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Soft tissue injury or potential fracture??
So is it a soft tissue injury or potential fracture? A sprained ankle can be a tricky one to navigate. Check out our guide to assessing severity when onboard a ship.
In the medical world, we use a tool called the Ottowa Ankle Rules to decide whether an x-ray is needed for an ankle injury. The tool was developed to meet a need for a rapid and accurate way to assess severity and avoid unnecessary x-rays. Of course if there’s a bone sticking out, or some dodgy looking deformity, then your decision may be a quick one!
Ankle sprains are a common injury in the general population and certainly not uncommon onboard vessels of all kinds. According to NICE Guidelines, lateral ankle sprains are the most prevalent form of musculoskeletal injury in physically active populations and an Australian study found that up to 70% of people reported having an ankle injury during their lifetime. Other studies indicate a higher incidence in females compared to males and that the risk is greater the younger you are.
Historically, ankle injuries are seen frequently in emergency departments, but only 15% have significant fractures. The Ottowa Ankle Rules were developed as a tool for identifying ankle and mid-foot fractures. Less than 1.7% of patients presenting with no symptoms are likely to be suffering a fracture. This figure reduces the sooner after the injury that the assessment can be made.
So how do the Ottowa Ankle Rules work and is it possible for an onboard medic to use them? Let’s start with a diagram…
This diagram shows the key areas of the foot and ankle that the rules apply to. Don’t worry about the big words, we’ll keep it simple! This short video might help too:
There are 5 components to test to assess whether your patient is positive for the Ottowa Ankle Rules. Always make sure you palpate areas thoroughly.
- Find the lateral (outside) malleolus at points A or B. Is there bony tenderness on palpation of 6 cm above the tip of the lateral malleolus?
- Find the medial (inside) malleolus at points A or B. Is there bony tenderness on palpation of the 6 cm above the tip of the medial malleolus?
- Is there bony tenderness at the base of the 5th metatarsal?
- Is there bony tenderness at the navicular bone?
- Was the patient unable to bear weight immediately after the injury and for 4 steps during your assessment?
If there is pain in the malleolar zone, or the mid foot zone, or if the patient ticks the box for any of the above points, an ankle and/or foot x-ray is indicated.
Certain patient groups are excluded, for instance someone who happens to be intoxicated, if there is another reason that they lack ability to follow the test, or if the patient is pregnant.
If you, or in conjunction with your Telemedicine provider, decide that your patient does need an x-ray, you will need to follow your vessel procedures for disembarkation or medevac, depending on your circumstances and location.
But how would you treat an ankle injury if a fracture isn’t suspected?
On medical courses over the years, you’re likely to have come across mnemonics such as RICE, PRICE and POLICE in relation to the management of acute soft tissue injuries. We’ve listed them in full at the end of the blog for information.
But hey, we’re now moving on to
PEACE and LOVE! Far out man!
The aim of PEACE and LOVE, is to optimise recovery and healing as part of the soft tissue injury management from the first point of care. It takes into consideration some important factors to aid recovery, but also highlights the potentially harmful effects of using anti-inflammatory medication as part of the process. Wowsa! So does this mean that taking anti-inflammatories isn’t the right thing to do any more? Let’s look into this PEACE and LOVE a bit more…
P - PROTECT
- Unload or restrict movement for the first 1-3 days.
- This reduces bleeding.
- It prevents distension of any injured fibres.
- It reduces the risk of aggravating the injury.
- Minimise rest - prolonged rest actually compromises the tissue strength and quality.
- Let the patient's level of pain guide the removal of protection and gradual reloading.
E - ELEVATE
- Elevate the injured limb higher than the heart. This helps to keep interstitial (in the spaces between the cells) fluid flowing out of the injured tissue. Although the evidence of its benefit is poor, there’s a low risk to benefit ratio and it may help some patients.
A - AVOID ANTI-INFLAMMATORY MODALITIES (medications and treatments)
- Anti-inflammatory medications may negatively impact long term healing, so don’t use them! This is because the inflammatory process actually supports optimal soft tissue regeneration. Using medications to inhibit this process can impair the healing process.
