduly if the instruct the medics to keep the set up of the camera using
file size is kept about 500 to 700 KB (definitely less low megapixels, otherwise resized which sometimes is
than 1 MB) and then you can send all pictures in a done by our Regional Coordinating Doctors (RCDs).
single e-mail. A useful and free picture resize
Alternatives to resize images:
programme can be found at
http://pixresizer.en.softonic.com; or if in a hurry can
be done with Microsoft Paint by reducing size of the
image.
17. Send all pictures* in a single e-mail with the

history and then check the e-mail was received. *If
your camera is set up to default picture size of 2 or 4
MB, this will not work; to repeat, resize the pictures to
the best balance of size and resolution.

Step 1: Open the digital photo with “Paint” Step 3: Resize and press “OK”
Also available in windows start
Step 4: Save the new resized image in the desired folder

before sending by email.
Step 2: Select the desire resize
Thank you. Do not forget to acknowledge this e-mail.

Initial Response to a Patient with an ‘Acute Abdomen’ – Page 15
writing about and unable to get comfortable tend to have

Initial Response to a Patient
renal, biliary or intestinal colic.
with an ‘Acute Abdomen’
If the vital signs are abnormal, e.g. tachycardia,
The correct diagnosis of abdominal pain depends very hypotension, tachypnoea and fever, we should start to
much on precise past and recent medical history, worry* (without showing signs that we are, to the patient)
functional inquiry and attention to detail of examination. and expedite vascular access for fluids (for resuscitation
Hence, there is a need to have a comprehensive picture and drug administration) in, and blood out (for testing,
of the patient before we move on to the next steps - even if you cannot test it on your site should accompany
treatment and disposition. the patient to definitive care). (*There is an old adage
“When I see a patient with abdominal pain sweating, I
That said, we need to have in our skill set the ability to should start to sweat myself.”
move rapidly through the assessment of a patient with
To repeat, if the patient is in pain, give analgesic. The
severe abdominal pain and not keep him/her waiting in
more pain the patient is in, the more necessary it is to
pain for a cruelly long time before we relieve his/her pain.
give this intravenously. Using analgesic does not, despite
what you may have heard, interfere with helpful clinical
examination. In fact, as the patient can be more
cooperative and less distracted because his/her pain is
being relieved and he/she does not feel we are hurting
him/her, I find that use of narcotic analgesic early on
greatly improves my ability to make a rapid diagnosis.
1. Present Complaint
How bad is the pain? This complaint is best evaluated on

the familiar 1 to 10 scale. The scale is not reproducible
between patients, but in any single patient who allows
assessment of trends in response to analgesic and other
treatment.
How long has he/she had the pain (is this a recurrence of
The recommended way to get the diagnosis right is to
a long established recurring pain and has he/she
have a system and follow it, so that we do not miss
previously been investigated for it? Is this a severe
anything. We are going to describe one particular
exacerbation of a long established recurring pain? Is the
systematic approach; if your approach differs from that, it
sum completely new that he/she has never experienced
is not a problem, but if you do not have a system, please
before)?
adopt one.
When approaching diagnosis of the patient with

abdominal pain, we start assessing the patient during our What was he/she doing when it started/what had he/she
physical approach. When we first say hello and introduce been doing when it started? The pain that starts suddenly
ourselves, we should be looking at how much pain the and increases in severity suggests renal colic, perforated
patient is in, to see if we need to reach for parenteral bowel, ischaemia (this could be cardiac - with referred
analgesia. Note that a patient who is lying still for fear of pain - or testicular or ovarian torsion) or haemorrhage.
exacerbating the pain is likely to have a very different What has he/she recently eaten? Correlate this with the
underlying diagnosis than a patient who is restless and presentation and location of the pain both in time and if it
uncomfortable, and cannot lie still. fits into the diagnostic net of true indigestion; however,
Patients who prefer to sit leaning forward a little are often remember that indigestion is usually a diagnosis of
found to have pericarditis or pancreatitis, and those who exclusion because it is a description, not a diagnosis.
do not want to move at all and often curl up with hips and Additionally, remember that pain that starts or gets worse
knees flexed, are often found to have peritonitis. Patients with eating is usually related to the pancreas and gall
Topside Newsletter – Initial Response to a Patient with an ‘Acute Abdomen’

© 2016 AEA International Holdings Pte. Ltd. All rights reserved. Unauthorised copy or distribution prohibited.
bladder and the pain relieved by eating is often due to

peptic (acid/ulcer) disease.
Any history of effort? Correlate this with the physical

examination to show that the abdominal pain is muscle
wall not visceral.
Radiation of the pain? For example, consider a cardiac

cause, if this is presented as "indigestion"; consider aortic
aneurysm, if there is radiation to back/shoulders; consider
gall bladder disease, if there is radiation to back on right
side/right shoulder tip; consider diverticulitis, if there is
radiation to the lower left; consider appendicitis, if there is
radiation to the lower right, etc.
Any involvement of the urinary system with pain?
For women, we must carefully and diplomatically

check and rule out (or not) the possibility of ectopic
pregnancy.
If he/she has been vomiting, was this spontaneous or self-

induced? Some patients make themselves vomit
throughout because they feel it will relieve the pain.
If the patient is vomiting, is the vomit "coffee

ground”/bright red/bile or any combination of the above?
Any altered bowel habit, either constipation or diarrhoea?

Remember the presence of paradoxical, i.e. overflow
diarrhoea, when the primary problem is in fact
constipation further upstream. Be very careful about
calling abdominal pain gastroenteritis, if diarrhoea is not
2. Past History
present. Likewise, while diarrhoea suggests
gastroenteritis, it is present to a degree in up to 1 in 5 Any family or past history of cardiac disease, gall bladder
patients who suffer from appendicitis. disease, hernia, peptic or gastric ulcer, gastritis, hiatus
hernia, indigestion, etc.?
Any lower-end bleeding from gastrointestinal (GI) tract?
Some patients may be blissfully unreactive to the Is the patient a smoker? Useful in cardiac and ulcer risk
presence of occasional recurring bleeding, until they assessment.
collapse from hypovolaemia; and much lower in bleeding
Any medications taken and if so, what for? For example,
is painless.
erythromycin commonly causes abdominal pain;
Any recent anorexia (and if the pain is chronic, how does antibiotics commonly cause diarrhoea; and there are well-
this correlate with any noted weight loss)? Patients who known associations, especially in elderly patients between
have not acutely lost their appetite, probably do not have diabetes, hypertension, atrial fibrillation and a subsequent
an acute underlying inflammatory condition. sometimes delayed diagnosis of ischaemic bowel.
Any non-prescribed medications? Ask about alcohol

consumption and sometimes a sexual history may be
relevant. Patients with excessive alcohol intake usually
present with a triad of alcohol-related difficulties, i.e.
pancreatitis, hepatitis and gastritis, and of course,
allergies.
Any past abdominal or other surgery and if so, what for?

Surprisingly, quite a number of patients do not remember

the diagnosis that resulted in an abdominal scar, but the

location of the scar should tip us towards the likely
pathology - is the scar long and midline, short and the
right lower quadrant, and so forth.
3. Present Examination
All the vital signs? Note that a temperature of 35°C almost

always indicates an incorrectly taken reading; it is too low
to be compatible with a conscious patient.
Saturation of oxygen (SaO2) on room air? If they are

desaturated, fix this.
Where is the pain least in the abdomen?
Where is the pain worst in the abdomen?
And follow the usual pattern - look, listen and feel.
LOOK for distension, ascites, contusions and scars.
LISTEN for bowel sounds, either absent or over present.
FEEL for the location of maximal tenderness, guarding

and/or rebound tenderness, as below, masses, enlarged Look for Murphy’s sign that will help confirm pathology in
organs and hernias. the right upper quadrant. It is almost always present in
Make sure you have warm gentle hands and lightly cholecystitis, but can also occur with pancreatitis and
palpate the abdomen, starting away from the point of hepatitis and occasionally peptic ulceration.
maximum tenderness and working towards it. Do not dive If you know how to carry out these manoeuvres, conduct
straight in and try and compress the abdomen back to the them to evaluate specific areas for tenderness; if you do
vertebral spine with deep palpation over the point of not know all 3 of these manoeuvres, learn them in a
maximum tenderness; this will hurt the patient, he/she will clinical setting with someone to guide you about obturator
cry out. Be gentle throughout the examination, so that sign, psoas sign and Rovsing’s sign (named after a
he/she does not lose confidence in you. Danish surgeon).
It is always a good idea to draw a diagram, so that we are

If you need to check for the effects of deep palpation, stop all clear on the area of the patient that we are, e.g.
when the patient is getting distressed and do not repeat regarding as the point of maximum tenderness. However,
the process. Likewise, if you are looking for rebound this is going out of fashion, since most people do not use
tenderness, let the patient know you are going to push fax machines anymore. If you are not going to draw a
down gently, suddenly take the pressure off, and you diagram, make it very clear in your written communication
would like to know if that makes the pain less or not. And which of the 6 anatomic locations the pain is primarily
again, do not repeat the process. centred around or below:

 Right upper quadrant, epigastric zone, left upper Remember that many cases of appendicitis will resolve if
quadrant helped by an appropriate antibiotic cover, such as
Rocephin and Flagyl. You will, as mentioned earlier,
 Right lower quadrant, suprapubic area, left lower
already have blood in tubes to go with the patient to the
quadrant
shoreside hospital and even if you can do only dipstick
Pain from any of these locations often helpfully suggests testing for urinary difficulties offshore, you should do that.
the source of the problem. Additionally, the pain mostly in An electrocardiogram (ECG) test is frequently indicated,
the midline is most likely bowel-based; this is not an especially given the age and co-morbidities of many older
ironclad rule, but is helpful. workers on remote sites.
5. Once the patient is moving to definitive care, if that is

what we have decided, he/she should be referred to an
appropriate facility/ward. As a rough guideline below,
these dispositions change according to country:
Obstetrics/gynaecology (OB/GYN): Ectopic

pregnancies, ovarian torsion and cysts, pelvic
inflammatory diseases, post-delivery complications,
uterine masses
Internal medicine: Pancreatitis, hepatitis, ulcer disease,

inflammatory bowel disease, GI bleeding, gastroenteritis,
pyelonephritis (without stone)
Urology: Pyelonephritis (with stone or complicated),

complicated renal colic, scrotal hernias, testicular torsion,
epididymitis
Surgery: Of course, primarily for conditions that need

surgery to be fixed: Appendicitis, cholecystitis, perforation,
ischaemic bowel, incarcerated hernias, acute or subacute
bowel obstruction, and all traumatic conditions resulting in
penetrating injuries, intra-abdominal haemorrhage and/or
ruptured intestines
A rectal examination is often necessary and should not be 6. Regardless of how much or how little ability we have on
overlooked because of your or the patient’s our site to investigate the patient beyond history and
embarrassment. This is not a hospital-only procedure; it examination, we must come down to a differential
needs to be done in an appropriate clinical context. A diagnosis and preferably, the most likely diagnosis. It is
majority of retrocaecal appendixes are missed primarily not a good idea to decline to reach a diagnosis “because I
because of the lack of rectal examination. do not have enough information”. Get off the fence!
4. By the time you have done all of the above, you will be
able to observe the results of your first treatment and you
should have a good idea of what the underlying pathology
is, as well as having administered analgesia and fluids.
Both, you and topside should consider the use of
prophylactic antibiotics, especially if there will be a delay
in bringing a patient to shore up to definitive hospital care.
If you do use antibiotics, make sure you document the
dose and timing carefully.

Anaphylaxis – Page 19
 Steroid
Anaphylaxis
 Beta-agonist
The term dates back approximately 110 years.
Anaphylaxis is an acute, potentially life-threatening
hypersensitivity reaction. The pathophysiology is well
POSSIBLY ALSO
understood, not that we really need to worry about that or
know that; we just need to know how to interrupt/abort it.  Advanced airway management tools and techniques
The presentation is defined by a number of symptoms If you are not sure that you have got all the first 5 to hand
and signs, alone or in combination, which can start within and can lay your hands on them in 30 seconds or less,
a minute or less after exposure to the agent provocateur, stop reading and check now. As unless countered, severe
but may also start hours after the initial exposure. Most of anaphylaxis is the consummate Terminator™. "It can't be
us reserve the term anaphylaxis for severe or critical bargained with, it can't feel pain or mercy, and it will stop
hypersensitivity reactions. Most allergic reactions are of at absolutely nothing until you are dead!" (or resuscitated).
course mild, but anaphylactic reactions are life
People die of anaphylactic shock. Shock is of course,
threatening.
as we have said before, lack of perfusion of vital organs
Peak severity usually occurs within a 5-minute to half- by oxygenated blood.
hour time frame, usually lasts for some hours especially
People who have had a previous episode almost always
without rapid and effective treatment, and a minority of
know what is coming… And may communicate quickly to
these reactions can last days.
you what they think has happened and possibly even the
As a life-threatening medical emergency, it is once again agent they know has caused it this time. If they are
something that requires a combination of exactly the carrying an EpiPen and know how/want to inject
appropriate actions effectively coordinated and taking themselves, do not stop them.
place in parallel, not in sequence (that means you need
Signs and symptoms of shock caused by anaphylaxis
more than just your 1 pair of hands…) and something that
include pallor with cool and clammy skin (peripheral
you cannot resolve without appropriate equipment that
vasoconstriction and hypoxaemia), tachycardia often with
must (be checked) be ready every hour of every day in
a poorly palpable pulse and progressive respiratory failure
your facility.
leading inexorably to further hypoxic, confusion, loss of
consciousness and finally collapse.
A more complete list of symptoms and signs would be:
 Neurological: Patients who do recover often

remember feeling mortally afraid and about to die.
Some patients in anaphylactic shock proceed directly
to being unconscious.
 Gastrointestinal and genitourinary: Abdominal

pain, faecal urgency or incontinence, urinary urgency
or incontinence, nausea, vomiting and diarrhoea.
 Oral/facial: Itching and swelling of soft palate,

tongue, lips, periorbital oedema, conjunctival
oedema, occasionally rhinorrhoea and ‘tears’.
 Respiratory: Upper airway obstruction from quickly

developing massive swelling/oedema of the soft
tissues in the oropharynx and larynx; bronchospasm
AT A MINIMUM
with a feeling of a very "tight chest", occasional cough
 Epinephrine (adrenaline) early on and significant wheeze (but do not let the
fact that the wheeze will diminish over time reassure
 Oxygen *
you; the wheeze may be less audible simply because
 Antihistamine less air is moving through very constricted tubes).
Topside Newsletter – Anaphylaxis

