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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 December blog, which is all about the recovery position and how to manage an unconscious casualty who is breathing normally. Unconsciousness is a medical emergency as the person is very vulnerable and may not be able to manage their own airway effectively. We also need to think about the cause of unconsciousness. Is it a simple fainting episode due to illness? Is it a massive hemorrhage causing hypovolemic shock? Or is it due to some kind of external factor or injury? This blog looks at how to manage an unconscious casualty. So, if we have a casualty who is unconscious, but who is breathing normally for themselves, and we’re not suspecting a serious injury, the recovery position is the best position to use while monitoring them. The recovery position keeps their airway open and makes sure that vomit or liquid won’t cause them to choke.
All the guest blogs! When we started adding blogs to our website back in early 2021, we did a little feature on each of our instructors of the time. They’re quite a fascinating bunch and the series proved quite popular amongst our followers. In addition to our amazing instructors, we work with some utterly incredible human beings all over the world, and the idea of sharing their stories grew and developed into what eventually became a monthly guest blog. It’s been interesting to find out more about how medical care at sea or in remote locations features in their work, and to discover a few fun facts along the way. This month, we thought that it might be a fun idea to give you a chance to go back into the archives and review all the guest blogs over the last few years! Maybe even let us know which your favourite one is?
We’ve taken a look at the 2023 Casualty Summary Report from the Maritime Authority of the Cayman Islands (MACI) to see what kind of incidents and trends their data shows us, even with relatively small data sets, and how this may be able to transfer to our own risk assessments and actual practice. You can find the report here: Cayman Maritime Report 2023 The first thing we noted was the authors note that the data is split out into incidents. This means that one incident may include a number of events. So a collision and any resulting injury is one incident, but is reported as two events, or more, if more than one person is injured. It made us wonder whether this method of reporting by an authority represents how incidents are reported onboard and whether it should be a consideration? Of course, for any set of statistics presented at the moment, we also have to consider the COVID-19 pandemic and the impact this has on trends including that period. While essential shipping continued, the cruise and superyacht sectors reduced activity and staffing, often to a skeleton crew while anchored somewhere. So this will be reflected in the historic data sets that we analyse from 2019 to 2021 and may not accurately reflect increases and decreases during and since then. In some situations, we may need to look further back for accurate data. We also need to consider whether increases in incidents and events is also down to increased reporting - suggesting an improvement in the awareness of reporting requirements and greater engagement from the industry and individual sectors - this can only be a good development. Since 2020, the type of injury has been recorded in 8 different categories, with hand and foot injuries topping the leaderboard, closely followed by head, body, and back injuries. So if you were looking to run drills, or practise medical skills, these would be the key areas to cover. Only one death was an occupational accident, and is being investigated here: MAIB Investigations (search for case #9229607). It relates to a fall down a ventilation shaft on a bulk carrier in a Greek shipyard. The full report was still pending at the time of writing. Merchant ships are heavily regulated by a number of authorities, and the requirements for personal protective equipment and safe systems of work are enforced and applied to reduce accidents and incidents onboard. This has led to a lower reporting of incidents than in the commercial yacht sector. Could there be room for improvement here in this area? We certainly think so. Many of the hand and foot injuries reported can be career ending or life changing, but are preventable. Follow up has shown that there is a link here with injuries being sustained when inappropriate or no PPE was used. The supply and use of appropriate PPE is mandatory on vessels subject to the MLC and it’s worth remembering that some PPE can be produced in styles and designs compatible with the aesthetics of a yacht if required! On a much wider scale, a lack of transparency and standardisation globally can affect the collection of data and the issue of under reporting. While the MACI figures may be accurate, we need other accurate figures to compare them to, in order to build a bigger picture across the world as we have in aviation. From December 2024, the Maritime Labour Convention (MLC) will be enforcing an amendment so that seafarer deaths will be recorded and reported annually. The MACI and Cayman Islands Shipping Registry produces a number of safety flyers that are publicly available HERE that may be useful. In summary, analysing data can sometimes result in more questions than answers. But even this can lead to interesting and important developments that result in improved safety and reduced incidents and accidents onboard. Key points to take from this report are: Use the correct PPE for the task. Employ approved systems of work and risk assessments for the task. Reporting is key for safety in the future of our industry. Enjoy a night ashore, but don’t over do the cocktails! As always, if you’d like any input on medical training onboard or ashore, or drills that you can run yourselves, please just get in touch. References: https://www.lloydslist.com/LL1145359/Increase-in-incidents-of-deaths-at-sea
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.