- Avoid ice. The benefit of ice is mainly for pain relief and although it's used widely, there’s little high quality evidence to support its use in healing soft tissue injuries. Ice could also disrupt inflammation, the restoration of blood flow to the injured area and formation of new blood vessels. It can delay the infiltration of neutrophils and macrophages to fight infection, and potentially increase immature microfibres, resulting in impaired tissue regeneration.
C - COMPRESS
- Joint swelling and internal bleeding may be limited by external compression such as taping or bandaging. But, it must allow full range of movement at the joint.
E - EDUCATE
- Contrary to popular belief, there are many benefits to an active rather than passive approach to recovery.
- Many passive therapies (e.g. electrotherapy, manual therapy, acupuncture) have minimal effects on pain and function compared to an active approach.
- Load management will avoid over treatment. Over treatment can increase the likelihood of injections and surgery.
- Dependence on therapies such as physiotherapy can actually contribute to persistent symptoms.
- Set realistic expectations about recovery times.
L - LOAD
- Evidence shows that an active approach with movement and exercises is beneficial, so normal activities should start as soon as symptoms allow.
- To provide optimal loading without increasing pain is indicated. It promotes repair and builds tissue tolerance and the capacity of tendons, muscles and ligaments.
O - OPTIMISM
- Our brains can play a significant role in rehabilitation interventions. Research shows that these factors may explain differences in symptoms and limitations better than the degree of injury.
- Barriers to recovery include many psychological factors, such as catastrophisation, depression and fear.
- Pessimistic patient expectations can negatively influence the outcomes and prognosis of an injury.
- It’s important to stay realistic and encourage optimism to improve chances of optimal recovery.
V - VASCULARISATION
- Cardiovascular physical activity is needed to manage musculoskeletal injuries.
- While more research is needed, evidence suggests that pain free cardiovascular activity increases blood flow to injuries and is a motivation booster.
- Benefits of early mobilisation and aerobic exercise improves function and work status and reduces the need for pain relief.
E - EXERCISE
- Evidence shows that exercise therapy can reduce the risk of a recurring injury.
- Exercise can restore mobility, strength and proprioception (sense of self-movement, force and body position) after an injury.
- Avoiding pain can help to promote optimal repair initially, and pain can be used as a guide to progress the difficulty of exercises gradually.
This short film might help to explain it too:
https://www.youtube.com/watch?v=HGTabgG7GIU&t=1s
So what does PEACE and LOVE mean onboard. Nope, it’s not a cue to smoke weed and hug each other while wearing flowers in our hair!
What it does mean is that crew with ankle injuries where a fracture isn’t suspected, can take pain relief (but not anti-inflammatories), use compression and elevation initially and keep the joint moving gently. As the pain allows, they should be encouraged to start to weight bear and exercise the joint.
Of course if you’re managing a crew member with a musculoskeletal injury and you aren’t sure what to do, please remember to contact your telemedicine provider.
Previous mnemonics used in the treatment of soft tissue injuries:
RICE - Rest, Ice, Compression, Elevation.
PRICE - Protect, Rest, Ice, Compression, Elevation.
POLICE - Protection, Optimal Loading, Rest, Ice, Compression, Elevation.
Resources used for this blog:
https://cks.nice.org.uk/topics/sprains-strains/background-information/prevalence/
We love this blog, it is so informative.....why not share the peace and love.....