 Skin: Widespread redness/blushing/flushing; the patient still needs to be moved to a higher level medical
appearance of urticaria over part or all of the body, facility, as a precaution.
rapidly developing (angio) oedema and itching
Apparently, patients who have refractory or very severe
(usually a secondary symptom).
anaphylaxis (with cardiovascular and/or severe
 Cardiovascular: Hypotension leading to syncope respiratory symptoms) should be admitted or treated and
and hypovolaemic shock, arrhythmias initially tachy observed for a longer period in the emergency
then brady, and (ischaemic) chest pain even in the department (ED) than less severely presenting
previous fit in the young without coronary artery patients. However, all patients need to be referred
lesions. because of the possibility of a biphasic response.
But we do not want to wait until we have seen and In terms of the provocative stimulus, this is one of the few
documented all of these! times where taking a history at the onset of the episode is
less important than treating the patient. If the patient
manages to go about the history of what the likely
allergen was and what he/she has had previously, this is
useful to know; however, it does not affect what you are
going to do to treat the present reaction.
Anaphylactic reactions can come from a variety of

provocative stimuli, for example:
The priorities are, again and as always, Airway, Breathing,  Pharmaceuticals: Primarily, but not exclusively, the
Circulation. antibiotics, such as penicillin, sulphonamide or
cephalosporin; and muscle relaxants, including
 Get the person in a comfortable position and elevate
suxamethonium (‘Scoline’), alcuronium, vecuronium,
his/her legs.
pancuronium and atracurium. By themselves, the
 Check the person's pulse and breathing and, if muscle relaxants account for 4/5 of all allergic
necessary, administer cardiopulmonary resuscitation reactions during general anaesthesia narcotics both
(CPR) or other first-aid measures. legal and illegal apparently. Rapid injection of a
particular drug is more likely to result in a quickly
 Give medications to treat an allergy attack, such as
severe reaction.
an epinephrine autoinjector or antihistamines, if the
person has them.  Food Items: Especially, but not only, nuts (primarily
peanuts), fish, shellfish, milk, eggs, seeds (especially
Be aware that even when we have successfully treated
cotton and mustard), many fruits and vegetables.
the initial acute severe symptoms, several hours may
Some people will develop severe reaction to inhaled
pass before the development of a second reaction, the
particles, e.g. the odour of frying fish or an open
so-called "biphasic response". Even if the patients survive
packet of peanuts.
the initial episode, a minority of such patients may die
days or even weeks after the initial anaphylactic event. If  Plants: Pollen (often in association with apples,
you have successfully treated the patient for anaphylaxis potatoes, carrots and celery), ragweed (often in
and he/she appears and feels well, and you see no association with melons and cantaloupe) and latex
problems with the vital signs after observation, you still (frequently seen with banana, avocado or kiwifruit).
need to consult with the Assistance Centre because the Food-associated, exercise-induced anaphylaxis may
occur when individuals exercise within 2 to 4 hours

after ingesting a specific food. Exercise without the

‘triggering’ food does not cause problems, likewise,
eating the triggering fruit without exercising does not
result in problems.
 Insects: Bees, ants and wasps.
 Blood and blood products.
 Contrast media used in imaging.
 Our old favourite ‘idiopathic’, which means we do

not know why it happened/we have not been able to
isolate or identify the offending agent.
Myocardial oxygen consumption (MVO2) of the heart:
Cardiac State MVO2

(ml O2/min per 100 g)
Arrested heart 2
* The importance of oxygen Resting heart rate 8
We are going to digress for a little while to talk about the Heavy exercise 70
use of oxygen in emergencies, including of course
anaphylaxis. As soon as you see a very ill or severely
injured patient or someone who has the potential to By comparison, the oxygen consumption (ml O2/min per
rapidly deteriorate, such as in anaphylaxis, get him/her 100 g) for other organs is:
breathing a higher inspired oxygen concentration. Look at
it this way. The heart and other organs, especially the Organ O2 Consumption
brain, need a certain amount of oxygenated blood per (ml O2/min per 100 g)
minute to survive. If your patient’s lung capacity is say 5
litres and he/she is breathing air, he/she only has 1 litre of Brain 3
oxygen in reserve in case he/she suddenly stops
breathing. Oxygen demand by the heart and brain is Kidney 5
always high, and higher under stress (see the table

Skin 0.2
below). If you can fill his/her lungs with 100% oxygen,
then he/she has 5 litres of oxygen stored for the heart to
Resting muscle 1
keep working 5 times as long, in case you have trouble
opening and maintaining an airway. Contracting muscle 50

The newsletters are being issued as part of your CME.

We always try to tie the newsletters into real life events
and actual cases, or as in this case the drills which have
been conducted on the different rigs.
Last month unified drills were held on all Seadrill rigs in

Asia/Pacific and Africa. Moving forward, we hope to
include all regions in these drills.
The recent drill case was the one attached to this

newsletter: a patient with a severe anaphylactic reaction –
a life threatening condition. The average score on the drill
was around 95%, meaning that you were all able to
recognize the condition and its implications, and to initiate
the right treatment. Please use this newsletter as a
referral on anaphylaxis and allergies, and as a theoretical
background to your own clinical thinking and management.
Enjoy your reading, and do let us know if you have any

questions or comments.
Level 2 Drill Seadrill

Swelling and Breathing Difficulty_2015 April.docx

Ramadan Special 2015 – Page 23
Ramadan Special 2015 Preventing Medicine Scarcity

This edition focuses on the health and safety issues FASTING in Ramadan includes NOT TAKING ANY
concerning fasting during the holy month of Ramadan. MEDICINE at daytime.
th
The term 'Ramadan' corresponds to the 9 month of the
There is much anecdotal, as well as scientific, evidence
Islamic calendar, which lasts for 29 to 30 days. This year
that the use of antacids increases significantly in the adult
Ramadan falls on the 17th of June, ending on the 17th
fasting population during this month. During Ramadan, as
of July. Apparently, 2015 refers to the Gregorian
a consequence of the physiological changes and lack of
calendar used in the West, being the year 1436 of the
regular medication intake, sick bays and clinics should be
Islamic calendar.
prepared in advance and carry a sufficient stock of such
It is the Islamic annual month of fasting, in which medications. You should also review the indications for
participating Muslims refrain from eating any food or such prescriptions and the dosage regime you will advise
drinking water from dawn to sunset. It is intended to the patient to take (as the medicine will be taken only
teach Muslims about patience, humility and spirituality. during the non-fasting period overnight).
Apparently, the extended Islamic habits of fasting will

have some effects on health and efficiency of those who
observe the custom. It is, therefore, prudent for our Ramadan Rules and Fasting Exemptions
medical colleagues, as well as nonmedical co-workers, to The local imams are the ones who interpret the Holy
be aware of some of the potential effects of such fasting Quran about this, but the following seems to be accepted:
on occupational health and safety, as well as on the
person's own health. In a Muslim population, if anyone is clinically unwell and
requires any medication (oral administration), a special
RAMADAN routine combines early waking hours and diet or invasive treatment, then he/she is allowed to take it.
changes in diet causing: This is not considered as breaking the fast. Menstruating
 Lack of sleep (waking up before dawn for the last women cannot participate during the menstruation as they
meal before the 12-hour fast). are considered "unclean", and have to fast the days they
have missed after Ramadan.
 Relative dehydration during the fasting day due to a
lack of fluid intake. For Muslims, they can pay the fast (with a fast) at another
time. Also, whilst traveling >120 km, one is allowed to
 Relative fall in circulating nutrients, especially, but not break the fast for that day, as long as this day is made up
limited to, glucose due to a lack of food intake. at another time. Anything that is taken into the body
These habits cause PHYSIOLOGICAL EFFECTS ON purposefully during a fasting time (from sunrise until
HEALTH. Scientific studies have confirmed that the sunset), such as liquids or food, will break the fast.
combination of loss of sleep and changes in diet results in: Normally, if in any doubt, the patient needing regular
 Significantly shorter period of the most restful type of medication or emergency medication is encouraged to
sleep (rapid eye movement (REM) sleep). consult with his/her imam or other appropriate religious
authority. It is written that the fast may be broken for
 Lower levels of circulating melatonin (affecting sleep
clearly necessary medical reasons and people suffering
time restful properties).
from an illness or injury need not place their health in
 Disruption of the usual circadian rhythms for the (further) danger.
month of Ramadan (for up to 5 to 7 days afterwards).
Consequently, this has an effect on daytime alertness

(from the loss of sleep). We do not need to exaggerate Islamic Views
the importance of this, but it will be prudent to account As an ulema has said:
for it when assigning staff to tasks requiring the
"If a faithful doctor you trust advises that fasting is harmful
utmost concentration.
for you, or if you feel worried that your condition would
worse due to fasting, it is not mandatory, not even allowed
(to be) fasting and fasting would not be legitimate. But if
you are not worried about your condition, then there is no
Topside Newsletter – Ramadan 2015
prohibition of fasting. However, the validity of your fasting serial urinary specific gravity pre- and post-shift as an
depends on the fact that fasting would not endanger your indicator of how well it is being managed.
health."
The other main medical problems you are likely to
As a verse from the Quran states: encounter during Ramadan are urinary tract infections
and gastrointestinal problems. For antibiotics you can give
"So whoever among you is sick or on a journey let him
drugs, such as azithromycin (once daily) or choose twice
replace it on another day and those who feel the weight
daily regimens where possible.
then let them ransom by feeding the poor and so whoever
overstate the goodness then that is good for him and Good medical judgment always prevails, and if the
fasting is better for you if you know (QS. al-Baqarah: patients choose not to follow our advice, it is their own
184)" responsibility. I am not sure that by asking them to sign a
statement to the effect that it is against medical judgment
will make any difference, so oral advice on the
Recommendations for International Assignees implications of adjusting treatment during Ramadan may
be acceptable.
Communication Work Wise
Adapting Work Hours
It is advisable to start the education/communication
program at the earliest convenient time, prior to the Remember that the day is psychologically back to
commencement of Ramadan. This provides employees front so increase supervisor ratios in the day as they
enough time to digest the information provided and allows are off at night, they will stay up and so be tired during the
for changes to medication plans with adequate support day.
prior to Ramadan. Otherwise, there remains a risk that Most employers in the Middle East will reduce the working
employees will just stop taking all medications during day to 6 hours to accommodate Muslims during Ramadan.
Ramadan. By implementing communication programs It also depends on the labor laws of the country and work
from early-on, you will find that employees are willing to shift schedules during Ramadan, especially when
come to the clinic and discuss the options available to Ramadan falls in summer (as it does presently in the
them. This will also allow them to complete their fast. Northern Hemisphere).
At Friday prayers, a discussion is encouraged to ensure If it is a full activity, 24-hour platform, then your best
that there are no misunderstandings. advice is to encourage predawn hydration and plan the
It is important that they take enough fluids by mouth to shift changes around the sunset and sunrise prayers.
last them the next 12 hours. Eating and drinking properly
and fully at the allowed times twice a day is the single
most useful precaution they can take to look after A Ramadan Experience at Emirates Aluminium (EMAL
themselves. Abu Dhabi, United Arab Emirates)
Medical Checks "We had a limited number of reported cases of heat

stress or heat related illnesses, we did however notice an
REMEMBER: No matter what your policy is, if the imam
increased level of sickness absence in employees who
(or on a rig whoever they feel is most knowledgeable
were respecting the fast.
about the Quran) does not concur then they would not
follow it. So, you always need to work in this space. We At EMAL the working hours did not change for operational
have found that most Muslims working on our sites employees, i.e. they were exempt from the local law of
would rather "cope" than break the fast, as they take working for a period of 6 hours per day. If possible it is
this very seriously. beneficial to change the working patterns of employees
who are respecting the fast to work night shift and those
The biggest problem is for patients with diabetes,
not respecting the fast to work on days. This was done at
especially those on insulin or undisclosed diabetics. We
the EMAL site, but there was still a requirement to have
should try to put them on a once or twice a day regimen,
employees working on day shift who were respecting the
wherever possible, and then address any control
fast.
problems by measuring HbA1c after Ramadan. Do your
best to have people on bd medication (not tid or qid We did note that employees were willing to break their
because they would not take them). One can perform fast if they were becoming symptomatic whilst working

during normal working day shift duties, this was not an What you may find:
easy decision for employees but they did understand the
 Measuring the surface temperature or a more
value of information being provided to them from clinical
"peripheral" temperature under the armpits or even in
staff where applicable.
the mouth does NOT give a good idea of how high
One area of interest and it may be worth consideration for the temperature can be. If you suspect heatstroke,
remote sites and offshore installations was the increased you must measure the patient's rectal temperature. If
use of antacid medication, as at EMAL the amount of you haven't done this recently, re-familiarize yourself
usage almost trebled during the month of Ramadan how to do it accurately... rectal temperature over
compared to other months." 104oF/40oC is an emergency!
LAST BUT NOT LEAST, while those of us who do not  Skin may be hot but dry, even under the arms and
engage in fasting may continue to eat and drink as other areas which are normally damp with sweat in
usual, it is a courtesy to be observed that we not do the heat. Look at these areas, not just at the patient's
so in front of our fasting colleagues, for obvious face.
reasons.
What you must do:
 Call for help and move the patient quickly, but

Dealing with Heat and carefully, to a cool area/your clinic.
Dehydration  Remove much of the clothing and place the person,

especially if unconscious, on his side in the
Prevention of dehydration and heat by management of recovery position, exposing as much skin surface to
meals/drinks after sunset and before sunrise is important. the air as possible, because you have to cool the
person by sponging and spraying cool water
(absolutely not cold water; cold water may start
Heatstroke: First Steps the person shivering which further generates
heat) all over his/her body.
Heatstroke occurs when the body is unable to regulate its
own temperature and literally "overheats", with  Have an Advanced First Aid trained person assist
temperatures above 40.5oC at the "core" of the body (see with this, as well as fanning the patient, while you
below). start an IV (necessary in all patients with altered
consciousness (see below*)) and call Topside.
Patients who suffer severe heatstroke become
unconscious, but there are warning signs before this  Apply ice packs to the groin, neck and armpits, where
happens and these need to be observed carefully, large blood vessels lie close to the skin surface, but
especially when we see people working hard for long do not put the person into an ice bath. This is
periods in a hot environment. They may run out of the dangerous, and people have drowned.
ability to keep cooling themselves (which normally occurs
 Your goal is to get the core temperature back
as our sweat evaporates from us).
below 39oC. Again, this has to be checked as a rectal
temperature; temperatures taken in the mouth, from
the eardrum or under the arm are NOT accurate!
Symptoms and Actions to Take
 Do not give "usual" antipyretics, such as aspirin or
What you may see: acetaminophen; they will not be effective and may
 Tachycardia (fast heart rate) cause harm to the patient.
 Sweating that may have stopped or may be very  *Only if the patient is awake and alert enough to
pronounced before shutting down drink safely can you attempt oral rehydration. By the
time people present with heatstroke nearly all have
 Restlessness, anxiety, irritability or confusion an altered level of consciousness and cannot safely
 Gasping, rapid and erratic breathing drink on their own.
 Brief bouts of unconsciousness and convulsions  Last but not least, the true measure of a good
(seizures) circulating volume is (the kidneys) producing a

healthy amount of urine. As part of your response

to this newsletter, advise your MS supervisor on
the minimum acceptable rate of urine output in
ml. per hour for a 70 kg man, (or ml./kg/hr if you
prefer), for an adult patient.
MUST DO
 Encourage both your colleagues and their
supervisors to be aware of the inevitable flow on
effects of fasting, and to lessen these as much as
possible.
 From the workers’ side, make sure those observing

the fast are primed and encouraged to eat the
allowed 2 meals a day (this will mean getting up
earlier than usual in order not to miss the morning
meal, but it is worth doing to set themselves up well
for the day).
 Familiarize yourself with the handout on heat

illness prepared by our colleagues in Sydney, which
is being sent to you as a separate attachment.
 Heatstroke is a serious potential consequence of

becoming dehydrated while working hard in a hot
environment or a hot climate year-round; therefore, it
is timely to re-familiarize yourself with the
important first steps to take for heatstroke
ABOVE, read your clinical reference materials for
more details, or ask any of the Topside Medical Team
for further advice.

Heat Stress – Page 27
 It is too humid because sweat evaporates less in

Heat Stress humid conditions, as there is already a lot of fluid in
Introduction the air.
Body Temperature Basics  The air is still because wind increases evaporation.
Our bodies are meant to stay at a fairly constant Sweat alone does not cool the body. It only cools
temperature, around 37°C (98.6°F). Bodies automatically when the moisture evaporates.
balance heat gain and heat loss. Bodies gain heat using
muscles during physical activity, and from the surrounding
environment. Bodies lose heat through exhaling hot air, Sweat is not Just Water
the skin and sweating.
 It also contains salts and minerals, such as sodium,
When the body cannot stay cool, the inner “core” potassium, chloride, magnesium and calcium.
temperature can rise too high, the body symptoms break
 If you sweat a lot, your body needs water AND salts
down, organs become damaged and it can result in death.
replaced.
Heat-related illness and death are preventable.
Losing Heat Losing the Heat: Interesting

Factors
Losing Heat: Through Skin
Some people have a more difficult time shedding excess
When things go right:
body heat. If you have had a heat illness previously, you
 The brain automatically sends more blood to the skin. are at a higher risk. Below are some more interesting
factors:
 Heat is given off into the air or whatever the skin is in
contact with. Age Children below 4 years of age and adults
It is hard for the skin to lose heat if: 65 years of age or older.
It is too hot! Weight Overweight or obese people.

 When the air around you is almost the same
Chronic People with heart diseases, high blood
temperature as your skin, or hotter, your skin cannot
Conditions pressure, diabetes or malnutrition.
lose much heat.
If you are too physically active Medication Some drugs for depression, circulation
issues and psychiatric conditions can raise
 Blood is sent to your muscles rather than the skin’s
risk – ask your doctor about any drugs you
surface, warming you rather than cooling you. take.
 Your activity also generates more heat.
Lifestyle People who are physically fit, eat a
nutritious diet and get enough rest can
usually tolerate heat better. Drinking
Losing Heat: Through Sweat alcohol makes it harder to handle heat.
When things go right:
Activity Athletes and people who work outside or
 The brain signals sweat glands to make sweat. Level in hot facilities are at risk even though they
may be healthy and physically fit.
 The fluid evaporates, leaving you cooler.
It is hard to lose heat through sweat if: Adjustment People new to the job or the city are in
more danger because they are not used to
 You are dehydrated because your body needs
the heat yet.
enough liquid to produce sweat effectively.
Topside Newsletter – Heat Stress

Heat Stress: When Sweat and Skin are not Enough Avoid too much direct sun on bare skin:
It is important to identify heat stress early, and take it  Cover skin with loose, lightweight clothing.
seriously.
 Wear a wide-brimmed hat to shade your face – this
If the body cannot get rid of extra heat, your body also keeps you cooler!
temperature rises and the heart rate goes up. These are
 Use sunscreen with a sun protection factor (SPF) of
the painless beginnings of heat stress.
at least 30.
When your body is overwhelmed by heat, things can
 Limit time spent outside during peak sun hours (1000
get worse quickly: Your body temperature can reach
to 1600 hours).
dangerously high levels in 10 to 15 minutes.
Heat Cramps
Heat Rash (Prickly Heat)
Heat cramps can also be a symptom of heat exhaustion.
Heat rash is the most minor and most common heat
They occur due to a loss of salt and water through
illness. It can be an ‘early warning’ sign that your body is
sweating. Heat cramps are most common in people
affected by heat.
involved in strenuous physical activities in the heat.
Heat rash is caused when the skin gets irritated by heat
Symptoms of heat cramps:
and sweat; sometimes sweat ducts get blocked.
 Muscle pain or spasms.
Symptoms of heat rash:
 Can appear at the time of physical activity or later
 Itchy rash – a red cluster of pimples or small blisters
even when not active.
 Usually appears in areas where sweat collects
 Usually appears in the muscles being used, such as:
o Neck/chest
o Arms
o Groin area
o Legs
o Elbow creases and other skin folds
o Abdomen
Management of heat rash:
What to do if you have a heat cramp?
 Cool the skin (spend time out of the heat, take cool
 Stop activity and rest in a cool place.
showers).
 Drink clear juice or a sports drink (you need to
 Keep the rash dry – choose cotton clothing, avoid
replace salt and water).
synthetic clothes that do not “breathe”.
 Gently massage painful areas.
 Sometimes low strength hydrocortisone cream may
be recommended.  Rest, for several hours after the cramps have gone.
 Avoid ointments and oily creams – moisture can

make the rash worse.
Heat Syncope (Heat Collapse)
See a doctor if:
Fainting can be serious, especially if the person is
 The rash lasts beyond a few days.
operating machinery or is in a dangerous environment.
 The rash covers a lot of skin or seems infected.
Causes of heat syncope:
Not enough blood reaching the brain. This is more likely

when it is hot as more blood is taken to the skin. It is also
A Word about Sunburn
more common when there are blood pools in the legs by:
Sunburn is painful, can be severe, and can lead to skin
 Standing still for a long time.
cancers. But it is preventable!
 Standing suddenly from a seated or lying position.

Symptoms of heat syncope: It is more serious if:
 Feeling dizzy and lightheaded  Symptoms get worse or last more than 1 hour.
 Fainting (passing out)  Victim refuses water or vomits.
What to do if you or someone is suffering from heat  Person shows signs of Heat stress.
syncope?
 Lie down in a cool place – symptoms improve as

blood gets back to the brain. Heat Stress (Sunstroke)
 Slowly drink water, clear juice or a sports drink. Heat stress can cause permanent brain damage, and can
kill quickly. It is caused when the body is overwhelmed by
See the doctor if:
heat. Heat stress can happen within 10 to 15 minutes,
 There is any injury. without much warning.
 The person has lost consciousness. Symptoms of Heat Stress:
 The person does not immediately improve after lying  High body temperature
down.  Hot and dry skin, not sweaty
 Signs of Heat stress are present.
 Fast, strong pulse
 Throbbing headache
Heat Exhaustion  Dizzy
Heat exhaustion can develop over several days. If not  Nauseous, vomiting
recognized and treated, it can lead to Heat stress. Heat
 Acting “crazy”
exhaustion is caused by the loss of salts and fluids due to
heavy sweating.  Confused
Symptoms of heat exhaustion (wet, white and weak):  Seeing or hearing imaginary things (hallucinations)
 Looking either pale or flushed  Clumsy, may be angry or aggressive
 Skin is cool and moist (clammy) – person is sweating  Lose consciousness (passing out)
 Dizzy or passing out (heat collapse)  Seizure or convulsions
 Headache Call for immediate medical help:
 Nausea RIGHT AWAY. This is an emergency.
 Fast, weak pulse
 Feeling weak, clumsy and a little confused What to do for Heat Stress
Things to do until help arrives: while you Wait for Medical
 Stop activity and lie down in a cool place. Help?
 Remove/loosen tight clothes.  Call for emergency medical help.
 Slowly drink water, clear juice or a sports drink.  Move victim to a cooler place to lie down.
 Take a cool shower, bath or sponge off with cool  Cool the person; however you can:
water.
o Remove/loosen clothing.
 Spray with cool water and fan.
o Cool the skin with water: Gently spray or sponge
or wrap in a cool wet sheet or put in a cool bath
or shower, if possible (only if the patient is
conscious!).

 Make a breeze – fan the person once he/she is wet. Are you at Risk?
 Place ice packs on neck, groin and armpits. Anyone can be overcome by heat, even people who are
fit and healthy.
 Offer cool water to drink, if the person is awake and
able to drink. People who are outside in high temperatures are at a
higher risk, especially:
 Take the person’s temperature every 10 minutes.
 If it is humid.
 Stop cooling efforts if the temperature reaches
around 38.5°C to 39°C (101°F to 102°F).  If they are in the sun.
 Watch the patient’s breathing, as it may stop.  If they are working or exercising.
 Be ready to give rescue breathing, if needed (or find a Some indoor places are also a higher risk:
coworker who can).  If stationed near radiant heat sources (e.g. furnace)
Seizures look scary. But you can help. or direct heat sources.
 Clear the area around the person; move furniture,  If air is still and not moving (it is stuffy).
sharp things and other people out of the way. Job-related tasks
 Let the person’s body move freely; never hold him/her  Working with hot objects
down or restraint the person.
 Firefighting, baking, farming, mining, construction or
 Do not put ANYTHING in the mouth; leave it clear laundry
and empty. Do not offer liquids.
 Staffing a boiler room or factory
 Wearing heavy clothing or protective gear

Things to Avoid when Assisting
 Long shifts
 Offer cool – but not ice cold – drinks. Do not offer
Same job, different day
caffeinated drinks (coffee, cola, etc.) or alcohol.
Heat tolerance changes every day based on the
 Victims should not smoke or take any medications temperature, humidity and your level of hydration. You
(including aspirin).
may get sick one day even though you have been doing
 If the person starts to shiver, slow your cooling the same job for 5, 15 or 50 weeks.
efforts. Shivering builds body heat backup. Never ignore symptoms!
 Avoid alcohol rubs; only cool water and ice packs
should be put on the body.
What is the Danger? Understanding Heat and
 Unconscious people can drown in a few inches of
Humidity
water. Use baths safely.
Thermometers measure the temperature of the air. But a
 Do not be shy about loosening clothing in an
worksite may actually feel hotter than that temperature,
emergency – a coworker would rather be undressed
especially if it is humid. The heat index and humidex are
and embarrassed than dressed and dead.
measurements that determine how hot a place feels (felt
 Do not use ice baths. air temperature).
 Do not let the person gulp liquid - ½ a glass every 15 Felt air temperature also goes up:
minutes.
 If you are in the sun.
 Stay with the victim until help arrives – his/her
 If you work near another heat source.
condition could get worse.
 If you are wearing protective clothing or equipment.

