Imca Drills

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First Aid and

Other Emergency Drills

IMCA C 013

April 2009

International Marine

Contractors Association

www.imca-int.com

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The International Marine Contractors Association

(IMCA) is the international trade association

representing offshore, marine and underwater

engineering companies.

IMCA promotes improvements in quality, health, safety, environmental and technical standards through the publication of information notes, codes of practice and by other appropriate means.

Members are self-regulating through the adoption of IMCA guidelines as appropriate. They commit to act as responsible members by following relevant guidelines and being willing to be audited against compliance with them by their clients.

There are two core activities that relate to all members:

 Competence & Training

 Safety, Environment & Legislation

The Association is organised through four distinct divisions, each covering a specific area of members’ interests: Diving, