Falling head over heels – Part One

The cliff divers of Acapulco
The cliff divers of Acapulco

6:30am and another rude awakening by the tannoy for a trauma call this time. Trauma is rare at sea but it does happen. There are no cars or motorbikes to crash but the cane-wielding drivers of mobility scooters can get up a fair clip with the wind behind them and the threat of industrial disaster is never far away when you are living in a kilometre long machine. But this one was for outside the medical centre on Deck 3. Perhaps there had been a fight? Alcohol and frayed tempers do occasionally lead to serious assaults but these were few and far between. So you quickly throw on your scrubs and make your way down one flight of stairs to the medical centre.

How would you manage this less than hypothetical scenario?*

At the bottom of the stairs is your first responder nurse with what looks like a young man in his early twenties. He had been drinking all night and was doing the walk of shame back to his own cabin having struck it lucky earlier in the evening. He had stopped to boast of his conquest to one of his friends from the deck above so he sat on the balcony and leaned backwards to pass on the details. There was a brief tussle between gravity and dexterity and gravity won.so he tumbled down the centre of the stairwell, a distance of five flights, hitting his head and limbs hard enough to leave dents in the polished brass stair rails on every floor on the way down.

A small crowd is forming so you make your way forward to perform a primary assessment. Security have already made the scene safe and cordoned off the stairs and nearby lifts.

  • Airway – Maintaining own, bilateral epistaxis
  • Breathing – Bilateral air entry, no flail, haemo/pneumothorax clinically – tender ribs 5-8 on the left
  • Circulation – Bleeding from scalp, nose and right open elbow fracture, palpable radial pulse
  • Disability – GCS 14/15 (E4V4M6), moving all four limbs with an obvious open fracture/dislocation of the elbow. Pupils equal and reactive
  • Exposure/Environment – Missed impaling himself on the wheelchair outside of the medical centre by one foot!

So what would you do? How would you get the patient 20 feet away into the controlled setting of the medical centre?

In order to answer this question you need to know what resources are available on board. You have two doctors and three nurses, one of which has been up all night seeing patients with gastroenteritis. She gets sent to bed at the earliest opportunity and before you can even get IV access a nurse has put on a rigid cervical collar on and the fully loaded Stryker is brought out of the medical centre. In a situation like this when someone has an arm pointing the wrong way analgesia is a priority otherwise there is no way you are going to be able to lift him. Given the nature of his injuries you elect to use ketamine and gently move his broken arm into a mouldable plastic splint. You don’t know if he had sustained a pelvic fracture and the mechanism certainly makes it a distinct possibility so you flip a KED (Kendrick Extraction Device) upside down and jury-rigged a pelvic splint. The essence of cruise ship medicine, just like rural and remote medicine, is making do with what you have – what Casey Parker would call MacGyver Medicine. The well-drilled stretcher party help with the spinal board to Stryker transfer and you’re inside. The whole process takes 10 minutes.

In the high dependency room of the medical centre the two doctors get to work establishing further IV access, taking bloods and giving antibiotics whilst the senior nurse is warming up the x-ray machine. It’s relatively easy to do a plain chest, pelvis and long bones but shooting laterally for cervical or thoraco-lumbar spine injuries is next to impossible on a moving ship. I would have been given my eye teeth for an ultrasound machine. Primary and secondary survey complete and you have identified the following injuries.

  • A closed head injury
  • Open fracture/dislocation of the elbow
  • Multiple rib fractures with no flail or pneumothorax
  • A very tender C6

The problem with the EMST/ATLS style approach is that it falls down once you have ruled out most life or limb threatening injuries. To put this accident in geographical context, you are a day and a half away from Auckland with no provision for a helicopter retrieval and there is no way to divert to another port as you are already heading straight to NZ. How are you going to manage this patient over the next 36 hours?

 

*some minor details have been changed to preserve anonymity

Dr. Andrew Tagg left the shipboard life in 2009 to settle down and lose weight. He is currently an advanced trainee in EM working in Melbourne’s western suburbs. He still has the uniform. Contact him via Twitter @andrewjtagg

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