Heat and Humidity in the Choose Avoid
Arabian Gulf Cool drinks Ice cold drinks

 Average temperatures in the cities are very high. For
Drinking on schedule Waiting to feel thirsty to
8 months of the year, the average daily high
drink
temperature is >30°C.
 The hottest month is August, when the average Drink ½ to 1 liter (16 to 32 Drinking a lot of liquid at
maximum temperature is about 41°C and minimum ounces) per hour – drink once, every few hours
30°C. It can reach 49°C. break every 20 minutes
 Humidity levels in summer are extremely high,

between 80% and 90%.
Acclimatization: Another Prevention Tool
The human body can get more tolerant of heat in a

Preventing Heat Stress at Work: process called acclimatization – getting adjusted to your
Understanding Heat and environment. It happens over several days to a week; not
in a few hours. Workers who have worked in heat stress
Humidity
conditions before can usually handle:
Stay healthy: Heat illnesses range from unpleasant to
 50% exposure on day 1
deadly.
 60% on day 2
Stay safe: Accidents are more likely if workers are heat
stressed. They might get tired, and feel weak and dizzy.  80% on day 3
Sweat can make hands slippery, heat can fog goggles,
 100% on day 4 (full working capacity): Check
falls can happen, etc. worker’s pulse, temperature and comfort level
Stay useful: Heat stressed workers are slower and make
Workers who have not worked in heat stress conditions
more errors.
before:
 20% on day 1
Hydration: A Key to Prevention  20% increase in exposure each additional day
Bodies need fluid to sweat and handle heat. When people  Pulse rate, discomfort and body temperature will be
do not drink enough they become dehydrated, and are at highest on the 1st day
a higher risk of heat illness. Take in as much fluid as you
 People who have been on holiday or sick leave need
sweat out – which could average ¾ liter per hour at work!
to acclimatize again before working at 100%
In hot environments, people need ½ to 1 liter (16 to 32
ounces) of fluid per hour.
Choose Avoid Things to Do

Water Alcoholic drinks Things Employers Can Do: Engineering
 Ensure worksites are ventilated. But remember, if air

Sports drinks Drinks with caffeine (coffee,
is hot (>32°C/90°F) fans do not work well to cool
cola, teas, etc.)
people.
Natural fruits or vegetable Very sugary drinks (soda,  Air condition spaces, when practical and necessary.
juices sweetened, etc.)
 Provide a “cool room” for breaks and first aid.
Ice pops/blocks made with Hot drinks
 Use a portable blower with built-in air chiller, as
fruits or juices
needed.
 Insulate equipment that generates heat.

 Reflect heat away from people when possible (e.g.  Make rest breaks and other preventive measures
use shields or move the hot item to a separate room, mandatory.
if possible).
 Ensure workers are acclimatized before taking on full
 Consider power assists and tools that can reduce the shifts.
staff’s physical labor.
 Use relief workers.
 Monitor work conditions: Keep track of the heat,
 Assign extra workers to physically demanding tasks.
humidity and other factors that add to heat stress.
 Match a worker’s job to his/her heat tolerance level.
 Repair faulty, leaking or inefficient equipment.
 Monitor workers who are at risk of heat stress.
 Consider providing personal cooling devices or
protective clothing for at-risk workers.
 Train all staff in basic first aid. Things Workers Can Do: On the Job
Work in a “buddy system”
Things Employers Can Do: Schedules  Heat stress sometimes makes people confused and
unable to tell if they are sick.
 Do maintenance and repair jobs in cooler months.
 Have a partner who watches you for signs of illness,
 Schedule hot or physically active tasks for the cooler
and you do the same for him/her.
part of the day (early morning or nighttime).
Be smart about breaks and fluids
 Schedule rest periods into the day, and ensure all
workers take them.  Take scheduled breaks in cool places.
 Provide cool water or other liquids.  Encourage others to take breaks, too.
 Break spaces should be cool and out of the sun.  Drink water or natural juice on schedule – about
every 20 minutes, before you feel thirsty.
 Workers should take several breaks throughout the
day. Take charge of your health
 Limit the number of people working in 1 space.  Follow an acclimatization schedule when you arrive,
and when you come back after leave.
 During unusually hot weather:
 You may like to monitor your heart rate, temperature
o Postpone non-critical tasks.
or body fluid loss while working.
o Provide more breaks.
Take symptoms seriously and report them
o Shorten work days.
 Everyone is different. Do not try to keep up with your
o Have safety meetings. coworkers or “push through” illness.
o Encourage workers to take a break, if they are If you wear protective clothing or equipment, you are
uncomfortable or show any sign of heat illness. under more heat stress. You need more breaks and
water.
Things Employers Can Do: Personnel

Things Workers Can Do: Lifestyle
 Give workers pre-assignment medical checks.
Dress smart
 Determine fitness for work in hot environments.
 Loose clothing is cooler than tight.
 Manage underlying medical problems and
medications.  Natural fibers (cotton, linen, etc.) are cooler than
synthetics (polyester, nylon, etc.).
 Educate staff about heat-related illnesses and how to
prevent them.  Light colors reflect heat and keep you cooler.

 In the sun, wear a hat to shade your face, ears and 5. Even mild heat stress can make people slower and
neck. clumsier.
Live healthy True/False
 Get enough sleep.
 Be careful with drugs or alcohol, as they change how 6. I will be able to tell if I have heat stress, and do not
your body handles heat. need a buddy system.
 Choose nutritious foods and eat several smaller, True/False

lighter meals. Avoid eating a lot of food at one time.
Healthier at home 7. If someone with heat illness is being cooled and

 Spend a few hours a day somewhere cool. starts shivering, we should keep trying to cool them
just as quickly.
 Use air conditioning or a fan.
True/False
 Open windows at night or whenever the air outside is
cooler than the air inside.
8. I will know when I need to drink more water, because
 Reduce the heat that comes in; use shutters or
I will feel thirsty.
reflectors, not heavy curtains.
True/False
 Cardboard covered in aluminum-foil works.
 Put plants in your house and yard.

9. There are simple self-tests I can do at work, and after
Turn off lights and electric items you are not using.
work, to see how well my body is handling the heat.
True/False
Test your knowledge – True or
False 10. After a vacation or leave away from a hot
environment, I need to get adjusted to the heat again.
1. Alcohol use, sunburn and drugs can change the way
my body handles heat. True/False
True/False
Answers:
2. If a person stops sweating, it means he/she is cool 1. True

enough.
2. True
True/False
3. True
4. False
3. Heat stress is a deadly emergency and needs to be
5. True
treated fast.
6. False
True/False
7. False
8. False
4. If I was OK on the job today, I will be OK on the job
tomorrow – I can handle the same workload every 9. False
day.
10. True
True/False

Analysis of Thrombolytic Therapy on Offshore Installations – Page 34
disallowed unless specifically authorised by a responsible

Analysis of Thrombolytic
physician. This would further restrict the likelihood that we
Therapy on Offshore could employ the agent even if the case meets the criteria.
Installations This is because in countries with robust prehospital
thrombolytic protocols, where the "pain-to-needle" time is
The theoretical case for prehospital thrombolysis is reduced, bolus thrombolytic is administered by road
sometimes strongly made. That said, we must fulfil the ambulance medics; the doctors responsible for these
prime role of medicine by "doing no (avoidable) harm"; as medics know them personally, oversee their training and
Dr Lars helpfully reminds us, in over 7 years/140,000 share accountability. This is not an offshore/remote site
consultations with Seadrill, we have never had to carry situation.
out thrombolysis offshore.
The following is a background reader on the risks,

benefits, traps and clinical environment surrounding what (Pre)Assessment of Patients
was a literally game-changing/life-changing treatment
A considerable amount of time will be saved if at the time
when it was introduced onshore, some decades ago.
a patient presents, his/her cardiac risk factors are already
known, both to the medic and to the topside coordinating
doctor (CD) responsible for the decision. However, as we
all know, these patients do not present as they would in a
clinic or hospital with medical records accessible. Perhaps,
most important of all, we do not have access, rapidly or
sometimes at all, to any electrocardiograms (ECGs/EKGs)
that the patient previously has had during pre-deployment
examination. Both parties should have the previous ECG
available to them, but this is especially important for the
topside CD (and the medical director (MD) on duty - all
such cases would be escalated to the MD on duty as
soon as possible). As again, doctors have the clinical
responsibility for the decision to proceed or not with
thrombolysis.
The difficulty, as other studies have shown, is that to

effectively shorten the process to the point where the
Training patient's outcome is improved, it requires the medics to
record and, with or without assistance, interpret a
It is not enough to know how to insert an intravenous (IV) prehospital ECG. Various methods of achieving this have
line, check off the list of risk factors and indications, and been described and we will review them briefly:
administer the drug. It is also essential to have refreshed
and retrained in basic life support (BLS), advanced  Computerised acquisition and automatic
cardiovascular life support (ACLS) and defibrillation interpretation of the ECG: Computer interpretation
techniques, and meet the ACLS standards for the team inevitably errs on the side of caution so that some
leadership of a cardiac arrest protocol. Since it is eligible patients will not receive prehospital
impossible to run the ACLS algorithm single-handedly, thrombolysis. Additionally, many people are
there are actually very few sites onshore and offshore uncomfortable with a computer making a potentially
where thrombolysis would be safe and yet is not available life-threatening decision.
at a nearby facility.
 ECG interpretation by liaison with the topside CD:
This has proved successful in some prehospital
Choice of Thrombolytic
programmes ashore, given the frequent
Clearly, this is primarily decided by the availability of communication breakdowns and delays in acquiring
thrombolytic agents in one’s region of responsibility. All and transmitting an EKG to the assistance centre, is
the newer bolus thrombolytic agents are usable; however, unlikely to be effective on a 24/7 global basis.
in many countries, administration of thrombolytic is
Topside Newsletter – Analysis of Thrombolytic Therapy on Offshore Installations

 ECG interpretation by onsite staff: This may well be

the future of prehospital thrombolysis, but at the time
of writing this report no training or medicolegal
"cover" existed to support this.
 Transmission of ECG to the medical staff at the future

receiving hospital followed by the use of two-way
mobile communications to authorise and support the
administration of prehospital thrombolysis. Again, this
works in some programmes onshore where the
teams’ capabilities are well known to each other and
the responsibility is clearly allocated. This cannot take
place in an offshore context. Communication from Rig/Installation
Recording an ECG before conducting thrombolysis is an We need the medic, OIM and topside CD to work together
important safeguard for the patient. The larger as a team during such an incident. There are 2 reasons
thrombolytic studies have found that patients with ST for this, the 1st is that the medic cannot do everything on
segment elevation or left bundle branch block showed the his own and the 2nd is we are all stakeholders in the best
greatest relative reduction in mortality, whereas those with outcome for the patient. Provided consent is obtained, the
normal ECGs or ST segment depression showed no OIM could document the timeline of the process as the
significant benefit. But more importantly, withholding medic asks the questions and records the answers.
thrombolytic treatment from someone with a normal ECG However, we would also need the OIM and/or the first-aid
reduces the likelihood of the harm that may result from team to be capable of and participate in BLS and ACLS
giving thrombolysis for a condition mimicking acute cardiopulmonary resuscitation (CPR).
myocardial infarction.
Given the responsibilities of the medic, the OIM or his
Checking the ECG first for confirmatory evidence of delegate would need to remain primarily responsible
infarction considerably improves the appropriateness and for facilitating the transmission of written communications,
safety of thrombolytic treatment. Another implication is especially ECG scans, and for documentation of the non-
that when the later ECGs are compared… We will need to medical aspects of the process. The medic and CD are of
have proven that we were able to record the initial 12 lead course and will always remain responsible for the medical
accurately and so, we would have to take and transmit a content of all verbal and written communications.
picture of the positioning of the chest leads applied to the However, without the involvement of other people on
patient... An alternative is that every patient over the age board, appropriate, accurate and time-stamped messages
of 45 coming on board a rig/coming to a remote site has a simply could not be passed back and forth quickly.
quick but structured cardiac risk assessment performed
within 48 hours of arrival, and that (whether directed by
International SOS or the client) a central repository of all In Summary
patient ECGs is available online and accessible from
Thrombolytic therapy offshore should never be given
anywhere in the world on a 24-hour basis.
without a good quality ECG and even then, only after
An appropriate health check programme, such as MedFit, escalation of the case to a responsible and qualified
would guarantee this. If we do not have a baseline ECG, topside physician/cardiologist. It should also be ensured
our evaluation of the present ECG(s) and our subsequent that the receiving medical centre is capable of continuing
decisions will be significantly less accurate… As we can the treatment started.
see, there are solutions to the concerns, but they are
The end responsibility for the treatment and decisions
much easier to do and much less costly to implement, and
taken lies with the authorising topside physician.
there would be much less concern about potential
breaches of privacy and confidentiality onshore than
offshore.
Adjuvant Therapy
While the most effective drug is the actual thrombolytic,

adjuvant anticoagulant treatment is also necessary.

