First Aid Afloat

Are you prepared for an onboard medical emergency?

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First Aid Afloat

Adapted from, Beating the Odds: A Guide to Commercial Fishing Safety, 7th Edition, Jerry Dzugan and Susan Clark Jensen, 2018

Even the most careful skipper can have an unexpected onboard medical emergency. Suppose rough seas throw a crewmember hard enough to break his leg. Or one of the newer crew gets his arm caught in the winch before it can be stopped. He bleeds a lot, and he looks like he will faint. Do you know what to do? The following CPR steps are for lay people, not healthcare professionals.

Do This First

Before treating anyone, carefully assess the situation and location. If it is not a safe scene, stop until it is made safe. This may require the assistance of specialized rescue workers and/or equipment. Failure to do so can result in you or crewmembers becoming additional patients.

The Safety Priority at all times is in this order:

Yourself.
Fellow crewmembers/rescuers.
Patient.

Assure that the scene is safe for you and responding crewmembers to proceed. If it is, then address the questions in the following five steps.

Step 1. What caused the accident? Look around for clues, and ask others what happened. What appears to be the mechanism for the injury or illness? Is this an exposure to environmental or hazardous materials? Above all, make sure it is safe to proceed. Use your eyes for visual clues, listen for things, use your sense of smell. Where and how was your patient found? Is equipment or gear involved? Did the person fall? Collapse? Get crushed? A crewmember who is seen unconscious or unresponsive in a fish hold or enclosed space should be suspected as a victim of noxious gas or a lack of oxygen. Do not enter the space until it has been verified that it is safe to do so. All of these clues and more can help guide you on what to do next. Recommended personal protective equipment (PPE):

Rubber gloves, medical type or heavy duty industrial grade gloves.
Pocket mask or barrier device for rescue breathing.
Goggles or protective eye gear of some type.
Rain gear and rubber boots.
Improvise with what you have. Do your best to minimize exposure to blood and other hazards.

Does the person respond to you? Use the AVPU scale to assess their level of consciousness (LOC). The Coast Guard and emergency responders are familiar with AVPU scale terminology.

A = Awake. Is your patient awake? If so, are they oriented, confused, agitated? Make note of how they are.

V = Voice. If they are not awake, gently tap and shout at them. Do they open their eyes, moan, or groan? If your patient responds in any way, they are responsive to Voice.

P = Pain. If your patient did not respond to your voice, see if they respond to painful stimuli. Pinch their bare skin between the shoulder and neck or near the ankle. Did they flinch, pull back, or moan? These are indicators that they are responsive to Pain.

U = Unresponsive. If they did not respond to your painful stimuli, your patient is unresponsive. This is a critical patient needing urgent evacuation, until proven otherwise. If you have not done so already, call for help from your crewmembers. If alone, call for help on the radio. Talk to your patient, regardless of where they are on the AVPU scale. Be positive and not panicked. Patients can often hear responders even when they are not awake.

Unconcious person on the deck of a commercial fishing boat. Place the breathing, unconscious person in the recovery position to help maintain an open airway.

Place a breathing, unconscious person in the recovery position to help maintain an open airway.

Step 3. Is the person breathing? Yes or No. Quickly observe your patient. Do you see their chest rise and
fall with breathing? Open up clothing or PFD if you need to for better observation. Can you hear them breath? If yes, they have a pulse and airway. Do the following treatment:

If they are on their back, carefully place them in the recovery position.
Quickly check their body from head to toe looking for severe bleeding. If severe bleeding is found, go to Step 5.
If no bleeding is found, keep the patient warm and protected. Provide at least twice as much padding or insulation under your patient as you do on top. Monitor their breathing. If no breathing is observed, carefully turn the person over on their back keeping the neck and back in line. Use the head-tilt, chin-lift method to open and assess the airway. Start CPR (cardiopulmonary resuscitation) immediately. If an AED (automatic external defibrillator) is available, turn it on and follow the audio instructions.

Rolling a non-breathing victim onto his back to perform CPR. If no breathing is observed, carefully turn the person over on their back keeping the neck and back in line.

If no breathing is observed, carefully turn the person over
on their back keeping the neck and back in line.

Step 4. CPR

Expose chest, interlock both hands/fingers, and place palms on center of chest.
Give 30 hard and fast compressions. They should be about two inches deep.
Open the airway. Pinch nostrils, and tilt head back with chin lift.
Provide two rescue breaths, just enough for the chest to rise. Rescue breathing is the action of blowing air into the patient to expand the lungs.
Repeat cycle of 30 compressions followed by two rescue breaths.
After five cycles or about two minutes, check if patient is breathing. If yes, follow Step 3.
If no breathing is observed, continue CPR. Switch partners at this time if another person is available.

Use the head-tilt chin-lift method to open the airway.

One-Rescuer CPR Standards

Age of Patient	For Compressions Use	Depth of Compressions	Number of Compressions to Ventilations
Less Than 1 Year	2 Fingers	About 1 1/2 Inches	30:2
1 Year to Onset of Puberty	One Hand	About 2 Inches	30:2
Onset of Puberty & Older	Two Hands	At Least 2 Inches	30:2

Special Considerations

If air does not go in, reposition head, and look for any object in mouth and remove. Try again.
If air still does not go in, continue chest compressions even if you are unable to get air in.
If patient vomits during CPR, roll them toward you on their side, attempt to clear the airway. Regardless of outcome, continue CPR.
When in doubt, do CPR. The benefits outweigh any harm or risk to the patient.
It is okay to stop CPR if you become exhausted or the scene becomes unsafe to continue.
CPR performed in remote settings is often unsuccessful despite valid efforts. You may be advised to stop by a higher medical authority.