Welcome to our latest guest blog where we’ve been chatting to James Griffiths, General Manager of Ocean Operations for Scenic Group and finding out more about what happens behind the scenes in order to keep a fleet of luxury expedition ships running. Here’s what James told us… As General Manager of Ocean Operations, I’m responsible for the operations of our fleet which includes four ships in service with around 850 colleagues. I currently live in Mumbles, near Swansea in the UK, but due to the nature of my work I spend a significant amount of time living in Croatia. Prior to this role, I spent many years working at sea and worked up through the ranks to Captain and over the last 15 years, my main focus has been on polar expedition travel. I hold a master mariner certificate of competency in addition to a degree in engineering and a post graduate diploma in law. Part of my job is to work with our medical service provider (Red Square Medical) to ensure that our ships are offering medical services that are appropriate for their deployment, and this can often be to some of the most extreme and remote locations around the world. It’s extremely varied, though during the COVID-19 pandemic, I came ashore when our operations paused for a significant period of time. I was fortunate enough to be given the opportunity to lead the restart of our Ocean Operations, which included setting up everything from a company to manage the ships, to selecting our crewing, medical, helicopter and submarine partners and providers, amongst many other things. Our areas of operation, and the nature of our cruises (expedition), plus having aircraft and submersibles onboard some, do mean additional elements involved in the management of these ships. You could say that this current position is more of a happy coincidence than one that I actually planned for! In some ways this is a great positive - I do think it’s possible to plan a little too much and then be disappointed if things don’t go quite the way you had imagined. But there’s no danger of that here!
Back in February 2022, we brought you one of our very first guest blogs from Simon Lawton, a Paramedic who has swapped out his ambulance for a Superyacht! You can read the original blog here: https://www.redsquaremedical.com/superyacht-paramedic-a-guest-blog-from-simon-lawton Over the last 2+ years, we’ve followed Simon’s career, and some of you may even recognise him as he does put a Red Square Medical instructor hat on from time to time. But, as for all healthcare professionals, Simon has to keep his skills up to date. So, we asked him to tell us a bit more about how he juggles this along with a rota onboard. Here’s what he told us… I’m originally from Stoke-on-Trent in the UK and trained as a HCPC registered Paramedic. I’ve spent almost 5 years working at sea now, with almost continuous employment on three different vessels, after leaving the ambulance service in 2019. My first role was as a Paramedic/Deck hand on Superyachts, and I now work as a Medical Officer on a maritime vessel. Even before I applied to become a Paramedic, I intended to complete my studies to help find employment in a remote or offshore environment. I had always been attracted to the idea of being able to travel the world while earning a salary. Working at sea has meant that I have travelled extensively, earnt a higher salary, and have a better work/rest balance than would be possible in a role on land. Note: At the time of writing, a qualified Paramedic’s starting pay in the UK was £28,407 and Simon’s old rota was 2 days, 2 nights (all 12 hours) and 4 days off with very inflexible annual leave. This year I decided to carry out some continual professional development (CPD) at a hospital in Mexico, to keep my skills up to date. I was interested in travelling to find out more about how healthcare services are provided outside the UK and Europe. The CPD activity in Mexico allowed me to do exactly that, while caring for and treating a wide variety of patients who had either self-presented in the emergency department, or been conveyed to hospital by ambulance.
Welcome to our September blog, and as we all start (in the UK at least!) to think about adding a few layers for warmth, we’d like to talk about getting naked! Well, to be more specific, getting bra’s off. Fact: Women are dying because bystanders are less likely to carry out CPR on women than men. Research shows that women are 27% less likely to receive CPR than men and if a defibrillator is used, their chance of survival is affected by bra’s being left on. Most of us have never had the chance to train using a female manikin. The #BraOffDefibOn campaign aims to address the inequality in CPR for women and we’re supporting it.
In August, we brought you a Guest Blog from Mark Hannaford, the founder of World Extreme Medicine. This month, it’s the turn of another of the key WEM faculty members… introducing Dr Will Duffin. Hello everyone, I’m Dr Will Duffin and I’m a GP in Devon in the UK. I’m the Joint Medical Director of World Extreme Medicine (WEM) and the Lead Medic for the US CBS TV show ‘Survivor’ - for Seasons 43, 44, 46 and 48, which is also through WEM. Extreme Medicine is healthcare that is delivered across the full spectrum of remote, austere and challenging environments. This includes high mountains, deep oceans, jungles, deserts, polar, low earth orbit and refugee camps… the list is endless. Being a part of the wider Extreme Medicine community through WEM has been a portal into new worlds of possibility and opportunity in my medical career as an NHS GP. It’s a huge privilege to treat patients in a remote setting. You get to do proper ‘hands on’ medicine that truly tests your clinical skills, risk management and decision making. Even basic techniques and principles done well can transform patient outcomes. That’s the big reward. I graduated from Bristol Medical School in 2008 and completed my GP Training in Cornwall, UK in 2016. In between, I spent 18 months in Australia to gain as much emergency department experience as I could, whilst doing Wilderness Medicine Courses. I landed my first expedition gig 12 years ago when I was post-FY2 (Foundation Years follow on after qualifying as a doctor). I covered a Kilimanjaro Trek after another doctor dropped out at the last minute. Once I had this under my belt, I was able to leverage this experience to get the next trip. So, I soon found myself providing regular medical cover for various commercial and charity sector expeditions. These expeditions have taken me all over the world: Kilimanjaro, the Peruvian Andes, the Himalayas, Northern China, Eastern Europe, Myanmar and Madagascar. One highlight was working as the private doctor for a Luxury Trans-Siberian Train! Though I became frustrated having to constantly wrangle annual leave to go away, so I made the switch to being a freelance (locum) GP, which has given me the flexibility I need. I joined WEM in 2018 after responding to a Facebook Ad for the ‘Survivor’ job. I was invited to a selection weekend in the Peak District, which is when I first met Mark Hannaford WEM founder and CEO and Dr Joe Rowles, WEM’s other Medical Director, and it all went on from there. Early on, I was given the opportunity to lead on the content for the annual World Extreme Medicine Conference and our various podcasts and webinars. Through doing this, I have met a colourful cast of characters; other extreme medics who are as audacious as they are inspirational! We have a lot of fun at the conference every year, learning from one another. https://worldextrememedicine.com/registration/wem-conference-2024 (Note from the RSM team – the conference is highly recommended and well worth a visit!)
Last year, the Red Square Medical team descended on the World Extreme Medicine (WEM) conference for the very first time. We’d been aware of this unique organisation for many years, but just not had the chance to get involved. Liz was involved in a panel discussion and spoke at the conference, and we came away literally buzzing with enthusiasm - our first impressions were that WEM is a place with no ego’s, where everyone wants to learn, and is willing to share. We met some of the most fascinating people ever and can’t wait to go back this year. But what about the person who started it all… We spoke to Mark Hannaford, founder of World Extreme Medicine and its far reaching impact. Here’s what he had to say. I’ve been involved in expeditions, working in low resource environments and extreme medicine for the past three decades! My family was made up of generations of seafarers from Cornwall although I was brought up variously in Devon, Antigua in the Caribbean and the Middle East; reflecting my father’s job as a Master Mariner. My father was at one time the youngest captain aboard the UK’s largest registered vessel, and my grandfather was Harbour Master for Malta and the first in that role in Plymouth at the start of Queen Elizabeth’s reign. I wear a number of hats but primarily I am the founder and CEO of World Extreme Medicine, and the annual WEM Conference. I also founded the MSc in Extreme Medicine at the University of Exeter and Graduate Certificate program at Bouvré College of Health Sciences, Northeastern University, Boston.