Accordingly, heparin must be as readily available as the The CD says

bolus thrombolytic. Although there is a relative (but not
“Treatment at this stage saves the lives of about 4
absolute) lack of firm clinical evidence as to the useful
patients for every 100 we treat. But it can sometimes
role of heparin, there is a strong cardiologist consensus
cause serious bleeding. The biggest risk is stroke which
that heparin is useful at least to reduce the incidence of
affects about 1 patient in every 200. Some patients also
post-thrombolytic reocclusion after treatment with bolus
have allergic and other effects that do not usually cause
thrombolytics.
any major problem”.
In summary, therefore, if heparin is not available,
Again, difficulties can easily arise with patients who have
implementation of thrombolysis should not proceed... For
not been forthcoming about their past medical history, or
similar reasons, to reduce the catecholamine "storm" that
simply may not know it.
increases infarcted muscle, an appropriate parenteral
analgesic must be available. If this is not available, the
implementation of thrombolysis should not proceed.
Competency
This needs to be assured for both the medics and the

CDs who advise them. Suggestions include, but may not
be limited to the following:
 Only the CDs and medics who have completed (and

successfully passed) an international-standard ACLS
course within the last 2 calendar years will participate
in the programme.
 During the 2nd afternoon of the 2-day training period,

each medic will be required to successfully conduct a
resuscitation scenario on a manikin according to the
ACLS standard and a pre-thrombolytic assessment of
a communicative ‘patient’ according to the checklist
standard, in order to be eligible. Failure to
demonstrate the 2nd competency in the classroom will
Patient Consent not compromise the medic’s employability, but it will
This may sometimes be a contentious issue because of mean that the medic cannot participate in
language difficulties. Appropriate scripting should be in thrombolytic treatment. (Obviously, part of every
line with the standard procedure used onshore… medic’s training is to demonstrate the 1st competency,
i.e. CPR according to the ACLS standard.)
The medic says
 Each medical service medic supervisor will be
“It is likely that you have suffered a heart attack, and the responsible for at least 1 yearly ‘practice’ assessment
best treatment we can give you before you get to hospital done while the medic is offshore and 1 videotaped
is a clot dissolving drug called (XXX). The quicker you practice scenario conducted during the medic's
receive this drug, the lower the risk from the heart attack, rotation onshore.
which is why the Topside doctors who have heard what
has happened to you and seen your ECG I sent to them,
have recommended we start this treatment as soon as ******************************************************************
possible. These drugs can cause serious side effects in a
small minority of patients which the doctor on shore can Complications
explain to you in more detail if you so wish, but the risks These can be very serious, sometimes lethal. They relate
attached to this treatment are very much less than the to the drug's performance as we want it, i.e. reperfusion
likely benefit. Would you like me to give you the injection, arrhythmias due to blocked coronary arteries opening up
or what you prefer to talk to the doctor first to have more again, and the drug's performance as we do not want it,
details?” i.e. bleeding, especially intracranial bleeding leading to
In the event that patient does want more information... serious cerebral vascular events. They also relate to a

problem common to every drug, namely allergy to the

point of anaphylaxis. Although the risk of complications is
low in a well-screened otherwise healthy patient, we must
remember that if severe complications occur, the patient
will not have access to tertiary medicine the way he/she
would have in an onshore setting and the medic does not
have access to a team of colleagues the way he/she
would have onshore.
In Summary
 Thrombolysis can often save lives and healthy heart

muscles to the patient's future benefit.
 Thrombolysis can occasionally do severe harm to

individual patients and the risk is higher with older
patients with multiple morbidities, especially vascular
system morbidity.
 Offshore thrombolysis would require a very

considerable investment in training, retraining,
refreshing, equipment, medical record collection and
storage, and very likely the ability to get an on-call
specialist/cardiologist’s opinions globally within 30
minutes.
I rest the case for the defence, in defending the status

quo.

Triage – Page 38
Triage
Triage is the classification and sorting of casualties for the
purpose of management and evacuation, according to the
degree of urgency.
Clearing the Accident Site

In order to minimise congestion that interferes with rescue
work and due to the danger of further casualties from
secondary explosion and building collapse, it is important
to remove casualties from the accident site as soon as
possible. Hence, the need for a triage system.
The Degree of Urgency
All casualties feel that their case is more urgent than

anyone else’s. However, the medic may have to decide
among several casualties who will be evacuated 1st and
Aim of Triage
with what degree of urgency.
The aim is to do the most good for the largest number of
It is important to remember that a casualty is in a dynamic,
people. It only applies to a situation where there is more
not a static, condition. It does not mean that because the
than 1 casualty. It does not apply to a single casualty,
casualty feels and looks good at the present time, he/she
although the principles involved can be used as a guide to
will be in the same condition in an hour or two. This is
determine the degree of urgency in the management of
important in head and abdominal injuries, where a gradual
the casualty.
deterioration in condition can occur.
An important principle to use, as a guide, is that saving a

The ‘Mass Casualty’ Situation life takes precedence over saving a limb. The treatment of
hypoxia and blood loss is of primary importance.
Accidents can occur in industry resulting in a number of Protection of the airway and the control of bleeding are
casualties, e.g. explosions, and collapse of building walls the most vital things for the medic to achieve. These are
or scaffolding. In such an incident, the medic may have to the conditions that are most readily managed by a
take charge of a team effort to attend to all the casualties. surgical team in a hospital. The principle conditions that a
In order to ensure the most serious injuries are treated in triage officer should watch for are shock and cyanosis.
their right order of priority, the medic needs to assess Those conditions that have caused, or are likely to lead to,
the casualties’ injuries according to a (prior) plan. shock and cyanosis have top priority for evacuation and
treatment.
Another important principle is that function takes priority

over appearance. A fractured limb may appear grossly
deformed, but there may be little damage to the skin,
blood vessels and nerves. On the other hand, an injured
limb may show no external deformity but numbness,
Topside Newsletter – TRIAGE

Triage – Page 39
pallor of the extremity and absent pulses may indicate the Group 2
need for urgent hospitalisation.
Those casualties who have injuries that would benefit
from some medical treatment, but who do not require
immediate hospitalisation (e.g. ankle sprain, large bruises
and abrasions, and back strain) can be evacuated to their
homes, in the care of friends, and instructed to seek early
treatment from their own medical aid after registration.
It is important to appreciate that casualties classified in

Group 1 and Group 2 still ought to receive appropriate
first-aid treatment, if possible, prior to disposal. It is,
however, equally important that such casualties should
not be allowed to crowd a hospital emergency area or
accident site. In mass casualty situation, they are more
likely to receive early medical treatment at home or at a
remote medical facility than being transported to the
hospital receiving the more seriously injured.
Main Principles
To decide the urgency of each casualty’s need for care

and evacuation, the medic needs to be able to assess
injuries according to a plan. In making such decisions, 2
main principles apply:
 Acute needs override long-term – A casualty with a

fractured spine will generally have lower priority for
evacuation than a casualty with internal abdominal
bleeding.
 Life takes precedence over limb – A casualty who is

not breathing has priority over a casualty who is
bleeding.
Group 3
These are the casualties whose injuries require early

Casualty Groups
transport to hospital. Some will require urgent surgery in
Broadly speaking, in a mass casualty situation, the injured order to survive, whereas others can afford to wait until
may be grouped into 4 main categories for the purpose of the more seriously injured have been treated. Casualties
evacuation from the accident site. categorised in this group can be further subdivided into
priority cases, according to the need for urgent surgical
treatment.
Group 1 This group can be further subdivided into priority cases:
Those casualties who clearly have trivial injuries and who,
Priority 1 – Requiring urgent transport to hospital
in the ordinary course of events, would probably not seek
medical treatment (e.g. minor bruises or abrasions, fright  Casualties with hypoxia – Severe chest injury (e.g.
and slight headache). These casualties can be instructed flail chest, sucking chest wound and pnumothorax),
to leave the accident area unassisted or with a friend, and obstructed airway (e.g. throat wounds, and facial and
to return to seek medical aid or their home after jaw fractures with ‘gurgling’ breathing)
registration.
 Casualties with severe bleeding – Abdominal injury
with signs of shock; external bleeding, e.g. open

Triage – Page 40
fractures, crush injuries, burns to 30% or more of Group 4 / Priority 4

body surface
Casualties clinically dead or probably going to die before
 Acute cerebral compression – Head injuries and reaching hospital (e.g. those who have been decapitated,
deteriorating level of consciousness have massive head or torso injuries, have been cut in half,
whose brain and skull have been very severely damaged
 Multiple injury casualties
or who have been incinerated).
Priority 2 – May require surgery within a few hours These casualties are the last to be evacuated. They
should be managed with dignity and protection.
 Unconscious with a clear airway
 Abdominal injury without signs of shock
 Large wounds where bleeding has been controlled Negative (a.k.a. ‘reserve’) triage
 Burns to 10% to 30% of body surface In a disaster, a medic may have to make a choice
between who to save and who to leave, perhaps to die.
 Fractures or dislocation of major joints
This is absolutely an unenviable task, and it is very
difficult to train and prepare for, even if one is extremely
experienced.
Priority 3 - Most will require surgery when practicable
The principles of triage remain the same, except that the
 Closed fractures triage officer would have to decide to give priority for
evacuation to those casualties whose injuries are such
 Facial injuries without airway obstruction
that they can be treated with a good chance of a good
 Eye injury outcome. In other words, they can leave the hospital and
 Minor wounds resume normal activities of daily living, rather than
devoting time and resources to those whose injuries
 Burns to less than 10% of body surface would be difficult to treat with the likelihood of permanent
 Spinal injury disability or death.
The above examples are to be taken only as a guide and In a disaster situation, therefore, the order of priority may
apply only to a mass casualty situation, where decisions be reserved so that people with less severe injuries are
have to be made in a relative sense. preferentially evacuated before those who are most
seriously injured and who have the highest likelihood of a
In single casualty situations or where there is no need to
fatal outcome.
distinguish between casualties, different principles may
apply. Reserve triage is, therefore, always unpleasant to
contemplate and is something for which there can be no
For example:
hard and fast rules. If you ever face such a situation, as
All unconscious casualties and all spinal cord injuries are the professional on the spot at that time, make the best
best regarded as emergencies. decision you can - that is all anybody asks.

Hand Injuries – Page 41
Hand Injuries
It is essential to get the management of new/acute hand
injuries right from the start. Getting it wrong can leave the
patient with a permanent disability and, especially in the
remote and offshore medical context, the inability to
continue to work and secure a lucrative career. Patients
who lose the use of their thumb, end up with a hand that
only functions as a hook or a hammer; patients who lose
the use of their fingers, end up with a low-power clasp...
Either result must be avoided because of the significant
occupational, as well as social consequences of what can
easily be a maiming injury.
As always in medicine, not only must we do no harm, but

we must also recognise as soon as possible injuries that
require urgent or emergent referral to a hand specialist.
In this newsletter, we are going to look at assessment,

initial examination and management, appropriate
diagnosis and documentation, and onward referral for
hand injuries.
We are not going to discuss traumatic amputation of

fingers, thumb or hand in this newsletter as this has
been covered previously: if you are in doubt, refer back
to that newsletter now.
When a patient presents to us with a recent hand injury,

the order of priority is:
1. Circulation - check if perfusion is still adequate,

3. Function - (without causing undue pain) evidence if
conversely check is bleeding uncontrolled
the affected part still moves and feels normal
2. Laceration - if the wound is open, this problem
4. Protection - if there is an open wound, once debrided
extends to a bone and/or joint
and clean, cover with sterile dressing and apply
Next images show multiple small but not trivial lacerations, comfortable splint(s), as indicated
sutured and monitored closely
Infection - check tetanus status and consider the need for
antibiotics (there is no invariable indication for these even
in open hand injuries) Examining the injured limb should
be straightforward, the usual triad of look, feel and move.
1. Look for…
a. Colour and perfusion
b. Visible wounds (measure them)
c. Deformity (angulation, shortening)
d. Swelling, discolouration and bruising
Topside Newsletter – Hand Injuries

2. Feel for… through an otherwise innocuous-appearing entry wound.

Make sure you take time to carefully document the
a. Sensation
precise mechanism of injury. For every injury, quantify the
b. Tenderness likely force and the time it occurred. In extremity wounds
c. Crepitation (check with consideration so as not to and especially for digits, the amount of energy applied
cause unnecessary pain) and absorbed by the soft tissues bears a direct
relationship to the amount of subsequent ischaemia and
d. Capillary filling necrosis.
e. Warmth
f. Pulses
3. Move…
a. If the patient is able to actively move and rest

hand and fingers voluntarily, it is unlikely that any
joints are injured. However, limited movement
does not guarantee a normal joint… and
continuity of movement does not guarantee an
undamaged tendon mechanism; partially cut
tendons may keep moving fingers early after an
injury and then weeks later, suddenly divide
completely.
b. Passive movement by us moving the limb is most How much worse this would have been if the patient had
helpful to identify movements that should not not been wearing protective gloves (see image above).
exist, as an early indicator of ligament ruptures or
The possibility of a high-pressure injection injury and the
unstable fractures of shaft bones. Again, do not
presence of broken glass or metal fragments in the wound
cause the patient unnecessary pain.
(that may also injure you when you are examining the
hand) need to be carefully checked with the patient.
Work through the following list of “injury principles” when Subsequent X-rays will be needed when the patient is
you see an injury like this, so as not to miss anything: referred, and these X-rays should be taken with the
knowledge available to the radiologist and radiographer of
1. Any skin wound near a fracture or joint must be
the likely location, angle of entry and nature of the
assumed to communicate with bony component and
material being looked for.
is therefore a compound injury until proven otherwise.
The presence of potential sources of bacterial
2. Penetrating injuries may produce lacerations with little
contamination, not visible on X-ray and not visible to the
tissue necrosis, e.g. stab wounds, indirectly produced
specialist (because you have cleaned it) must also be
open fractures (spiral fractures in which a sharp bone
asked for and documented. This particularly applies to
spike lacerates the skin from inside out), etc.; these
injuries sustained in contaminated water, dirt, involving
wounds have a significant risk of infection even when
industrial chemicals, or wounds that penetrated through
carefully managed from the outset. Note that in open
clothing or gloves.
wounds, there is little correlation between the severity
of injury and the size of any associated skin opening. Along with the history and mechanism of injury, must
come the appropriate patient demographics that include
3. Degloving injuries, which occur when skin and
patient allergies, patient medical history and, of course,
subcutaneous tissues separate from the underlying
patient’s occupation. As many hand injuries require
muscle, are common. Progressive swelling poses the
repeated surgical attention over weeks to months,
risk of compartment syndrome with further local
remember to update the patient’s home country and travel
ischaemia.
plans to the first specialist who sees the patient. Most
As always with injuries, the mechanism of injury is hand injuries do not require any special in-flight
important. In a previous newsletter, we covered the arrangements or seating other than the ability to keep the
catastrophic potential of high-pressure injection injuries, injured limb protected and elevated. Most patients

undergoing medium- and long-term hand procedures and

rehabilitation will be best at home.
In summary, your observations and care must include the

following as a minimum:
1. Visible changes in the limb's function, perfusion or

neurological state - as always, documented with
appropriate close-up and medium-distance digital
photographs (for the sake of professional
completeness, it is worth taking these with the
uninjured limb in the same shot, for comparison)
2. Any angulated fractures or dislocations that you had

to reduce (or could not reduce) during extrication or
splinting at the scene
3. Bone ends that were withdrawn into wounds that you

or other people saw exposed
4. Lavage/debridement, dressings and splints that were

applied
5. Any procedures done
6. Any delay incurred at the accident site or en route to

the hospital whether or not it was under your control
7. Tetanus status of the patient
Protection Against Infection