Step 5. Is the person bleeding a lot? Check your patient from head to toe for severe bleeding. Check
inside clothing and boots and underneath your patient. If bleeding is found, treat as follows:

Expose the sight in order to locate and see the source of the bleeding.
With a dressing or clean cloth, apply well-aimed, continuous direct pressure to the site.
If dressing becomes blood-soaked, remove and replace. Assure well aimed direct pressure is reapplied and maintained at the correct site.
If direct pressure does not control bleeding, make sure you are pressing on the wound. Remove clothing at site and get a good look at the source of bleeding and try again. It takes 15 to 20 minutes for blood to clot.
When bleeding is controlled, secure dressing or cloth with tape or bandage. It needs to be tight but not too tight as to cut off circulation below the injured site.
Keep patient warm. Provide a least twice as much padding or insulation under your patient as you do on top.
Make sure they are breathing. If they are not awake, place them in the recovery position to protect their airway. Do not give food or fluids unless directed by higher medical control.
Tourniquets, which need to be at least 2 inches wide, can be considered if:
- All other efforts have failed to stop the bleeding from arms or legs.
- If you are performing CPR and/or unable to apply well aimed, direct pressure.
Amputations: perform Steps a through d to the stump. Retrieve amputated parts and/or tissue; wrap in clean cloth. Place in watertight bag or container. Keep chilled, not frozen.
Impaled object: do not remove except for small objects such as fishhooks. Control bleeding. Stabilize item with bulky dressings or clothing. Trim or shorten object to help stabilize. Consider applying a well-padded splint for support.

Impaled object in a victim;s leg. Stabilize impaled objects.

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Treating Other Injuries

Choking
People who are choking often grab their throats. Some will cough. Do not interfere with coughing. Others will be unable to cough or speak. If you suspect someone is choking, ask them if they can talk. If they can, let them cough. Do not hit them on the back.

If they cannot talk, stand behind them and place your ﬁst on their stomach between the belly button and ribs. Put your other hand on top of the ﬁrst hand and—without touching the ribs—swiftly pull both in and up. Repeat this motion until the object is out and the person can breathe again, or becomes unconscious. If you cannot get your hands around the person’s stomach, or if she is pregnant, do the same maneuver on the chest, making sure you are in the middle of the breast bone.

If the person becomes unresponsive from choking, provide the following treatment:

Lay the patient on their back, and call for help.
Immediately begin CPR with 30 compressions.
Open the airway with the head-tilt, chin-lift; quickly look for any foreign object. If seen, remove.
Pinch patient’s nose, provide two rescue breaths, just enough for chest rise.
If air does not go in, reposition the head and try again. If no luck, resume compressions.
Repeat cycles of 30 compressions, looking in the airway and providing two rescue breaths.
Continue CPR until the patient begins to breathe or you become exhausted or are advised to stop.
If successful, place patient in the recovery position. They should be evaluated after this event by trained medical providers.

Hand position for abdominal thrusts on a conscious choking victim.

Drowning
People who drown look cold, blue, and rigid. They are not breathing, don’t have a pulse, and their pupils are big. However, it is sometimes possible to revive a drowned person if they are rescued from the water in time and CPR is started immediately.

Researchers believe that when a person drowns in cold water (under 70°F), the mammalian diving reﬂex or hypothermia extends the chance of living. This reﬂex, named after a similar response in sea mammals such as porpoises, whales, seals, and sea lions, causes the heart to slow and reduces circulation to the extremities. This allows the main blood ﬂow to concentrate in the brain, heart, lungs, and kidneys, helping to preserve these delicate organs. People who have been submerged under cold water less than one hour are most likely to be revived. CPR is not advised if the person is known to have been under water for more than one hour.

If you are not sure how long the person has been under water, do CPR. When someone has drowned, get them out of the water as soon as possible, keeping them in a horizontal position if this does not delay rescue. Be extra careful of their back and neck if a spinal injury is suspected.

Start CPR as soon as they are out of the water (page 129). Do not do any special maneuvers to remove water from their lungs. Contact the Coast Guard or a physician for further advice.

Heart Attack
Heart attacks occur when the heart muscle does not get enough oxygen and some heart muscle dies. Heart attacks can, but do not always, cause the heart to stop beating. One of the most common symptoms of heart attacks is chest pain, often described as a squeezing sensation or “like someone is
standing on my chest.” This pain, however, is not always present.

Some people have pain in the jaw or arms, especially the left arm. They may be sweaty, have pale or bluish skin, be short of breath, vomit, or feel nauseous, faint, or dizzy. Many patients deny they are
having a heart attack, while others may feel sure they are going to die.

If you suspect that someone is having a heart attack, follow the ﬁve Do This Frst steps above, then return here for further treatment instructions.

Allow the person to sit or lie down so they are comfortable.
Loosen tight clothing, reassure them, and try to be calm.
Give patient oxygen, if possible.
Have patient chew a 325 mg non-enteric coated aspirin if no allergy to aspirin.
Contact the Coast Guard or a doctor for further instructions, and make sure you continue to monitor their airway, breathing, and pulse.

Stroke
During a stroke, blood flow to the brain is blocked. One of the most distinct stroke symptoms is that strokes happen quickly. Other symptoms include:

Sudden numbness or weakness of the face, arm, or leg, especially on one side of the body.
Sudden confusion, or trouble speaking or understanding speech.
Sudden trouble seeing out of one or both eyes.
Sudden trouble walking, dizziness, or loss of balance or coordination.
Sudden severe headache with no known cause.

If these symptoms appear, a rapid response is needed.

Ensure airway is open.
Give rescue breaths if patient is not breathing.
Place in recovery position to prevent choking, if the patient is unresponsive. Stroke patients can’t swallow.
Give oxygen if available.
Provide psychological support by talking and touching patient.
Do not give aspirin in case the stroke is caused by bleeding.
This is a must-transport emergency.

Chest Injuries
Chest injuries can be caused by a blow or wound to the chest and can be life-threatening. If a lung is punctured, the person may cough up frothy, bright red blood. This can happen with or without a visible wound.

When a person has a chest injury, follow the ﬁve Do This First steps above, then return here. If the person has a gunshot wound, look for and bandage the exit wound (where the bullet went out). There may not be an exit wound. Some bullets stay inside the patient.

If a wound is visible where the bullet went in, seal it immediately with a piece of plastic, tinfoil, or other airtight material. A bulky bandage or clean clothing can also be used, although airtight material works best. Tape the plastic or tinfoil to the chest on three sides to allow air to escape from, but not enter, the chest cavity. Unseal the wound immediately if the person’s breathing gets worse.

Check for and treat other injuries, then contact the Coast Guard or a doctor for further instructions. Maintain the person’s airway, breathing, and circulation.

Abdominal Injuries
Follow the ﬁve Do This First steps above, then return here for further instructions. Bandage wounds with a clean, dry dressing or cloth. If the person’s intestines are hanging out, do not push them back in; this can cause a serious infection. Instead, cover the intestines with a clean plastic bag, or clean dressing or cloth moistened with clean water. Allow them to lie with his knees drawn up if they prefer that position.
Check for and treat other injuries, then contact a physician or the Coast Guard for further advice.

Burns
First degree burns are red; second degree burns are red, blistered, and quite painful; and third degree burns often look charred or leather-like. Feeling is lost in third degree burns, although the area around them may be quite painful.

Before approaching a person who has an electrical burn, make sure he is not in contact with the electricity, and be sure the power is off. Stop the burning without burning yourself. If someone’s clothes
are on ﬁre, stop them, and have them drop to the ground and roll.

If you have a wool blanket or article of clothing, roll them in it. Follow the ﬁve Do This First steps above, then return here for further advice. Be especially concerned about people who have been burned on the face; were in a smoky, closed, burning area; or who suffered an electrical burn.

If it has been less than 4 minutes since the burn, and if the burn is ﬁrst or second degree with unbroken skin, cool the burn by putting it in clean, cool water. Or put cloths dipped in clean, cool water on the burn. Do this until the pain lessens.

Use a glove to brush off dry chemicals such as lime, then rinse the area with clean water for at least 10 minutes. If the chemical is in the eyes, hold the eyes open and rinse them gently for at least 10 minutes with clean water. Flush alkali burns (ammonia, bleach, strong detergents, lye, etc.) for at least one hour.
Bandage the burned area (including entrance and exit wounds from electrical burns) with clean, dry bandages or cloths. Also bandage between burned ﬁngers and toes, but do not put anything else on a burn unless directed to do so by a physician.

Check for and treat other injuries, then contact the Coast Guard or a physician to determine further treatment. Be prepared to describe the person’s condition, how the burn happened, what it looks like, and how much of the body it covers.

Rinse chemical-contaminated eyes carefully for at least 10 minutes with clean water.

Confined Space Hazards

Shrimp dip (sodium metabisulfite), used to prevent black spots in shrimp, and water can produce the toxic gas, sulfur dioxide, which in an enclosed space can result in death in just minutes. At least six deaths due to sulfur dioxide have been recorded on shrimp boats in the Gulf of Mexico alone. (Reference: D.A. Atkinson et al., 1993, Sodium metabisulfite and SO2 release: an under-recognized hazard among shrimp fishermen, Annals of Allergy 71:563-566.)

Hydrogen sulfide and hydrogen cyanide can be produced by rotting fish. Prevention includes keeping holds clean and paying particular attention to hard-to-reach places where fish can be hidden and rot. Carbon monoxide and carbon dioxide are produced by engines and combustion. Check exhaust lines for leaks and obtain gas detectors, especially for carbon monoxide. Avoid crew sleeping on board without good ventilation to prevent these gases from working their way into living quarters. If you find a crewmember unconscious in the hold, assume they are poisoned and take confined space precautions to prevent injury to others. Rescuers should use SCBAs and take the patient at once to an uncontaminated area, maintain an open airway, give respiratory support, and get rapid transport to higher medical care.

Carbon Monoxide Poisoning
Carbon monoxide poisoning and death may occur if a vessel has a leaky exhaust system or if the wind is at the stern of the vessel. Air circulation around smaller vessels with cabins may cause the exhaust to cycle up toward the stern. Make sure you keep living and working spaces well ventilated, and do not use charcoal heaters inside boats.

Buy some carbon monoxide detectors for your vessel. They are relatively inexpensive and can help prevent this poisoning. Signs and symptoms of carbon monoxide poisoning include headache, drowsiness, nausea, dizziness, and unconsciousness.

Some of these symptoms are the same as seasickness. When in doubt, suspect carbon monoxide poisoning and act accordingly. Rescue the person from the area and get them into fresh air, but make
sure you are not overcome by the fumes yourself. Follow the ﬁve Do This First steps above, then return here for further instructions.

Give the person oxygen, if possible. Check for and treat other injuries, then contact the Coast Guard or a physician for further advice.

Ammonia Exposure
Anhydrous ammonia is a refrigerant found on a number of fishing vessels and is common in onshore fish processing plants. Ammonia is a pungent, colorless, noxious gas and high health hazard corrosive to the skin, eyes, and lungs. Exposure to 300 ppm is immediately dangerous to life and health. If concentration is above 300 ppm, the space should be entered only with a Self Contained Breathing Apparatus (SCBA) with a full-face mask in use. Ammonia is also flammable. When mixed with lubricating oils, its flammable range is increased. It can explode if released in an enclosed space with a source of ignition present or if
a vessel is exposed to fire.

Ammonia especially damages high moisture areas of the body such as the lungs and airway. This is a life-threatening emergency. Ensure the safety of others and take the exposed fishermen at once to an uncontaminated area. First aid consists of maintaining an open airway, respiratory support, and rapid transport to higher medical care. It is of vital importance that scene safety is assessed first, so that
ammonia will not affect additional unprotected crew.