Women’s health is a huge topic, while it’s true that in the maritime sector women make up just 2% of seafarers at sea, up to 34% of the shore based staff are female. Looking at the bigger picture, women’s health directly affects just under half of our population globally, and indirectly (whether you like it or not!) the other half, we thought it was worth a blog about some of the issues, and the taboo’s, that could be affecting our maritime workforce and the women in our lives. It's common knowledge that women experience huge hormonal changes at puberty and menopause, both of which can have significant physical and mental health impacts. In the UK, there is a growing discussion and openness about peri-menopause (the years before periods stop altogether) and how for some women, this has devastating effects across all aspects of their lives, including work. Of course men experience changes at puberty, but their later life changes are less significant and generally don’t affect their ability to work. In December 2023 the World Health Organisation (WHO) issued a statement to advise that every year, at least 40 million women are likely to experience a long term health problem caused by childbirth. So there’s a good chance that we all know one or more women affected, or if you are female… this could be you. As part of a special series on maternal health, the study showed a high burden of postnatal conditions that persist in the months and years after giving birth. These issues include more than a third of women experiencing pain during intercourse, urinary incontinence (8-31%), anal incontinence (19%), anxiety (9-24%), depression (11-17%), perineal pain (11%), a fear of childbirth (6-15%) and secondary infertility (11%). All in all it doesn’t paint a great picture of life after childbirth for some women. If any of your workers experience these issues, either on or off shore, it could have a significant impact on areas of their working life and it’s something they may be reluctant to open up about. Even before childbirth, we may take it for granted that contraception is available, certainly in the developed world. But in developing countries where sexual violence is not uncommon, contraception is considered lifesaving due to the high level of unsafe abortions carried out. Around 13 million women (and girls) under 20 give birth annually and complications in the pregnancy and birth is a leading cause of death. Consequently abortion is an option, but this carries its own huge risks.
We just love speaking to and finding out more about the people who inspire us and we guarantee that this month’s blog will not disappoint! We first got in touch with Wendy Sullivan via LinkedIn and thought she seemed like a pretty awesome human. Wendy and her company, Maritime Medical Solutions in Australia, certainly share the same outlook as Red Square Medical. Fast forward a couple of years and we’re now collaborating on a project in Australia and the Pacific Islands. What we’ve learnt along the way is simply fascinating and Wendy has kindly agreed to share her story with us… Here is Wendy’s Guest Blog: I was born in Canada, grew up in Africa and now call Australia my home. I feel lucky to live in paradise where the weather allows us to be on the water year-round. I had to work hard to gain my Australian citizenship and I credit my work in the marine industry with giving me a pathway to stay in Australia permanently. It took years of hard work and uncertainty to gain my residency and is still one of the achievements I am most proud of. I started sailing in Canada and since emigrating to Australia gained my professional and commercial qualifications as a vessel master, marine engine driver, trainer and assessor. I also have a Diploma of Paramedical Science, ship masters medical qualifications, business administration and development and there is still so much more to come.
Working at sea can be one of the most rewarding and fulfilling careers. But you can’t gloss over the fact that it can be dangerous. Whether you’re working on a tanker, ploughing up and down the oceans, a Superyacht enjoying a busy season of charters, or any vessel in between; our love/hate relationship buddy Neptune takes no prisoners! The Safety of Lives at Sea (SOLAS) Convention in its successive forms is generally regarded as the most important of all international treaties concerning the safety of merchant and other vessels. The first version was adopted in 1914, in response to the Titanic disaster, and went through several iterations up to 1974. The Convention in force today is generally referred to as SOLAS 1974, as amended. SOLAS regulations cover all areas of safety at sea, including construction, fire prevention and detection, life saving equipment, cargo carriage, navigation, communications and a host of other areas. Regulation 33 of the SOLAS Convention applies to all ships, and places an obligation on Masters to respond to distress calls at sea and proceed ‘with all speed’ to their assistance. Anyone working in the maritime sector, hopes that they are never on the receiving end of this regulation, but we’ve experienced two quite different instances, where the ships we work with have responded and our Medical teams have played an important part in rendering aid.
