Painful.

This is the third post in my new series about first aid and medical problems at sea.

Its important to understand that I’m writing this post with a particular group of people in mind and in a specific context.  In an earlier post I talked about the importance for sailors in gaining basic first aid knowledge by taking even the most basic level first aid course.      This post is one of  several in which I intend to steer the new sailing first-aider in the next steps beyond simple first aid and this one is the first in a group about medicines and pain.    The context then is that you might one day be in the position where knowledge of basic pain management , medicines and pharmacology might be useful or even essential.                    I think of these basic skills and knowledge, or at least information, as being just another branch of sailing and boats self-reliance that you need if you are going to do long voyages away from immediate medical assistance. If you own a boat for long enough and/or sail far enough then one day your engine will break down, you will tear a sail or break a halyard and if you are a generally self-reliant sailor you will almost certainly have some ability to fix some of those problems.    The same is true of people aboard boats….one day you or your crew are going to get sick or injured.  My  experience has been that the longer I have sailed the more problems with people I have had to deal with, even with my little liberty in the first year we had to deal with my partner’s severe toothache which can be a difficult pain problem at sea. What I am pointing you towards here are the basic people-problem fixes starting with first aid and then some of the medical issues that lie just beyond those basics.

In basic first aid courses pain problems and pain management are hardly ever touched upon except for a few very specific ‘types’ of pain problem. In most REC level 2 courses for example chest pain is dealt with sometimes within a small group of medical issues that the first-aider might have to deal with. On the courses I taught it was never possible to allocate that much time and I never found a completely satisfactory way of teaching it.  General pain management isn’t usually taught at all for several reasons : one is that there isn’t time on a 2 day course when there are other, more important things to do with any spare time, secondly and quite rightly first-aiders don’t usually have even the basic medicines knowledge to ‘prescribe’ and administer medicines.    There are four common exceptions here, that some trainers will teach the use of aspirin in chest pain/suspected heart attack ,the use of sugar jells in hypoglycaemic (diabetic) episodes, the use of epi-pens in anaphylaxis and lastly the role of inhalers in asthma attacks.   

  In the context of overall first-aid and boat medicine I have long thought that there is a place in the acquisition of knowledge and skills to run a basic medicines and pain management course for people who have done the basic level 2 or 3 course and want to add to that knowledge.     Along with many other first-aid and medical trainers I have had many discussions about what should be taught at the next level up from a basic first aid course. In the advanced first aid courses that I ran we taught a ‘mixed bag’ of unrelated skills , I tended towards teaching the use of the AED for example , medical gases, airway adjuncts, medical communication and casualty evacuation to name a few.  Today on a good BLS (basic life support) course the use of the AED will be taught at that level anyway so things are changing. For sailors I would definitely teach more thorough casualty assessment and give a strong focus to then communicating the problem at a distance via VHF using a structured approach.  The communication and handover of medical problems will get a post of it’s own in the next group of first aid posts.

Anyway, enough ramble and preamble, lets get down and dirty with pain.

Everyone has experienced pain at some time and are most likely to have longer or shorter episodes of pain at greater or lesser severity at some time in their lives so to some extent we all ‘get’ pain even if we don’t understand it. In the first section of my technical talk about pain i am going to set out some of the basic ideas about pain ‘types’, pain severity and pain ‘quality’ and relate those to real-life problems.  In the second section i will talk about basic medicines knowledge using analgesics (painkillers) as an example of the level of medicines knowledge that is useful.

When i mentioned severe toothache or dental pain i bet every single reader here almost got a near-physical reminder of just how bad and miserable a ‘hot’ tooth can be and how much of a problem that can be at sea.  I have had to deal with that one at sea several times and it’s one of the few times that i have ever used high level painkillers on top of the basics.    Toothache and dental pain is a really good place to start to talk about pain because it is so common and the ‘type’ of pain or pain ‘quality’ is something that you will understand almost viscerally.  Think about, or remember a hot tooth and you would probably describe that pain as burning/ throbbing (hot) and its level as anything from nagging/annoying right up to intense/severe almost unbearable.  So instantly we have the beginnings of a pain severity score and a pain quality.  We can easily turn that into a more formal pain assessment by asking 2 simple questions : how would you rate the level of pain on a scale of 1 to 10 and how would you describe the nature of that pain….for example, burning, nagging, aching, etc and so on.  With those 2 things and the site of the pain we have the beginning of a pain assessment.  If you have done a first-aid course you should have come across the useful ABCDE approach and you could now slot your pain assessment into ‘D’ and equally you would have a better ability to communicate that to someone else….say over the VHF.

Lets now take toothache and dental pain a stage further.  There are 2 main reasons why somebody will have toothache in normal situations excluding dental/facial trauma….and can i add a personal one of getting whacked on the side of my face by the titanium clewboard of a maxi blast-reacher.  If we were to gently probe (touch) the ‘hot’ tooth and the gum underneath it would be likely that the pain sensation would increase when there is an infection and therefore an inflammatory state under the tooth and around the nerve ending.   This is if you like a simple piece of anatomy/physiology and then pathology.  The relevant anatomy is the structures involved here ie the tooth, the gum and jaw and the affected nerve.  The pathology (disease process) is that there is a small area of infection which causes an inflammatory response and that is putting increased pressure on the nerve ending inside the tooth. Inflammation, sensed as pressure is basically then what you are feeling although there other chemical processes going on which also increase the pain response.  Looking at this from the reverse direction we could now say that an inflammatory response and/or infection will cause a typical ‘kind’ or quality of pain. It shouldn’t come as a great surprise then that a good first-aid response might be to administer medicines that have an anti-inflammatory effect and that at sea it might be necasary also to think about using an antibiotic under outside guidance for example.

Toothache is a very good example to start with but let’s move away from that now and begin to think about the body as a whole and to consider other types of pain. At first when i get you to think about describing the site of pain i always think that it’s a good idea to use plain language first but that it’s also a good time to begin learning some of the more ‘correct’ anatomical landmarks and descriptions.  If i was to say, for example, that a crewmember felt unwell, had a raised temperature and that she had a griping pain in her right ileac fossa…..well go and find out where on the body that is and what it might relate to.

Here is a simple tool that you might find useful….a simple body/pain diagram, maybe print a version of this and keep it in your medical kit.

Visser EJ, et al. Pain Pract Dec 3. doi: /papr

 

Have a think about pain ‘types’ now and how they relate to something that has gone wrong, a good place to start with this is to think about physical injuries and to attempt to describe the pain of a laceration (cut) or a bony injury….i for one have cut myself a few times, broken a few ribs and one ankle and they all had different pain levels and qualities of pain.  Where we are going with this is a basic ability to describe pain and to relate it to the thing that has gone wrong and/or to work backwards from the site and pain intensity/quality and begin to work out what is going on.  Here i want to be very clear that it’s generally not our part to diagnose a problem but that a clear assessment and precise communication could assist the person who is trying to help you at a distance…over the radio for example.  As i work though this series of posts it is my intention to talk about different types of pain, so far i have described inflmmatory pain, pain from injuries which we might technically describe as ‘nociceptive’ pain which i will explain later so for now i will add 1 more : ischaemic pain which will get a whole section to itself at some time.  For now i am going to focus on the simple pain assessment which can be summed up as :

Where is the pain (anatomical description)

How bad/intense is that pain.

What is the pain quaility (describe the type or nature of the pain)

We should also add, for later use : what brings on the pain, what makes it better or worse ?

For now lets get back out to sea and work with an actual example of a pain and injury problem.   What i am going to do here is a written version of the practical , scenario based, teaching i used to do on courses.  During a first aid course i would set up a ‘scenario’ or situation using course members to act out various roles, for example the casualty. It was always fun to have some noisy ‘actors’ for the kind of situation i am going to describe now.

(Borrowed photograph but the kind of thing i used to do on courses)

OLYMPUS DIGITAL CAMERA

A few posts back i left you with a crewmember on the deck of Liverpool Enterprise who had been thrown from the boom and as he landed, done so with is foot going between the spinnaker pole and the coachroof and then falling over sideways and as i said, the first i knew about it was the screaming on deck.

So, lets put this in first-aid scenario mode but where you, the readers, are my first aid students and i am going to ask you to deal with the accident.  First though i am going to give you a written version of the normal briefing that i would have given the class, in teaching mode i will also have briefed the casualty actor to be a very noisy and vocal one to match what happened in the actual incident.

Situation.  You are members of the crew of a large yacht undertaking a delivery trip from the Azores to the Uk with guests on board.  The boat is a 76′ maxi yacht , sloop rigged with conventional headsails. The gooseneck/boom is about 5 feet above the deck. Conditions have been variable for several days requiring frequent sail changes including reefing and un-reefing the mains’l.  The skipper has called for a reef to be put in, during the process of reefing the main a crewmember climbed up onto the goosenck to try and haul the sail down manually but has been thrown from the boom, landed with his foot between the spinnaker pole and coachroof, fell over sideways and is now laying on deck holding his ankle and screaming loudly.  You are currently about 5 days out from the Azores and still have about 4 or 5 days to sail to get to the nearest port. You are out of helicopter and lifeboat range.

Your task.  Your job as readers here now is to think about the scenario and describe what you would do in several different stages of the assessment and management of this casualty.  What i would like readers to do is take just one section which i will detail below and detail the actions they would take for that part of the situation.  Hopefully that will allow readers to write up a short response rather than writing out a huge long post.  Just to say that this kind of post takes a long time to write and edit….this one will be about 6-8 hours of work for me, to make this series succesfull i really need to get some feedback to make it worthwhile to continue what could be a long series of teaching in first aid and medical issues.  I would encourage you to step up and have a go at this, its much more fun for me and feedback on this will encourage me to continue the series of posts. In section 2 of this post i will begin to talk about basic medicines knowledge.

1.Your initial first-aid actions in the first few minutes after the accident.

2.Thoughts about immobilisation and getting the casualty below.

3. Managing the casualty below-decks including assessing the injury.

4.General management principles for dealing with broken bones and/or damaged joints.

5.Pain management

6.Caring for the casualty for the next few days at sea.

3317499-Atlantic Privateer

1 Comment

  1. 1. Tell the casualty to keep still, preferably lying them down with the ankle raised/supported, and offer verbal reassurance but be prepared to move them if their present location is dangerous. Look for any signs of bleeding and if there are any apply direct pressure with a cloth/piece of clothing but leave any protruding bones alone. Don’t panic!

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