It is best achieved by early, careful cleaning and wound
irrigation, NOT the early and indiscriminate use of
antibiotics. “Dirty” wounds do not all inevitably become
infected but clearly, the risks of both tetanus and
secondary bacterial infections are increased in the
following:
1. Wounds more than 6 hours old
2. Contused, abraded or avulsed wounds
3. Wounds more than 1 cm deep
4. Injuries resulting from high-velocity missiles (necrotic

tissue from cavitation - primarily from gunshot
wounds; these ought to be a rarity in our practice, but
a couple of these are seen every year globally on our
sites)
5. Injuries due to burns or cold
6. Wounds with significant contamination
7. Wounds with denervated or ischaemic tissue

dermatome, it is all well and good; otherwise, describe

what you see, what the patient reports, note the concerns
you have about the potential involvement of nerve/tendon
damage deeper to an open wound and, above all, draw
diagrams…
We are therefore not including a peripheral nerve

assessment guide in this newsletter; if you feel you do
want one, you can take a look here:
https://www.youtube.com/watch?v=8fmG9cNKjlg
Or here:
http://geekymedics.com/2010/10/05/hand-examination/
With careful examination, tendon damage can be

The 4 images above, show excellent initial care and
confirmed (but as above, partial tendon divisions cannot
keeping it clean and dry will produce a great result.
be confirmed). The function of each tendon must be
assessed for each digit.
Compartment Syndrome  The extrinsic deep flexors act on the distal

interphalangeal (IP) joints.
Whenever the pressure inside soft tissues increases
above the inbound circulating blood pressure, nerves and  The superficial flexors act on the proximal IP joints.
muscles lose their supply of oxygenated blood and can  The long extensors primarily extend (dorsiflex) the
become ischaemic and necrotic. This may not be present metacarpophalangeal (MP) joints.
when the patient is first seen; it may develop only after
hours. In hand, compartment syndrome is fortunately  The intrinsic muscles flex the MP joints and extend
uncommon with 2 exceptions that are an abscess in the the IP joints, as well as abducting (dorsal interossei)
palmar compartment due to spreading infection and a and adducting (palmar interossei) the MP joints.
significant crush injury across 3 or more metacarpals. If you do not know what the above means, do not worry,
Look for: go back to documenting what was the mechanism of
1. Pain that increases in the palm when you extend the injury, where the wounds are and what you can see from
fingers of that hand any range of active movement the patient still feels
possible.
2. Sensation that decreases when you test the nerves
transiting that hand
3. Swelling
(Note that weakness of muscles is a late sign; also note

that slow capillary filling is not a reliable sign. If you are in
any doubt as to whether compartment syndrome may be
developing, call topside support early and elevate the
hand as high as it can go well above the level of the
patient’s head.)
(Associated) Nerve and Tendon Damage
Our function is not necessarily to decide which precise

nerve has been damaged and where along its course; our
function at the initial assessment is to document an
apparent injury to the nerve and raise the level of
suspicion appropriately to the examining specialist. If you
are comfortable examining tendon mechanisms and

(Associated) Joint Damage a wound. If in doubt about the injury to deeper structures,
somebody is going to have to cut the sutures anyway and
Again, unless this is obvious, a definitive diagnosis of joint
there is no urgency to close open extremity wounds as
injuries must wait upon specialist examination and joint-
long as debridement has been done well; delayed closure
specific imaging. Without causing the patient a significant
(after 5 to 7 days, NOT 24 to 48 hours) very significantly
amount of pain, it is usually not possible to differentiate
reduces the risk of infection. To repeat, careful and clean
between dislocations and fracture dislocations without X-
surgical care and not “shotgun” attacks with antibiotics is
rays. So let’s not try.
the best way to avoid wound infections. Any antibiotic
treatment administered must be individualised to the
patient and the circumstances of the injury, and needs to
be cleared with topside.
Pain Relief
Hand injuries hurt because the hand is a sensitive organ.
It is a professional obligation, as well as kindness to treat
pain. Oral analgesics are usually sufficient; elevate the
limb so that it is not excessively throbbing due to high
perfusion pressures that accompany anxiety and its
consequent tachycardia. Never inject an anaesthetic into
a hand or finger to reduce the pain; always offer pain
relief as many patients are excessively stoic and will not
complain, but will happily accept what you can do for
them.
Pain is significantly relieved by careful splinting. A

temporary splint for a hand should replicate the
“anatomical position” of the hand, see picture below.
The images above show a crush injury, ‘upstream’ from

the hand
Initial Management Even if you do not have to splint the rest and forearm and
only need to splint a finger, do not splint the finger in
Bleeding from a hand injury is always and relatively easily extension.
controlled by direct pressure applied over a sterile
dressing and elevation. When controlling bleeding point
by direct pressure, take at least 15 to 20 minutes before
you release pressure to “take a look”. Many concerns
about bleeding being difficult to control relate to the fact
that every few minutes someone wants to have a look to
see if the bleeding has stopped… Do not use a tourniquet!
Do not try and clamp an artery! Do not stitch/suture such

Summary Appendix: Managing Minor-but-Not-Trivial

As always, of course, deal with life-threatening (A, B, C, D, Hand Injuries that Stay on Board
E) situations before attending to the injured hand.
Due to the social and functional importance of the hand,

examine meticulously, document carefully, communicate
fulsomely with topside and, for significant injuries,
anticipate that a referral to a hand surgeon will be our
priority, not a referral to an emergency room (ER) or
orthopaedic registrar… (But again as always, do not
promise anything in anticipation of us knowing what we
have been tasked to deliver.)
A crash injury with superficial laceration, healing well

though with considerable swelling on day 7
For both commercial and social reasons, people who do

not require to be disembarked often remain on board
under the care of the medic while the wounds heal. These
can be successfully managed under close surveillance
with daily reports and (again daily) digital photographs.
Things to watch for:
1. Be careful of occlusive especially circumferential

The above 2 images show that this will heal a lot better
dressings that allow the skin to get moist, slow
than many would expect from looking at it right now but it
healing and promote infection.
will only heal well and be functional for future manual
work, if all the Right Things are Done Right from Day 2. Do not use finger splints in an effort to keep the
One!! patient working. The patient should be on duties that
do not require the use of either the injured or the
uninjured hand.
3. Do not use alcohol or undiluted hydrogen peroxide

when cleaning; it will not only cause the patient pain,
but will damage subcutaneous fat and nerves.
Alcohol should not be necessary to use because

“sticky” plaster material should not be used as it is
occlusive and restrictive.
4. If a dressing does not come off easily, do not risk

disturbing the fragile new epithelium; soak for at least
20 minutes in sterile saline.
5. Change the dressing daily, more frequently only if the

dressing becomes contaminated or the wound bleeds
heavily; frequent dressing changes allow more
frequent opportunities for bacteria to contaminate the
wound. Make sure any dressing does not obscure the
fingertip so you can check perfusion and capillary
refill for the first few days after the injury.
6. Look for redness, swelling, tenderness and pus at

every dressing change; the presence of these and, of
course, the presence of red streaking, swollen lymph
nodes and fever mandate immediate contact with
topside regardless of the time of day or night.
7. If an antibiotic has been prescribed in consultation

with topside, check at every dressing change if the
patient is tolerating it and continues to take it in the
dose and with the frequency recommended. (In many
studies, compliance with prophylactic antibiotics for
the full course at the recommended dose is achieved
in less than 20% of patients).

Dengue Fever – Page 48
Dengue Fever – Towards an

Evidence-Based Response to
the Suspicion Diagnosis in
International SOS
Introduction
The diagnosis of dengue fever is frequently offered or
made in International SOS healthcare facilities across the
globe. The response of individuals to the diagnosis varies
considerably, and recommendations for referral and
international transport (evacuation) vary more so.
This newsletter reviews the basis for providing diagnosis,

treatment and transfer recommendations, so that we can
keep patients safe, avoid inconvenience to them unless
clinically justified, and avoid unnecessary medical and
transport expenses for patients and clients.
Differential Diagnosis
It is critically important to not overlook the potential
diagnosis of malaria; malaria is eminently treatable if
suspected, dengue is not. Symptomatic treatment of
Dengue fever is increasing in endemicity and lethality. dengue is all that is available; if only symptomatic
During the 19th century, dengue was recognised but treatment of malaria is given, the outcome can be fatal.
considered a sporadic disease that caused epidemics For both the diseases, there is no vaccine and no infallible
only intermittently, a reflection of the slow pace of vector rapid test. However, the rapid diagnostic test (RDT) for
migration and limited- or long-duration personal travel at malaria has excellent sensitivity and good specificity; this
that time. Today, dengue ranks as the most important still means a minority of patients may still be suffering
mosquito-borne viral disease in the world (yes, above from and continue to develop clinically obvious malaria,
malaria). especially in high-transmission environments, with a
In the last 50 years, incidence has increased 30-fold. An negative rapid diagnostic test. As always, treat the patient
estimated 2.5 billion people live in over 100 endemic not the lab result…
countries and areas where dengue viruses can be
transmitted. Up to 50 million infections occur annually with
AS ALWAYS: Malaria is a medical emergency and
500,000 cases of dengue haemorrhagic fever* (DHF) and
must be ruled out!
22,000 deaths mainly among children. (*Prior to 1970,
only 9 countries had experienced cases of DHF. Since
then, the number has increased more than 4-fold and
continues to rise (WHO statistics).
Dengue Fever
Three diagnostic entities of dengue, i.e. dengue fever,
DHF and dengue shock syndrome (DSS), are commonly
described following infection with the virus responsible.
The more serious complications (DHF and DSS) occur in
people who are infected with >1 serotype of flavivirus.
(There are a total of 4 serotypes; therefore, it is perfectly
possible, although unlikely for people to have 4 episodes
Topside Newsletter – Dengue Fever

of dengue infection sequentially. It is reinfection by a Time Required for Virological (Non-Clinical)

different serotype (heterotypic reinfection) that is much Diagnosis of Dengue
more likely to trigger complex immunopathologic
Collection
Diagnosis
Specimen
Shipment
responses.)
Time for
Storage
Results
Time of
Choice
Patient
Test of
Dengue Fever Presentation
Serum Less Let blood Ship Virus 2 to 4
The classical definition of dengue fever is an acute fever than 4 clot at room on ice isolation weeks
(39°C to 40°C / >100°F) with muscle pain, headache, days temperature, (at
after then store at 4°C) RT- 2 to 7
retro-orbital pain and a maculopapular rash, sometimes
onset 4°C. PCR days
but not invariably accompanied by leucopenia and
thrombocytopenia. Joint pain associated with severe Serum After 1 IgM 1 to 7
muscle pain is common, but not invariable week ELISA days
accompaniment to the syndrome, hence the old name for of
onset
dengue of "break-bone fever".
As you can see, even in areas where such sophisticated

Dengue Haemorrhagic Fever (DHF)
tests are available, and acknowledging that virus isolation
Dengue + high fever, haemorrhagic phenomena (initially, is by far the most reliable method, yet takes the longest,
a resting tachycardia not consistent with the degree of in our context, the diagnosis must necessarily remain
fever, followed by other signs of circulation compromise), primarily clinical. (PCR is more reliable than
accompanied by significant thrombocytopenia and immunoglobulin M (IgM) enzyme-linked immunosorbent
hemoconcentration. assay (ELISA), but is generally not as widely available
and results are generally not available the same day.)
Even so, case fatality rate of DHF is globally <5% (mostly
in children <15, mainly in those sequentially infected with There are also a growing number of increasingly reliable
more than 1 serotype; as is further discussed later, there rapid tests on the market, and one of our considerations is
is no cross immunity between serotypes). Any fatality rate whether this should also be introduced offshore.
is not to be ignored, but it is very clear that the patient’s
residential history, i.e. a period of recent residence and
the potential for infection with dengue in areas that are
endemic for dengue*, must play a major part in
differentiating the diagnosis of dengue from other causes
of fever and other viral exanthems.
*Refer to http://www.healthmap.org/dengue/en/
Dengue Shock Syndrome (DSS)
This is serious but fortunately rare. DSS = DHF + features

of extensive plasma leakage leading to ‘third-spacing’ of
fluids, extreme dehydration, coagulopathy and shock.

