The Unthinkable

© 2019 Jeffrey E. Isaac, PA-C

Major Trauma Offshore

By Jeffrey Isaac, PA-C

On 18 December 2008 the French sailor Yann Eliès fell on deck fracturing his femur (thigh). This would be a devastating injury under any circumstance, but Eliès was alone in the southern Indian Ocean. Somehow, he managed to get below decks aboard his Vendée Globe 60-foot open Generali and into his berth where he spent the next three days awaiting rescue.

The femur is a major weight-bearing bone. It is richly supplied with blood and surrounded by the largest muscles in the body. It is difficult to break, but doing so renders the victim physically incapable of walking or crawling. Muscle spasm and grinding bone fragments cause intense pain. Blood loss into the fracture site can cause volume shock. Dealing with an injury of this magnitude while alone aboard a racing yacht must have required a superhuman effort.

Nevertheless, Eliès’s survival is not a quite a miracle. He had a lot going for him. He is young and strong. His vessel is equipped with sophisticated communications including a GPS transponder. His position was constantly monitored by the race committee and there was an Australian frigate available to go get him. His safe rescue by competent professionals was the best possible outcome for a worst case scenario.

Eliès must have had something else going for him, too; a survivor’s instinct. He was able to overcome fear, pain, fatigue, and probably some degree of despair. This is a self-selecting prerequisite for anyone willing to drive a giant over-powered racing dinghy around the world. In fact, it is a good addition to the resume of anyone willing to take a small boat offshore.

In his excellent book Deep Survival, Laurence Gonzales points out that only 10 to 20 percent of people can stay calm and think in the midst of a survival emergency. “They are the ones who can perceive their situation clearly; they can plan and take correct action, all of which are key elements of survival. Confronted with a changing environment, they rapidly adapt”. In dealing with major trauma these qualities are more useful than medical skill, equipment, or any amount of medical advice. That’s why cultivating and refining the ability to make the best of a bad situation is core curriculum for any good wilderness and rescue training course.

Nobody likes to contemplate the worst, much less plan for it. There’s a good reason it’s called “the unthinkable”. As soon as you have it figured out, things change. The moment you’ve planned for every contingency, there’s a new one. It is impossible to be completely prepared or totally safe. Any sailor who believes they’ve mitigated all the risk is in for a big surprise.

Risk is a function of both probability and consequence. The probability of Yann Eliès breaking his femur in the southern ocean was a lot less than his chance of doing so at a ski resort in the Alps. But the consequences could have been far worse. The ski patrol would have had him off the slopes in an hour. The frigate took thee days to reach his boat. The risk associated with his injury was vastly magnified by time and distance.

While most sailors readily accept the risks involved in an offshore passage, most also strive to reduce them. Reducing the probability of serious injury is good seamanship. Reducing the consequence is good medicine. Knowing something about both makes a good sailor.

Trauma Management

For practical purposes we can separate major trauma into three categories: The kind that will kill quickly no matter what; the kind that will kill within an hour or so without medical intervention; the kind that is not directly fatal but exposes you to risk of death by hypothermia, dehydration, or infection. Regardless of your level of medical training you can disregard the first category; the cause of death is merely interesting. However, it is the other two that you should prepare for and might be able to do something about.

You don’t need to know a lot of medicine to effectively handle the immediate emergency. Bleeding control, spine protection, airway management and ventilation are all covered in any good first aid course. But, in addition to those basic skills you also need to know how to focus on the problems you can treat and not be distracted by the problems you can’t. Your goal is actually pretty simple; give your patient the best chance of survival under the circumstances you’re in.

Head trauma, one of the most common serious problems aboard small boats, offers a good example. You cannot do anything about brain swelling or intracranial bleeding. But you can protect your patient’s airway from blood and vomit and keep him warm, hydrated, fed, and secure from further injury. Let the brain take care of itself while you focus on everything else. Given a chance, most head trauma patients survive.

Severe bleeding is another example. External bleeding from a lacerated blood vessel in an arm or leg can be stopped with a pressure dressing or even a tourniquet if necessary. Internal bleeding from a ruptured spleen is out of your control. Again, focus on the possible. Keep your patient hydrated, fed, protected and warm and she, too, will probably survive. Most solid organ injury is not directly fatal, but the combination of blood loss and hypothermia is.

A fractured femur or lower leg is rarely fatal. Unless the bones have penetrated the skin there is only so much space available for bleeding, so shock does not progress. The danger is in the disability. The patient cannot run or swim to safety, or find food and water without help.

A leg fracture can be splinted to the other leg for quick extrication. Straighten the leg if necessary then wrap both legs firmly together with padding between them. A femur can actually be splinted this way for a long time. A lower leg will need additional splinting to include the ankle. As long as there is good blood flow all the way to the toes the patient can endure a days-long evacuation if you pay attention to pain control and the basic body needs. You don’t need to worry about putting the bones back exactly where they belong. The orthopedist can do that tomorrow or next week.

Preparing for major trauma includes practicing some techniques for quickly moving a casualty from the deck or water to the berth or cockpit. For the short handed crew this will be quite a challenge. You should be able to control bleeding and splint extremities, but you may have to modify or abandon the meticulous spine immobilization procedures you learned in your first aid course. Falling overboard or becoming hypothermic may represent the greater threat. A detailed plan is unnecessary, and even undesirable. A good set of rigging skills and the ability to adapt them to a variety of situations will be much more valuable.