Wearing contact lenses during an ammonia release is a risk. Ammonia gets trapped under the lenses, causing damage and preventing effective flushing of the eye. Flushing should continue for at least
15 minutes. An 8 ounce squeezable squirt bottle filled with water should be permanently stationed wherever ammonia is used; it can be used to get excess ammonia out of the eyes until a larger water
supply can be reached.

Hypothermia
Hypothermia occurs when the body’s core temperature drops below 95°F. Submersion in water is a major cause of hypothermia because water conducts heat away 25 times faster than air. Hypothermia can also occur in temperatures well above freezing, especially with wind and wet conditions.

It is often not practical to measure body core temperature in the field. However, a rapid assessment of a patient’s core temperature may be performed by placing a warm, ungloved hand against the skin of a patient’s back or chest. If the skin feels warm, hypothermia is unlikely.

Initial Treatment to Prevent Further Heat Loss:

Insulate from the ground.
Cover the patient with a vapor barrier.
Insulate the patient, including the head and neck.
Protect from the wind; eliminate evaporative heat loss by removing wet clothing, but only after the patient has adequate shelter.
Move the patient to a warm environment as soon as possible.
Hot shower/bath OK for patient just “cold,” not for hypothermia.

Levels of Hypothermia

Hypothermia Level	Core Temperature	Self-Rewarm?	Symptoms/Level of Consciousness (LOC)

Treatment for Mild Hypothermia:

Protect and/or remove patient from cold environment.
Remove and replace any wet clothing.
Supplement vigorous shivering with high calorie food and fluid with sugar as long as patient is able to swallow and protect airway. No alcohol or tobacco.
Apply heat to areas close to the heart, the chest and upper back.
Mild exercise is OK after patient is dry, has caloric replacement, and is stable for 30 minutes.
Monitor level of consciousness (AVPU).
If patient maintains or improves, evacuation may not be necessary.

Treatment for Moderate/Severe Hypothermia:

Check breathing/pulse for full minute. If no breathing, give 12 breaths per minute. If no detectable pulse, begin chest compressions.
Beware of slow, weak hypothermic heartbeats that may be hard to detect. A rate of only a few beats per minute is enough to provide adequate flow to vital organs. In such cases, starting chest compressions may cause cardiac arrest. Contact higher medical authority for guidance.
Protect and/or remove from cold environment. Any movement of patient must be done carefully with minimal jarring at all times. If clothing is wet, cut clothing off of the patient.
Keep patient horizontal.
No hot shower or bath.
Assure patient has an open airway; monitor breathing.
Place patient in the recovery position with insulation material above and below them.
Apply heat sources to high heat loss areas, especially the chest and upper back. Heat sources must be wrapped in cloth first to avoid burning patient’s skin.
Consider wrapping patient without clothing in a tarp with protected heat sources next to skin. Then wrap patient and tarp with a blanket or sleeping bag to maximize heat production.
Do not give any fluids or food.
Warm, humid environments are best.
Until proven otherwise, this is a high priority evacuation patient. Contact the Coast Guard or a doctor for further advice.

How Your Body Gains and Loses Heat

Heat Loss

Radiation: When the air is cooler than your body, you lose heat through your skin, especially the high heat loss areas of your head, neck, chest, upper back, armpits, sides, and groin.
Respiration: You lose heat by exhaling air your body has warmed.
Evaporation: Sweat evaporates your body’s moisture into the air, resulting in heat loss.
Convection: Heat radiated from your body is taken away by moving cold water and cold air.
Conduction: Being in contact with cold surfaces takes your body heat away. Knowing how your body loses heat makes it easier to understand why you lose heat 25 times faster in water than in air of the same temperature.

Heat Gain

External sources.
Conversion of food to heat.
Muscular activity: Note, however, that activity in cold water may cause you to lose more heat than you gain.

Heat Gain and Heat Loss

Cold Water Near Drowning (CWND)
For this emergency cold water is defined as below 70°F. The difference between warm and cold water is that in immersions longer than six minutes, the chance for survival in warm water is much less than in cold water. The colder the water, the better the chance for survival, and people have survived immersion up to an hour. The best survival is in water that is very cold (41°F). In most cases, there is no difference between fresh and salt water cold water near drowning regarding treatment or outcome. Since this is a life threatening emergency. It is vital that all mariners wear flotation on deck and that rescuers do not endanger themselves. Would-be rescuers are often drowning victims as well.

Treatment for Cold Water Near Drowning

Support spine/neck in case of injury.
Give five quick rescue breaths.
Give 10-12 additional breaths in next minute.
Check for resumption of breathing in patient. If patient still is not breathing on own, still in water, and a firm surface is more than 5 minutes away, give one more minute of breaths and bring patient to solid surface as quickly as possible without further breaths.
If firm surface is available within 5 minutes, continue rescue breathing.
Check pulse for one minute. If no pulse begin chest compressions with rescue breathing.
If AED (automatic external defibrillator) is available, dry patient’s chest, turn AED on, and follow voice commands. It is safe to deliver shocks with AED even on wet decks.
Be prepared to turn patient on side in case of probable vomiting.
Do not give abdominal or chest thrusts unless there is evidence of an airway obstruction with a solid foreign body.
Do not do maneuvers to remove water from the lungs; they are unsafe and ineffective.
Any patient who was submerged and unconscious should be transported to the nearest medical facility for further evaluation.

Frostbite
Frostbite occurs when body tissue freezes. It can be prevented by wearing proper clothing and being prepared for the weather. Frostbitten tissue usually looks pale or white. It is hard to the touch yet has no sensation.

To treat frostbite, follow the ﬁve Do This First steps above, then here for further advice. If the patient appears hypothermic, follow the treatment for Moderate/Sever Hypothermia, then return here for thawing instructions.

Decide whether or not to thaw the frozen part. Do not thaw it if you cannot do it completely or if it has a chance of refreezing. If you do not thaw the part, protect it from thawing and further injury, and contact the Coast Guard or a physician for further advice. Do not rub the part or put ice or snow on it.