This week’s blog is an introduction to telemedicine as although it’s probably been around for longer than you think, you might not be familiar with what’s available to help you. So whether you’re a leisure sailor taking on the ARC; work in commercial shipping, spend your time on a Superyacht, or anything in between, read on for more information… According to the UKs National Institute for Clinical Excellence, (NICE: https://www.nice.org.uk/), ships being on the water for months at a time mean that health can be a life-threatening challenge for sailors and seafarers. Access to healthcare providers has always been one of the most critical issues for offshore crews and it’s worth remembering that the International Labour Organization (ILO), dictates that access to medical treatments and health services should be guaranteed to seafarers in the same way as for people working ashore. Nowadays, telemedicine technology has emerged to improve healthcare delivery in many remote areas where there is no direct access to healthcare services using telecommunication services. Among them, maritime Telemedical Assistance Services (TMAS) have become more readily available and are now considered an integral part of a shipowner's emergency response operations. The advent and uptake of Starlink in both the commercial and leisure sectors can only be a positive from a medical perspective. So, what is Telemedicine? What does it do and how does it work? Telemedicine is a term that’s becoming more and more common in the maritime world. Quite simply, it is the provision of remote clinical services, via real-time two-way communication between the onboard medic (trained crew or healthcare professionals) and/or the patient themselves, and a shore-based healthcare professional, using electronic audio and visual means. The modern history of Telemedicine can be traced back as far as 1905, when a Dutch physician used long distance transfer of ECGs (electrocardiograms) to be read remotely. But as early as the 1920s onwards, radio communications were being used to pass medical information to patients at sea on ships and on remote islands. More recently, the COVID-19 pandemic has brought Telemedicine to the forefront of healthcare. Though we may not easily recognise what it actually is, the majority of GPs (certainly in the UK) and other allied healthcare professionals in the non-acute world, such as Physiotherapists and Mental Health support, have relied heavily on telephone and video consultations since March 2020. A survey conducted by Nautilus International and Martek Marine (2017) showed that a staggering 98% of seafarers believed that greater access to Telemedicine support would save lives at sea. Of those questioned, 68% had been on a vessel that was forced to divert due to a medical emergency and 70% had been on a vessel where there had been a medical evacuation. Emergencies experienced at sea ranged from severed limbs and broken bones, to gunshot wounds, tropical diseases, allergic reactions and sudden cardiac arrest. Whether you’re a commercial seafarer or leisure sailor, it would improve confidence in making a decision on whether an injury, or illness was severe enough to warrant a diversion, or evacuation, if there was a trained medic on the end of the phone or radio. Ever improving communications also means that we can now go far beyond voice calls. Photos of injuries, files of test results and even live streaming is all possible and helps to provide a much more indepth service. Our own team member, Rachel, received Telemedicine support via SatPhone and email, on a 7 metre Ocean Rowing Boat (yes, you did read that right!) in the middle of the Atlantic, when her rowing partner developed a painful injury. Remote intervention from a Doctor onshore helped to maximise use of the medical kit contents for the short and long term, rule out immediate worries of infection, and develop a pain management plan for the rest of the rowing race. One in five commercial ships a year are forced to divert for a medical emergency, with unknown numbers of other, non-commercial vessels on top. So there is also consideration for the cost and time involved, plus the stress to both the patient, and their medic who is managing a situation onboard, possibly alone!
At Red Square Medical, we’re keen to support those who have a passion for maritime medicine. While we can’t provide placements for everyone, occasionally a request pops up at just the right time and we can provide some experience and insight into our unique and specialised world. Last year we were contacted by Jordan Lin, a medical student with a love of the ocean. This is his story… When I was a boy, my dad and I used to go fishing with a local fisherman off the Norfolk coast. I absolutely loved being on the sea and so for quite a long time, I wanted to be a fisherman. When I got a bit older I kind of forgot about this and think I may have been slightly put off by watching the TV series ‘World’s Deadliest Catch’! But I have always loved being on the water and spent a lot of time sailing dinghies; I was also a swimming teacher for children back in high school and college. Later, I decided to study medicine and I’m now a final year medical student at the University of Bristol where I completed an intercalated degree; a Masters in Health Sciences Research. I’m now looking forward to starting work as a qualified Doctor in August. Though having spent 6 years training, my next 2 years will be spent working for the required two foundation training years that must be completed before being able to work independently as a Doctor in the UK. At university, I joined the VITA network which is a group dedicated to developing a health and public health approach at the heart of any response to human trafficking and exploitation. I became the blog coordinator for the organisation and you can read the blogs, including those that I have written, here: https://vita-network.com/blog/ In my spare time, I have been involved with the Bristol University Hot Air Ballooning Society and trained through the society to get my Balloon pilots licence. So, I often spend weekends during the summer flying in a leisurely fashion over Bristol and the surrounding area!