Be sure to have your life saving tools easily accessible. Aboard Generali. Eliès was incapacitated by pain and unable to reach the pain medication in his medical kit. Dee Caffari, sailing Aviva, made the comment that she would have had a similar problem. “These kits are heavy and they have to go somewhere – you can’t just leave them lying around. Mine is stacked on the shelf but it is not easy to get to.”

A comprehensive medical kit, like a life raft, is just expensive ballast if you and your crew can’t find it. Consider breaking it up into smaller kits that can be stowed where they’re needed. In doing this, remember that a short handed crew will not just be dealing with a medical emergency; they will be trying to manage a boat underway at the same time.

Keep a basic trauma module just inside the companionway. This should include a pair of protective gloves, a pressure dressing and tourniquet for bleeding, a splint and wrap for injured extremities, and a pocket mask or Numask for rescue breathing. It should also include a couple of extrication straps (long sail ties will do) and a stiff cervical collar to help you move your patient to safety.

Pain medication should also be easily accessible. Pain control is an emergency medical procedure, especially in the short handed survival situation. If pain is not controlled the patient will not be able to protect himself, eat, drink or effectively communicate. Pain is the most common and treatable cause of respiratory distress in chest and abdominal trauma.

The fear that pain medication will mask symptoms and allow a patient to injure himself further is unfounded. Any patient who is awake and able to move around will feel pain and modify activity accordingly. A dose of medication sufficient to mask all pain will put the patient to sleep. Unless you have plenty of crew to monitor him, drugging your patient into coma is not a good idea.

In a serious situation we want an injured person awake and talking, but feeling better and breathing easier. Use narcotics if you have to, but medicate with the lowest effective dose. When you call from the cockpit to see how things are going down below, you want an answer. The more the patient can care for himself, the more you will be able to focus on the overall management of the emergency and the vessel.

A reasonable choice for severe pain initially is the opioid fentanyl. It can be given by nasal atomizer, no injection necessary. Fentanyl is short acting; the effects will usually be gone within an hour. This gives you enough time to splint and move an injured crewmember to a safe and more comfortable location aboard, but not create a long term management issue if the dose has more of a seditive effect than you wanted.    

Another useful drug is a broad spectrum antibiotic. While use of antibiotics to prevent infection in high-risk wounds is controversial in the civilized setting, you need all the help you can get when you’re far offshore. The sooner antibiotics are administered, the better they will work.

For long term survival you will need to manage the “ins and outs”. This means providing fluid, electrolytes, and calories. If the patient can eat and drink, you’re all set. If not, you will need to start an intravenous or subcutaneous fluid drip or try to rehydrate rectally. Managing output may require using a urinary catheter for a disabled patient and managing defecation with an incontinence diaper. This is the part of trauma management that goes beyond first aid, and illustrates other skills and materials that you should consider acquiring.

Ashore, prehospital trauma protocols often require that patient be immobilized on a backboard or vacuum mattress to reduce the chance of exacerbating a spine injury. However, the risk/benefit ratio for this practice does not translate well to the small boat setting. In 2006, a woman drowned when the rescue boat to which she was secured on a backboard capsized in the Connecticut River. Her original injuries were minor.

Blind obedience to conventional protocol can kill people in the unconventional setting. Remember, you are not practicing medicine in an ambulance or emergency department. Your boat is a high risk environment where a lot more can go wrong. Your problem list includes maritime hazards as well as the medical problem. Even a partially disabled patient will have a much better chance of survival with some freedom of movement. Usually a well padded berth with a lee cloth is perfectly adequate protection and stability.

The ultimate goal, of course, is getting a severely injured crewmember safely off the boat and into a hospital, preferably before the diaper becomes necessary. But beware of the rush to evacuate. In contrast to Yann Eliès’s situation, some rescue efforts may not actually improve the casualty’s chance of survival. With several crewmembers aboard the typical voyaging sailboat the risk/benefit of evacuation can be more carefully weighed against the risk/benefit of staying on board. Exercising this judgment is where good seamanship and good medicine really come together.

Instead of an Australian frigate in fair conditions, your rescuer may be a tramp steamer wallowing in 20 foot seas or a helicopter trying to lower a basket in 60 knot gusts. It would be deeply disappointing to have worked so hard to keep your patient alive only to see her drown in the rescue effort, or later for lack of appropriate care. Your patient might have a better chance of survival if you sailed her into port yourself, even if it takes five days. You should gear your training, equipment, supplies and attitude toward that possibility.

Certainly, the chance is remote that you will ever deal with a situation as difficult as Yann Eliès’s fractured femur in the southern ocean. You are unlikely to ever need the survival skills and temperament described by Laurence Gonzales. If you do, it would be nice to have given it more than a passing thought in preparation. Eliès’s crisis and its happy ending is powerful motivation for rethinking the unthinkable.

Recommended Reading:

Deep Survival: Who Lives, Who Dies, and Why. Laurence Gonzales. Norton 2003.

Wilderness and Rescue Medicine 7th Edition: Jeffrey E. Isaac, PA-C and David E. Johnson, MD. Wilderness Medical Associates 2019.