Thaw frostbitten parts in moving warm water (99° to 102°F) until normal color and sensation return. Then loosely bandage the part, placing bandages between thawed ﬁngers and toes. Elevate the part,
and prevent it from refreezing. Try to prevent the person from walking on thawed feet. Contact the Coast Guard or a physician for further advice.

Heat Emergencies and Hyperthermia
Hyperthermia occurs when the body’s core temperature increases. This can be life threatening if not corrected. Heat emergencies are caused from external sources such as high environmental temperatures and high humidity. High humidity interferes with the body’s ability to dump heat efficiently. The main external cause of a heat emergency is exercise. Hot engine rooms, hot and humid climates, intense work, and inadequate hydration can all lead to heat emergencies in commercial fishing. Sweating and evaporation are the body’s defense to getting overheated.

There are three main stages leading to hyperthermia:

Heat Response: Blood vessels dilate and sweating occurs, but body temperature, vital signs, and consciousness are all normal. All are signs that the body is compensating for the hot environment:
a normal workday in the tropics. To prevent this from getting worse, decrease heat/exercise and
increase fluids and salt/electrolyte intake.
Heat Exhaustion: Now the body stops being able to adjust to the heat and loses too much fluid through sweating, vomiting, and diarrhea. The signs and symptoms of heat exhaustion can include skin that is clammy or flushed, weakness, thirst, nausea, vomiting, muscle cramps or spasms, increased pulse/breathing, and decreased or normal blood pressure with a body temperature
under 105°F. Consciousness is normal however, and this is an important sign. Heat exhaustion can be corrected but is getting dangerous. To treat heat exhaustion, reduce heat/exercise, increase shade, and use a fan. Drink fluids if no severe vomiting exists; intravenous hydration is even faster. Any food provides electrolytes, but no alcohol! Seek medical help if heat exhaustion lasts longer
than one hour. Radical rapid cooling is not needed.
Heat Stroke: This is a life-threatening emergency and is due to uncorrected heat exhaustion. Signs and symptoms include no sweating, skin clammy/flushed/dry or variable, a throbbing headache, weakness, thirst, nausea, vomiting, increased pulse/breathing, body temperature of 105°F, blood pressure normal or decreased, seizures, consciousness abnormal, an important sign and extremely life threatening condition. To treat heat stroke, perform radical rapid cooling by cold/ice water immersion. Minutes count. Oral fluids are too slow and not practical. Radical cooling is generally safe.

Another complication of heat emergencies is having too much fluid in the body, and not enough electrolytes or salts. A high fluid intake without electrolytes can flush/dilute the remaining electrolytes
from the brain and cause death. Signs and symptoms include a normal to low body temperature, low blood pressure, rapid heart rate, sunken eyes, confusion or loss of consciousness (even briefly), poor
skin elasticity, seizures, and loss of consciousness. This is why sports drinks are better in a hot environment, and salty snack foods are now recommended for working in hot environments.

General Hot Weather Tips

Increase fluid intake with increase in heat.
Avoid alcohol; it is a diuretic.
Drink fluids, including sports drinks; avoid salt tablets.
Wear light colored, lightweight, loose fitting clothing, and a broad rimmed hat.
Use sunscreen and UV (ultraviolet) protective eyewear.
Pace yourself when working.
Acclimate to environment.
Use buddy system and common sense in hot weather.

Heat Cramps
Heat cramps are caused by profuse sweating, which depletes both water and salts and causes painful muscle cramps. Heat cramps are treated by stopping activity, finding a cool place, drinking clear
juice/sports drink, and no strenuous activity for a few hours after the cramps subside. If cramps do not subside in one hour, seek medical attention.

Heat Rash
Heat rash is caused by skin irritation due to excessive sweating during hot, humid weather. Signs and symptoms include red clusters of pimples or small blisters. The treatment is to move to a cooler, less humid place, keep skin dry, and avoid lotions. No other treatment is needed.

Sunburn
Working outdoors in the sun with the reflected light off the water can give fishermen sunburn even in colder northern environments. To prevent and treat sunburn avoid repeated sun. If sunburnt, use cold compresses or immerse in cool water. A moisturizing lotion is good to use but do not use salve, butter, or ointment. If badly burnt, do not break blisters. Prevention includes avoiding using photosensitizing drugs and wearing a hat, light clothing, and waterproof sunscreen with a high SPF (sun protection factor).

Eye Damage by Sun
Studies have shown that fishermen have a higher incidence of cataracts and glaucoma than the average population. This makes sense since fishermen have a high exposure to sun and glare. Your risk can be reduced by wearing eyewear that reduces the amount of damaging ultraviolet light.

Fractures (Broken Bones)
Most fractures are not life threatening. If a patient is in danger, do not hesitate to move them to a safe location, even if you suspect a neck or spine injury. Patients will be more comfortable and there is less likelihood of permanent injury if long bones are straightened prior to splinting.

Do not attempt to straighten injuries to the joints (elbows, knees, wrists, and ankles) if the patient has good circulation to hands or feet. If the hand or foot is warm and appears to have circulation, then splint joint injuries in the position you find them.

Do not move patients with suspected fractures before the fractures are splinted unless the person’s life is in danger. If you need to move them before splinting, support the fracture site and the joints above and below the fracture during the move.

Splint the fracture using whatever materials are handy. Try to splint the fracture in the position it is in with a padded splint, making sure you immobilize the fracture site and the joints above and below
the fracture.

If the person complains that the splint is too tight or if their ﬁngers or toes turn blue when the limb is splinted, loosen but do not remove the splint. Apply cold compresses to the fracture site to help reduce
swelling. Check for and treat other injuries, then contact the Coast Guard or a physician for further advice.

Back or Neck Injuries
Unstable spine and neck injuries are rare. However, fractures of the neck and spine may cause life changing injuries. Treat them carefully. But do not let that consideration interfere with treating life threatening injuries such as no breathing, pulse, or severe bleeding. Airway and breathing trump the spine at all times. If, for example, the patient is not awake and oriented, they need to be placed in the recovery position.