Transmission 1. Stays at the usual residence, reviewed as an

outpatient
Dengue viruses are transmitted by mosquitoes of the
Aedes group. These are relatively small mosquitoes that 2. Give analgesics and antipyretics (but not aspirin due
feed predominantly on humans and less so on other to platelet effects)
animals. They tend to bite during the day throughout the 3. Watch for signs of DHF
day; highest biting intensity is about 2 hours after sunrise
and before sunset.
When the diagnosis of dengue is probable and the
The responsible mosquitoes are usually found resting in
patient's condition causes concern for dengue
dark places inside human housing. They breed in small
haemorrhagic complications:
deposits of relatively clean water in or around human
housing (flower pots, saucers under plant pots, old tyres, 1. Admission
etc.). This mosquito has a peculiar white-spotted body
2. Analgesics and antipyretics
and legs, and is easy to recognise even by laymen.
3. Oral rehydration if this can be performed with a
It has a flight range of only 100 to 200 metres (the
compliance and accepting patient
difficulty with this is that we can be very careful with
avoiding the possibility for mosquito breeding in our own 4. Intravenous (IV) rehydration if oral rehydration fails to
backyard by removing all sources of stagnant water, but it maintain appropriate circulating volume
is our neighbours who can cause us to be still exposed…). 5. Monitor for signs of shock (if this is to occur, it usually
Do remember to emphasise in community and patient occurs after the 3rd day during transition from the
education that since the mosquito does not travel far, febrile to afebrile phase)
"house cleaning" by all members of a community will
ensure that no breeding places exist, preventing dengue
from occurring or recurring as the mosquito gets the In terms of disposition, consider disembarkation and/or
dengue virus (only) after biting a human being infected commercial escorted evacuation at this stage. Always
with dengue virus. escalate to topside support. Note that the majority of
patients who transition to DHF do not transition to
requiring blood or blood products… so it is only necessary
to disembark and/or fly, when continued deterioration of
the patient's circumstances would be in a position or
location that he/she cannot be referred to a hospital with
the necessary haematology resources within 6 to 12
hours of beginning of any such clinical deterioration.
When the diagnosis of dengue is probable and the

patient's condition causes concern for dengue
haemorrhagic complications:
1. Inpatient hospital treatment with serial haematocrit

and platelet counts, treatment of hypovolaemic shock
and treatment of any haemorrhagic complications
Response
Since there is no specific treatment for the dengue virus, Disposition After Suspicion
we want to relieve our patients’ symptoms and
The physical examination for suspected dengue should
appropriately onwards refer the minority of such patients
include an assessment of:
who are at risk of acquiring more than symptomatic
treatment.  Blood pressure - both level and pulse pressure
When the diagnosis is probable and the patient's  Evidence of "external" bleeding in the skin or other
condition is presently without circulatory compromise or sites (sometimes evident by bleeding from the gums,
coagulopathy: especially with teeth brushing, increased flow during

menstruation, and of course petechiae and "easy otherwise and previously healthy patients do not
bruising" appear until below 30,000.
 Hydration status  Third, it is the previous flavivirus exposure of the

patient in whom we are measuring the falling platelet
 Evidence of increased vascular permeability as
count that is far more significant than the rate of
evidenced by pleural effusions or ascites
decrease of the platelet count…
 Tourniquet test: Inflate a standard manual blood
 Fourth, when the platelet count starts to fall below
pressure cuff to a point midway between systolic and
50,000 for a previously healthy patient without
diastolic pressure for 5 minutes. Then deflate, remove
significant recent exposure, we usually have at least
the tourniquet and wait for the skin to return to its
12 to 16 hours before the count falls below 20,000.
normal colour. A positive test is if you can then count
more than 20 petechiae per square inch (see In summary, therefore it is rarely necessary to evacuate
attached example for how petechiae appear). The or disembark improving patients without clinical evidence
test does not directly check platelet fragility but rather of bleeding based purely on the platelet count above
capillary fragility, and is not invariably accurate if 20,000 and below 50,000.
negative; but is helpfully specific as a guide to the
potential for severity when positive in the relevant
clinical context. Other points to note:
 Children below the age of 15 are more prone to the

complications of dengue. Infection even convince
adults with similar previous flavivirus exposures; but
there is no additional sensitivity to the disease itself
according to age; in other words, all ages can get
dengue fever, it is just the children are more likely to
get more ill.
 If there are going to be haemorrhagic complications,

they usually (not invariably) arise after the fever
subsides, so it is important to keep checking the fever
Always remember that a ‘positive’ tourniquet test result
and not relying on the patient's subjective
does not equal a diagnosis of DHF. Four criteria must be
appreciation, especially if using antipyretics.
present for a diagnosis of DHF; the tourniquet test is as
above a non-specific indicator of capillary fragility.  Dengue plus bleeding does not equal DHF. There are
4 criteria for defining DHF, and the critical difference
between dengue fever and DHF is not bleeding, but
Dengue and the Platelet Count the increased vascular permeability that occurs in
DHF - this is what causes shock and death (though
When the differential diagnosis of dengue is considered
these patients may have severe haemorrhage, the
likely, there is frequently an over emphasis on "following
more common scenario is that the patient goes into
the number" and disembarking/evacuating based on a
irreversible shock because of excessive vascular
falling platelet count. This is understandable but
permeability, and this shock is what causes fatalities).
frequently illogical.
 International residents are generally at low risk of
 First, the platelet count continues to fall when the
complications of dengue fever unless they have had
patient is improving. If a patient is clinically improving
exposure(s) in the past, so a past history must be
without petechiae or evidence of bleeding, and the
very carefully taken (as a past history must always be
platelet count is falling below 50,000, we should be
carefully taken).
reacting to the patient's clinical improvement and not
a laboratory result.  Tourists are generally at lower risk than resident
international assignees, but they still can get
 Second, while the normal platelet count is 150 to
sequential infections and end up with DHF.
400,000, complications of low platelet counts in

 Protection against 1 serotype of the dengue flavivirus

does not confer protection against another; in fact,
there is epidemiological evidence to show that the
presence of antibodies against 1 serotype increases
susceptibility to acquire infection from another
serotype. So previous clinical suspicion of dengue
fever raises the possibility that a current episode may
be more severe.
 IMPORTANT: Any history or laboratory evidence

(through stool testing for occult blood) of
gastrointestinal bleeding (coffee ground vomiting,
fresh blood in stools, melaena) is of course an
indication for immediate hospitalisation in a capable
tertiary facility.
Dengue cannot be transmitted from person to person,

other than by the bite of an infected mosquito; therefore,
continue the use of mosquito repellents on the patient or
by the patient while treating the patient in the infected
phase to reduce person-to-person transmission.
Not every person who is infected with dengue shows

classical symptoms; it is thought that the ratio of those
with no symptoms or very mild symptoms compared to
those with apparent dengue fever is at least 5 to 1.
The main strategy in the prevention and control of dengue

is "source reduction", or prevention of breeding places,
mentioned above.

Suspension Trauma Treatment – Page 53
The Potential Lethality of Orthostatic Shock

Orthostatic and Hydrostatic This is sometimes called "suspension shock" and
Shock "harness hang(ing) syndrome". Although it can occur in
other situations besides being suspended in a safety
If our patients and we are lucky, we will never need to harness, for example, following a failed attempt at
know what to do in this type of situation. But, every year, parachuting and stopping short of the ground, also
a considerable number of patients die around the world occasionally with circus performers, abseilers, window
because these forms of shock are unrecognised or cleaners, cavers, climbers and even Hollywood stunt
underappreciated in their severity, and are not people.
appropriately reacted to by first responders.
Both hydrostatic and orthostatic shock are synonyms of

relative hypovolaemic shock, whether patient's total
circulating volume has not been reduced by loss of fluid,
but by physical compartmentalisation of that fluid and a
subsequent physiological ability to adjust quickly enough
to changes in the volume of the human "container".
Most of you may not be old enough to remember the

relatively brief fashion of MAST. MAST in this context
stands for Military Anti-Shock Trousers and sometimes
also called Pneumatic Anti-Shock Garment (PASG). It
was invented during the Vietnam War and literally looked
like an inflatable pair of trousers (or more accurately a
pair of inflatable trousers) with fastenings down the side
and around the waist, so that the trousers can be opened
out and then fitted around the legs and pelvis/lower
abdomen of a trauma patient. The trouser leg, and the
separate pelvic section, could then be inflated to
"squeeze" blood in the extremities and pelvis up to the
chest and keep the heart pumping with an appropriate
volume of preload in the presence of hypovolaemic shock.
It has to be said that the theory is sound. The patient

could benefit, provided the trousers were correctly applied
and only deflated when large bore intravenous (IV) lines
were already running. The patient could also benefit,
provided the relative loss of (blood) volume that would
otherwise occur as soon as the pneumatic trouser and
abdominal sections were deflated, had been allowed for
and replaced. Unfortunately, a considerable number of
patients would die when the trousers were sometimes
literally cut off. Suddenly a large venous reservoir opened
in the pelvis and both legs, blood drained from the torso
and brain, and cardiac arrest and death resulted.
Hydrostatic and orthostatic shock can kill patients with a

variant of this principle. Let us look at them in turn.
Topside Newsletter – Suspension Trauma Treatment

encroaching hypotension will result in loss of

consciousness and ultimately hypoxic brain death. There
does not have to be any associated injury whatsoever - all
that is required is that the legs cannot move or do not
move, and are below the heart…!!
If a patient remains conscious and does not have injuries

preventing voluntary muscular movements of the large
muscles of the legs, if he/she is temporarily stuck in a
suspension harness and can apply pressure against a
rigid surface (such as a ladder, catwalk, construction
beam or stairwell), regular rhythmic pushing against a
(preferably vertical) surface while he/she is waiting to be
rescued will improve venous return to the upper body. But
if the person is stranded literally in mid-air, then keeping
the legs moving may not be helpful because of the
increased oxygen demand required for the muscular
movement, associated with poor venous return from only
isometric contraction of the leg muscles.
As you can see from the picture, if the body is suspended

upright without voluntary muscular movements any length
of time, blood will pool under the influence of gravity into
the venous reservoir of the vessels in the lower
extremities, and result in unconsciousness/syncope due
to lack of cerebral perfusion with sufficient volume of
oxygenated blood. This does not happen quickly, but if a
patient is suspended long enough, it is basically inevitable.
The loss of consciousness may occur literally within

minutes of suspension, depending on the construction
applied to the harness and the reason why the patient is
no longer moving (lack of movement resulting in no
When coming across such a casualty, first make sure you
muscular "pumping" of venous blood from the legs back
are safe and not going to come to harm or end up in the
upwards). However, in most circumstances, it does not
same predicament as the patient. The next step should be
start before 20 to 30 minutes of hanging, BUT occurs in a
to raise his/her legs to a horizontal position as much as
minority of patients within 5 minutes of hanging. Initial
possible, as if he/she is sitting "on thin air", with the aid of
symptoms from the patient's point of view are those
spider harness straps around the thighs and lower legs, or
similar to vasovagal syncope and hypovolaemia; these
even duct tape as a temporary measure. It should then be
include feeling faint, looking pale, shortness of breath,
possible - provided it is safe to do so without
blurred vision, sweating and vertigo. If untreated, the
compromising his/her airway - to extract the patient. As

always, the sequence of Airway Breathing Circulation is

the basic life support algorithm to follow.
That said, do not then lay this patient immediately

horizontal. We need to beware of so-called reflow
syndrome. Blood that has pooled in the extremities has
not been subject to the normal metabolite scavenging and
nutrient replenishment that occurs with each heartbeat of
normal circulation. Sit the patient up in the same position
you rescued him/her in; provide him/her with
supplemental oxygen; monitor the vital signs, especially
heart rate as you transport him/her to the clinic; monitor
his/her rhythm and do at least a baseline
electrocardiography (EKG).
This newsletter is not going to discuss near drowning or
Now please review the attachment provided below,
drowning in detail; this will be the subject of a later
entitled "Suspension Trauma Review" and “OSHA
newsletter. But, when called upon to retrieve a patient
Suspension Trauma & Orthostatic Intolerance”. Note
from (cold) water who has been immersed for a
especially the evidence-based recommendations on
considerable time, we must be very careful. For a patient
pages 14 and 15 of the review. Take your time reading
floating with only head above the water, as is normal for a
and understanding these, then return to this newsletter.
patient wearing a life jacket, there will be a continuous
hydrostatic pressure effect applied to the entire body
below the water surface. Pulling the patient out of water
Suspension Trauma OSHA Suspension suddenly promotes squeeze effects and can easily lead to
Review.pdf Trauma Orthostatic Intolerance.pdf significant, even lethal orthostatic hypotension.
As always, prevention of orthostatic/suspension trauma

and shock is preferred to dealing with the physiological
and anatomical consequences. Prevention is not a clinical
issue, it is a technical issue.
Hydrostatic Shock
This is sometimes called "immersion shock", as it is the
result of the pressure of water surrounding a body
immersed in it. Hydrostatic shock is further contemplated
by the fact that it is very uncommon for a person to float
for any length of time and in thermally neutral water, in
other words water where heat loss from the body by
radiation and conduction is perfectly balanced by heat
production from homoeostatic metabolism. Therefore, just
about everybody who floats in water for any length of time
This is compounded by the fact that the normal cardiac
is subject to both the cooling effects and the hydrostatic
response to relative or absolute hypovolaemic shock is
"squeeze" effects of the surrounding water. In most
severely affected by the cooling effect of water. A cold
recreational circumstances, these effects are so minor as
heart lacks the ability to increase cardiac output in
to be trivial, but following an accident, especially involving
response to perceived lowered preload. If the patient has
an intoxicated, injured or unconscious patient, and
been in water for many hours, both cold and hydrostatic
especially in water <25°C, the risk of hydrostatic (and
pressure may have promoted diuresis and the increased
hypothermic) shock is significant.
blood viscosity as a result of that (unless the patient
continues to stay hydrated, which is of course highly
unlikely...) further potentiates the hypovolaemic shock

effects of a relative loss of circulating volume. This Out of interest, you may also wish to look at this link:
combination of effects has been seen in laboratory http://www.afloat.com.au/afloat-
studies with volunteers, and there is little doubt that the magazine/2008/november-
combination is a cause of post-rescue death in many 2008/Man_Overboard#.Vg9FRuyqpBc; and definitely do
people rescued from the sea. read the ‘Man Overboard’ section 9 to 36 in the “Catch-
Share 2015” attachment. Once again, the appropriate
When coming across such a casualty, first make sure you
management of hydrostatic shock is prevention.
are safe and not going to come to harm by falling in water
yourself... The next step should be to position the patient,
while still in water, horizontally, with the legs at the same
level as the chest/thorax, while of course protecting the Catch-Share 2015
airway as usual. Chapter 9.pdf
Unless there is a critical urgent need to retrieve the

patient from the water immediately, take time to position
the patient in a basket stretcher while still on the water
(submerge the basket stretcher under the patient, do not
lift the patient), and then leave the basket stretcher
horizontally and slide it onto the boat or helicopter;
keeping it horizontal all the while or even with the legs
slightly elevated. Even if the patient appears willing to
climb up the ladder or into the boat, do not allow this.
Position horizontal before he/she leaves the water, keep
him/her horizontal as you are transporting him/her, and
make sure he/she is fully warmed before he/she engages
in further activity. Check the temperature to determine if it
is safe to do so, because normal venous return does not
resume until a job that is significantly above 33°C. Handle
the patient gently; a cold myocardium is considerably
more likely to develop spontaneous arrhythmias,
bradycardias, and go into systole.
Note that positioning this patient horizontally is

different than the requirement for the response to
orthostatic/suspension shock.
Now please review the attachment provided with this

newsletter entitled "Cold Shock Review". The effects of
both hydrostatic shock and hypothermic shock are at least
additive and very likely compound it. In other words, the
combination of both is worse for the patient than simply
assuming that the effects of both are added together.
Take your time reading and understanding this.
Cold Shock
Review.pdf