Signs and symptoms of back injuries may include a wound, pain at the site, numbness, tingling, lack of feeling, or inability to move the body below the injury site. It is possible for a person to have a back injury and show none of these signs or symptoms.

Moving people with back injuries is a very special skill. It should be practiced during training before it is done to an injured person. If you’re a ﬁsherman and you haven’t taken a ﬁrst aid course, you should sign up for one soon.

If there is a chance the person has a back injury, treat them as if they do. The key is for the patient to be in, or removed to, a safe environment by whatever means or method that is reasonable in the given situation. It may be that they get up and are walked with assistance to a safe place.

The term that is now preferable is “spine protection” as opposed to “spine immobilization.” Lying in a position that is most comfortable for the patient is spine protection. If you must move the person, place them on a backboard, or something hard like a bin board, in the position they are in. Put a blanket on the board before you move them. Cover the person and secure them to the board. Contact the Coast Guard or a physician for medical advice.

Head Injuries
If a person has been knocked unconscious by a blow to the head, there may be bleeding inside the skull causing pressure on the brain. Any loss of consciousness, no matter how short or long the duration, is a concussion. The patient needs to be transported to a medical facility as soon as possible. This may be a life-threatening emergency. Even if they wake up within a few seconds or minutes, they cannot stay on the boat. If you are not in port, contact the Coast Guard for an evacuation.

Any head-injured patient needs to have their level of consciousness monitored regularly using the AVPU scale (awake, voice, pain, unresponsive). Patients who have received a concussion need to be monitored for 24 hours for three early warning signs of this increased pressure. It only takes one of these signs and not all three to warrant evacuation.

Changes in mental status. For example a patient in category A of the AVPU scale is still awake but is now confused, or has more extreme changes to V, P, or U.
Severe headache.
Persistent vomiting or dry heaves.

If any of these apply, the patient needs urgent evacuation. Remember that “concussion = evacuation”. Don’t wait for worsening symptoms to appear to make the call.

Head injuries may be bloody, painful, or swollen, or the person may have bruising around his eyes or behind his ears. He may have breathing problems, his pupils may be unequal, he may have vision
problems, or he may be having a seizure. He may be unconscious.

If a person has a head injury, assume that he also has an associated back or neck injury, especially if he has been knocked unconscious. Follow the ﬁve Do This First steps above, then return here for further advice.
Look for and treat other injuries, then contact a doctor or the Coast Guard for further advice.

Seizures
Seizures are caused by a massive electrical discharge in the brain, and they are often accompanied by convulsions (involuntary body movements). Seizures can be caused by epilepsy, old or recent head injuries, alcohol withdrawal, diabetic problems, poisoning, fevers, drugs, and low levels of oxygen in the brain.

When someone is having a seizure, do not try to restrain them, and do not put anything in his mouth. Protect them by clearing the area of sharp objects or items they might knock onto themselves. Contact the Coast Guard or a doctor immediately if a person has one seizure after another. This is a serious emergency.

When the convulsion is over, follow the ﬁve Do This First steps above, then here for further advice. Look for and treat other injuries, then contact the Coast Guard or a physician for further instructions.

Paralytic Shellﬁsh Poisoning
Paralytic shellﬁsh poisoning (PSP) is caused by a poison produced by small organisms called dinoﬂagellates. Clams, mussels, oysters, snails, scallops, and barnacles ingest these organisms while
feeding, and the poison is stored in their bodies. This toxin has been found in these seafoods every month of the year, and butter clams have been known to store the toxin for up to two years. One of the
highest concentrations of PSP in the world is reported to be in the shellﬁsh in Southeast Alaska.

Some people have died after eating just one clam or mussel, others after eating many—each with a small amount of poison. You cannot tell whether the dinoﬂagellates are present by looking at the water with your naked eye. There is no simple, reliable test for PSP and most beaches in Alaska are not tested. If you are not sure the seafood is toxin-free, avoid eating it if it is from an area with a high incidence of PSP.

Signs and symptoms of PSP most often occur within 10 to 30 minutes after eating affected seafood. Problems can include nausea, vomiting, diarrhea, abdominal pain, and tingling or burning lips, gums, tongue, face, neck, arms, legs, and toes. Later problems may include shortness of breath, dry mouth, a choking feeling, confused or slurred speech, and lack of coordination.

If you think someone has PSP, follow the ﬁve Do This First steps above, then return here for further advice. If the person is conscious and alert, and can speak clearly, have them drink at least 2 glasses of water, each mixed with 3 tablespoons of activated charcoal. Contact the Coast Guard or a physician for further advice.

Fishing-Related Injuries
Fish Hooks
When working around hooks, prevent getting hooked by thinking about your body placement. If someone does get hooked, control bleeding with gentle direct pressure without removing the hook. If the hook is embedded in the eye, ear, nose, joint, bone, or other critical area, stabilize it where it is, and transport the person to a medical facility.

Remove ﬁsh hooks only if they are surface snags or you cannot get to a medical facility within 6 to 12 hours. If you are unsure whether or not to remove a hook, contact a physician or the Coast Guard for medical advice.

If you are going to remove the hook, wash the area and hook with an antiseptic solution such as Betadine™ and then hot, soapy water to lessen the chance of infection. Then numb the area with clean ice, and decide which hook removal method is best.

To remove surface snags, sterilize a razor blade or sharp knife with Betadine™ or heat, then cut through the skin to the barb and remove the hook. If the hook is more deeply imbedded, use the push and cut
method: Use needle-nose pliers to push the barb through the skin, cut the barb off with bolt cutters, and pull the rest of the hook out in the opposite direction.