Blood-Borne Pathogens and Needlestick Injuries - Page 57
proportion of infectious blood-borne virus particle titres of

Blood-Borne Pathogens and
all body fluids and is the one we must be most wary of,
Needlestick Injuries but let us not forget the others.
This newsletter is about the real hazard posed to Those who have worked for some years in healthcare will
everyone's health by carelessness with used needles; we remember the high morbidity and mortality associated
will also briefly review the risks associated with blood and with hepatitis B infections contracted in the workplace.
body fluids. This has largely but not completely disappeared because
of the high uptake of hepatitis B vaccination, which has
resulted both in a smaller pool of potential people to
contract the illness from and considerable coverage of
hepatitis B immunity in the vaccinated staff. That said
there is, of course, no vaccination available for hepatitis C
or HIV.
Blood-borne pathogens are simply those pathogenic

microorganisms that survive in both fresh (circulating)
blood and stored blood, and can infect other people.
These bugs most importantly include hepatitis B virus
(HBV), hepatitis C virus (HCV) and human
immunodeficiency virus (HIV), the virus that causes AIDS;
additionally, of course, we have all had to learn the new
awareness of the possibility for blood to carry the viruses
that cause the viral haemorrhagic fevers, notably Ebola.
We know from the historical transmissibility of hepatitis B
Before we continue, everybody whether involved in through needlestick injuries that the risk of hepatitis B
healthcare or not should understand the basic urgent infection from a contaminated needle, i.e. a needle
response to exposure to blood or body fluids, whether by (usually injection) with hepatitis B positive blood, varies in
a needlestick/sharps injury or by other risky* types of non-immune people from 6% to 30%. The wide range
exposure (blood spattering on superficially intact skin is a exists because there is a difference depending on the
possible but not a high-probability hazard). The following hepatitis B e antigen (HBeAg) status of the source person.
steps need to be followed immediately: Individuals who are both hepatitis B surface antigen
 Wash needlestick injuries, puncture wounds, (HBsAg) positive and HBeAg positive have more viruses
lacerations and abrasions with soap and water. in their blood and are more likely to transmit HBV. Just
because hepatitis B vaccination cannot protect against
 Flush splashes to the nose, mouth and skin, other forms of blood-borne pathogens, it does not mean
especially adjacent to mucous membranes, with that it is not 100% necessary for those who deal with
copious water. patients, and for those who do not deal with patients, but
 Irrigate eyes with clean water, saline or sterile have access to the injection, to be vaccinated. Even if you
irrigants. get prompt post-exposure treatment to lower the risk of
contracting hepatitis B if you are not already immune,
 Report the incident. there is still a 10% failure rate of post-exposure
 Immediately seek medical advice for treatment. prophylaxis. Hepatitis B could be eliminated if everybody
was vaccinated, so there would be no pool of infected
Remember that saliva, semen and all excretions or
people to contaminate others, whether by a needlestick
secretions can be contaminated; but note that sweat does
injury or exchange of blood and body fluids.
not carry these diseases. Blood contains the greatest
Topside Newsletter –Blood-Borne Pathogens and Needlestick Injuries

We know from the following what happens to healthcare

workers exposed to hepatitis C infection through a
needlestick injury or other penetrating injuries that the risk
of becoming positive for anti-HCV antibodies
("seroconverting", indicating infection) averages,
fortunately, less than 2%. Currently, there are no strong
indications for immunoglobulin and antiviral therapy to be
given post-exposure as prophylaxis, but because
treatment is available (albeit extremely expensive) if
people seroconvert, if exposure is known people will need
to be monitored for a long-term follow-up.
It is clear from the above discussion that in order to know

the risk of a needlestick injury if we are lucky enough or
careless enough to have one, we have to know where the
needle had last been used, on whom it had last been
used, and for that patient to consent to have a blood test.
It is equally clear that needles carelessly left lying around
are a significant risk and a considerable amount of
distress can be caused while a person who has had a
needlestick injury may wait for weeks or months to see
whether he/she will seroconvert. It is not just bad manners
to leave needles lying around once they have been used,
but also highly dangerous to us and our colleagues.
The risk for HIV is very difficult to assess. Some studies
have found an average transmission rate of approximately
0.3%, but because some populations have orders of
magnitude higher HIV prevalence than other countries,
combined with major differences in intravenous drug use,
both legal and illegal, as well as different social
stigmatisation and simply unknown reliability of reporting,
we cannot be sure that the risk is higher or lower. What is
clear is that the risk of HIV transmission increases
significantly if there is visible blood on the needle, the
needle has been used for venous or arterial cannulation,
or the needlestick injury was deep in the victim rather than
superficial. The risk after exposure of the skin to HlV-
infected blood is estimated to be less than 0.1%. At the
time of writing, there have been no published cases of
HIV transmission due to brief exposure with a small
quantity of blood on intact skin; however, the rest may be
higher, of course, if the apparently intact skin has had an
unappreciated injury, is a recently healed wound, or if
contact is prolonged. Post-exposure prophylaxis for HIV is
recommended in certain circumstances, but the drugs You should know who on your site is on injectable
used have many adverse side effects. Every case should medicines, such as insulin. You should absolutely be
be managed on a case-by-case basis, with occupational immune to hepatitis B yourself by having the full course of
health, infectious disease and other specialists involved. vaccination and this is, of course, recommended to
everybody for the reasons above.

You should be 100% familiar with both International SOS’ should be asked to consent to testing for HBV, HCV, and
and our clients' policies for recording and reporting HIV, and these tests can be arranged through the
occupational injuries and exposures. After taking the first- responsible Assistance Centre.
aid steps outlined above, the next call should be to
Note that after this initial evaluation and case reporting,
shoreside support, with full confidentiality maintained
the specialists above will be tasked on next steps,
(obviously), and the following is the minimum amount of
including a long-term follow-up.
information to be reported:
Far better, of course, is to avoid the exposure in the first
 Date and time of exposure.
place.
 Details of the procedure being performed, including
The best way to do so is to change our behaviour when
where and how the exposure occurred, whether the handling blood, body fluids and needles. This requires not
exposure involved a sharp device, the type of device,
only care with behaviour when working with needles and
whether there was visible blood on the device, and
other sharp devices, but the appropriate use of personal
how and when during its handling the exposure protective equipment and, of course, the disposal of the
occurred.
blood-contaminated sharps as soon as it is no longer
 Details of the exposure, including the type and required for treatment.
amount of fluid or material and the apparent severity
of the exposure.
o For a percutaneous (penetrating through the skin)

injury, include the (estimated) depth of the wound,
the gauge of the needle, and whether fluid was
injected.
o For a skin or mucous membrane exposure,

include the estimated volume of material, the
duration of contact, and the condition of the skin
(e.g. lacerated, scored, abraded or intact).
 Details about the exposed person - whether yourself

or another person (including, of course, hepatitis B
vaccination and medical history; it is especially
important to know if there is a long-standing or recent
Poor management of used sharps usually relates to
potential source of lowered immunity).
insufficient education and/or lack of appropriate self-
Note that in case of human bites, there are 2 potential discipline - overall 25% of needlestick injuries are due to
sources of blood contamination with 2 potential victims; people forgetfully recapping the needle after using it - and
blood transmitted from the biter to the bitten and from the the lack of readily available sharps containers.
bitten to the biter.
As we have already seen, it is essential to know the

antigen status of the person from whom the blood was
accidentally transmitted. This will require careful, tactful,
but complete consenting history, not just in terms of risk
factors for the diseases mentioned, but for follow-up
testing both in the immediate future and later. Clearly, if
the needlestick injury was acquired from a person known
to be infected with HBV, then his/her HBeAg status
should be available as a baseline. If the source was
infected with HIV, it is essential to know the
stage/duration of disease, history of antiretroviral therapy
and the most recent laboratory tests for viral load, if The sharps container must always be at the location of
available. In many cases, little or none of this information any procedure, and sharp devices are never to be reused
is available. However regardless of this, the source and needles are never to be recapped at any time,

whether before or after use. The person who uses the No sharps container can keep you safe if you overfill it.
sharps is 100% responsible for disposing of them safely. Do not fill any sharps container to more than 3 quarters.
If you have to hand off the needle or blade, never hand it Never place a sharps container on a floor or a narrow
to your colleague directly, rather place it on a tray and shelf; they should be stored attached until disposed of.
pass the tray. Never reuse a sharps container. As always, sharps
containers should be disposed of carefully as medical
Never, never, never, never and never hand transfer a
waste.
contaminated sharp to anybody else.
Upon finishing reading this newsletter, please go to your

clinic at a reasonably convenient time, take a picture of
your sharps container without moving its position or doing
anything with it in any way and send it back to Dr Lars for
review.
Please also read the below document on Blood-borne

Diseases Occupational Exposure Management.
Never, never, never, never and never walk away from a

contaminated sharp, it must be disposed of once it is no
longer being used.
Bloodborne Diseases
The best sharps container is one that has an auto-safety Occupational Exposure Management.docx
mechanism that traps the discarded sharp behind the
safety barrier. If the mechanism requires to be manually
activated, do so as soon as you have safely put the sharp
in the container.
Disclaimer
This information has been developed for educational
purposes only. It is not a substitute for professional medical
advice.
Should you have questions or concerns about any topic
described here, please consult your healthcare professional.


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Topside Support

Topside Newsletter – Pre-Hospital Pain Management

RULE 9: While reading this, if you do not have enough

RULE 10: When referring a patient with, for example, an

RULE 6: Use a big enough dose of the best drugs you

RULE 7: Intramuscular injection of analgesics 20141205 Seadrill

Topside Newsletter – Pre-Hospital Pain Management

Topside Newsletter – Pre-Hospital Pain Management

Antidepressants Consider finally the fact that every study of pre-hospital

Topside Newsletter – Pre-Hospital Pain Management

supply difficulties), because we do not adjust our clinical

In closing, let us return to the guiding principle behind

Post-Christmas/Wish: Methoxyflurane for trauma and

Topside Newsletter – Pre-Hospital Pain Management

 Beta-blockers and calcium channel blockers

Topside Newsletter – HYPOVOLAEMIA

 As always, attend to the basics of airway, breathing

 Give high concentrations of oxygen.

 Insert a nasogastric tube and apply suction; this

 Insert 2 large (16 gauge) intravenous (IV) needles

This is likely to be the most common type of shock one

 Tachycardia is the earliest sign of shock - any injured

Topside Newsletter – HYPOVOLAEMIA

o Transient response - Indicates a loss of 20% to

 While these are standard ‘bread and butter’ cases in

 The treatment of cardiac tamponade in the

Topside Newsletter – HYPOVOLAEMIA

 The classic signs of spinal shock are hypotension

 Septic shock is more likely when patients are brought

 Signs of septic shock include modest tachycardia,

Topside Newsletter – HYPOVOLAEMIA

SOS’ doctors and staff who are all bound to medical

It is understandably difficult either on the phone or in

Consent and Confidentiality

1. Always get the patient's consent and document it in

Topside Newsletter – Taking and Sending Clinical Pictures

3. A basic digital camera is all you need. A good setting

universal symbol for this setting is a flower . Use

Figure 3 This is a mole

Figure 2 Focus on right part of the scene

Figure 4 This is also a mole

Topside Newsletter – Taking and Sending Clinical Pictures

Figure 6 The gold standard for wound measurement

12. The camera is often very helpful in documenting

Topside Newsletter – Taking and Sending Clinical Pictures

 Focus set to centre spot (not multiple areas)

17. Send all pictures* in a single e-mail with the

Topside Newsletter – Taking and Sending Clinical Pictures

Also available in windows start

Step 4: Save the new resized image in the desired folder

Step 2: Select the desire resize

Thank you. Do not forget to acknowledge this e-mail.

Topside Newsletter – Taking and Sending Clinical Pictures

writing about and unable to get comfortable tend to have

How bad is the pain? This complaint is best evaluated on

When approaching diagnosis of the patient with

Topside Newsletter – Initial Response to a Patient with an ‘Acute Abdomen’

bladder and the pain relieved by eating is often due to

Any history of effort? Correlate this with the physical

Radiation of the pain? For example, consider a cardiac

Any involvement of the urinary system with pain?

For women, we must carefully and diplomatically

If he/she has been vomiting, was this spontaneous or self-

If the patient is vomiting, is the vomit "coffee