The ﬂicker method can also be used for small, deeply imbedded hooks. Do not use this method on circle hooks, as they collect too much tissue when removed this way. First, put the hooked body part on a ﬁrm surface and hold the curve of the hook with needle-nose pliers. Then, use your ﬁnger to push down on the shank of the hook to disengage the barb, and quickly pull hard on the pliers.

After the hook is removed, wash the wound with Betadine™, and then hot, soapy water. Bandage the wound to reduce the chance of infection, and contact a physician for further instructions. The person
may need a tetanus shot.

Use the flicker method for removing small, deeply imbedded fish hooks.

Infections from Handling Fish
Infections from handling ﬁsh, sometimes called ﬁsh poisoning, can develop when bacteria from the ﬁsh enter your body through cuts, scrapes, or punctures. Antibiotics such as Keﬂex™ or erythromycin are commonly prescribed for ﬁsh poisoning. Before the ﬁshing season begins, ask your doctor for a prescription for an antibiotic to take along in case you’re a long way from port.

Prevention includes trying to keep your hands and gloves clean and dry, changing or washing out your gloves each day, and washing your hands with Betadine™ and then hot, soapy water at least twice a day.
Swelling and redness at the wound site is common and can increase as the infection spreads. A fever or chills may also develop with a worsening infection.

Wash wounds with Betadine™, and then hot, soapy water as soon as they occur. Then dry and bandage the wounds. If the wound looks infected, soak it for ½ hour in hot, soapy water (as hot as you can stand without burning yourself) at least three times a day. Then dry and bandage the wound.

Some doctors recommend wrapping a wet, room-temperature tea bag around the wound for 10 minutes several times a day. Use regular, not herbal, tea bags. Then dry and bandage the wound. Contact your doctor or the Coast Guard if the infection gets worse or does not clear up in a few days. In very severe cases, surgery may be necessary to drain the pus from the infection.

Fish Punctures
Spine sticks from northern sculpin, ratﬁsh, short spine thornyhead, and a number of rockﬁsh and other spiny ﬁsh can cause a serious infection or death if they are left untreated. Signs and symptoms of ﬁsh punctures can include trouble breathing, a painful cut or puncture, swelling, nausea, vomiting, cramps, and paralysis. Extreme tenderness and a fever are signs of a spreading infection.

Treat all ﬁsh punctures as soon as they happen. Follow the ﬁve Do This First steps above, then return here for further advice. Carefully pull the spine straight out, making sure you get all of it. Be gentle, the spine breaks like glass. Save the spine so a doctor can check it for broken remnants left in the body.

Wash the wound with Betadine™, and then hot, soapy water. Then soak the wound for at least 30 minutes in water as hot as you can stand without burning yourself. Hand or dish soap, or Betadine™ can be added to the water. Bandage the wound and keep it clean and dry.

If swelling or redness occurs, soak the wound at least three times a day in hot, soapy water until the infection clears. Contact a doctor or the Coast Guard if the wound becomes extremely tender or you develop a fever.

Spine punctures from spiny fish can cause serious infection or death if they are not treated.

Jellyﬁsh Stings
Jellyﬁsh stings occur when the stinging cells on the jellyﬁsh’s tentacles touch your skin. For ﬁshermen, this is most likely to occur when pulling line, taking ﬁsh out of nets, or hauling nets. You can prevent most stings by wearing rain gear, gloves, and goggles, and by smearing petroleum jelly on your face before you
begin pulling nets. Make sure your hands are clean before you wipe or rub your eyes.

When the stinging cells hit your skin, they release a poison that can cause a temporary burning pain and a skin rash. In serious cases, the stings may cause difﬁculty breathing, shock, nausea, vomiting, or cramps.
To treat jellyﬁsh stings, follow the ﬁve Do This First steps above, then return here for further advice. If tentacles are in the eyes, rinse eyes with a clean saline solution (or clean water if saline is not available) until the burning stops.

If the tentacles are not in the eyes, pour vinegar on the site to help prevent the stinging cells from ﬁring. Put a baking soda and water paste on the site for 15 minutes, then wash the paste off with saline solution or clean seawater. Put another baking soda and water paste on the site for 5 minutes, then gently scrape the paste off with a knife. Give aspirin or other pain relief medication to help control pain. In severe cases, contact the Coast Guard or a doctor for further advice.

Carpal-Tunnel Syndrome
Carpal-tunnel syndrome is a common afﬂiction, especially among longliners and cannery workers. Tendons are tough, long cords that connect muscles to bone. Any abnormal strain on the tendons can cause chaﬁng and swelling, which creates pressure on the median nerve as it passes through the tight carpal tunnel in the wrist.

You can prevent carpal-tunnel syndrome by doing arm, wrist, and hand exercises before the ﬁshing season opens. Doing stretch exercises to limber up the wrist and ﬁngers before work and after
long closures is also helpful.

Compression of the median nerve can cause a weak grip, clumsiness, numbness, and burning pain, which is often worse at night. Neglected carpal-tunnel problems can lead to permanent damage. Treatment includes resting the injured wrist, wearing a splint at night (and during the day if possible), and taking aspirin or ibuprofen before, during, and after heavy wrist use. Although some physicians think cortisone injections are effective, others believe that they can cause weakness in the affected hand. Surgery may be necessary to open the carpal tunnel in severe cases.

Anatomy of the hand, wrist, and carpal tunnel.

Medial Nerve Position, Tendons, and Tendon Sheaths on the Wrist

Tendonitis
Tendonitis results when a tendon is overworked, and the tendon and the sheath surrounding it become swollen and painful. Fishermen are most likely to experience tendonitis in their wrists, ﬁngers, thumbs, and elbows because of repetitive or hard movements such as pulling pots and lines, and baiting hooks for hours on end.

Many cases of tendonitis can be prevented by taking time to strengthen muscles and tendons in your upper body before the ﬁshing season begins. During the season, try to use smooth rather than jerky motions, and chest and abdominal muscles instead of shoulder or arm muscles. Reduce wrist strain by cutting hard, frozen bait with an ulu, cleaver, or hatchet instead of a regular knife. Periodically switch hands when performing repetitive tasks, and hold lines with the thumb gripping on the same side as the ﬁngers to minimize pressure on the hand. Aspirin or other non-steroid, anti-inﬂammatory drugs can prevent the initial swelling, especially if taken before an opening. Take large doses only under a physician’s direction.

One early sign of tendonitis is swelling, although it does not always occur. Another is squeaking or creaking at the injury site. This creaking can be felt by applying slight pressure at the site while moving the joint. Pain and stiffness in the palm or underside of the ﬁngers or thumb are also common.

Tendonitis is aggravated by hitting or otherwise injuring the area, continuing to use the injured joint, and wearing constricting clothing and wrist bands. Rest is usually required for tendonitis to totally heal. A few treatments may help ﬁshermen who must continue working despite the pain. Reduce swelling by soaking the affected joint(s) in cold water or applying cold packs on the area to help reduce the swelling. Other
people report that hot packs help. Use whichever works for you. Aspirin may help reduce the pain.

Tendonitis is not a permanent condition, although scar tissue may form on injured tendons in severe cases. A serious injury may take several months to return to normal or may require surgery. These are compelling reasons to take steps to prevent tendonitis from occurring.

Helicopter Evacuation

Evacuating patients by helicopter is a hazardous operation for both the patient and the aircraft crew. A small vessel, high masts, conﬁned work area, high seas, gusty winds, and darkness compound the hazard. Evacuations will be attempted only in the event of a serious injury or illness. Gather the following information. The Coast Guard needs it before they can decide how to help:

Vessel name, call sign, position, course, and speed.
Nature and time of injury.
Patient’s name, sex, age, and nationality.
Patient’s pulse rate, breathing rate, blood pressure, and temperature, if known.
Amount of blood loss, other signiﬁcant symptoms, present medication or treatment being given.
Whether you need Coast Guard assistance.
Local wind direction and speed, sea state, and cloud cover.

Then, contact the Coast Guard.

Preparations Prior to Helicopter Arrival
Maintain continuous radio guard on VHF channel 16 or 4125 MHz, or speciﬁed voice frequency. You may receive medical advice, positioning instructions, or be told to head for a rendezvous point. Advise the Coast Guard immediately if there is a change in any previously relayed information, especially changes in the patient’s condition.

The air crew will discuss the most suitable hoist area with you. Pilots and crew generally prefer areas to the stern of the vessel with minimal obstructions. Because rotor wash approaches 100 mph, it is important to secure loose gear, awnings, running rigging, and booms. Keep antennas up to maintain radio contact.

If the hoist is at night, light the pickup area and any obstructions, but do not shine any lights on the helicopter or use a ﬂash camera, they can blind the pilot. Because helicopters are noisy and voice communication will be almost impossible, it is important to prearrange a set of hand signals among the assisting crew.

Change course to permit the ship to ride as easily as possible with the relative wind 30 to 45 degrees off the port bow if the helicopter is working off your stern, which is usually preferred. Find the best speed to ease the ship’s motion but maintain steerage way.

Place a PFD on the patient if their condition permits it, and put information about the patient’s condition in their pocket or some secure place. Make sure it will not be blown away by the rotor wash.

Hoist Operations
If the patient’s condition permits, move them close to the hoist area, but be alert to the dangers of rotor wash. If a litter is required, the Coast Guard will lower one, along with a medic. If you do not have radio contact with the helicopter, signal “Come On” with your hand when you are ready for the hoist operation
to begin. The helicopter will light the area at night.

To avoid static shock, allow the helicopter’s basket or stretcher to touch the deck prior to handling it. If a trail line is dropped by the helicopter, use it to guide the basket or stretcher to the deck. It will not shock you. You may need to pull the rescue device to the vessel. Do not stand on or in front of the line and do not tie it off.

If it is necessary to take the litter away from the hoist point, unhook the hoist cable so the helicopter can haul it in. Do not secure the cable to the vessel or attempt to move the stretcher without unhooking it.

If a basket is used, sit the patient in it, with their hands inside. If a stretcher is used, lay the patient in it face up and strap them in. If cable has been unhooked, signal the helicopter to lower the cable and hook up.

Signal the helicopter hoist operator when ready for the hoist. The patient nods their head if they are able, and deck personnel give thumbs up. If the trail line is attached, use it to steady the stretcher or basket, keeping your feet clear of the line. Do not get between the device and the rail. If time permits, the helicopter crew will retrieve the trail line.

Positioning fishing boat for helicopter evacuation of injured crew. Before rescue helicopter arrives, position your vessel so the wind is 30 to 40 degrees off the port bow.

Before rescue helicopter arrives, position your vessel so the wind is 30 to 40 degrees off the port bow.

Filing a Form

You may be required to ﬁle a form with the Coast Guard when an accident or injury occurs on board your vessel. Check the Resources page to determine when. The information covered in this chapter will help during an emergency, but it is not intended to take the place of ﬁrst aid training, which should be offered to all crewmembers.

First Aid Kit

Stock your ﬁrst aid kit for the type of injuries you are most likely to encounter. The items below are for a basic kit; your physician may suggest including other items.

1" × 3" adhesive bandages
1" and 2" adhesive tape
4" × 4" sterile ﬁrst aid dressings
2" × 10 yards gauze bandages
14" × 14" sterile dressings
Triangular bandages
Aspirin and ibuprofen
Burn dressings
Tweezers
Betadine™
Splinting materials
Saline solution
Needle-nose pliers (for removing hooks)
Razor blades or a sharp knife (for removing ﬁsh hooks)
Matches (for sterilizing razor blades or knives)
Bolt cutters (for removing ﬁsh hooks)
Prescription antibiotics and other needed prescription medications. Be sure your crewmembers are not allergic to them.
First aid book or reference

Anchor 1

Anchor 2

Anchor 3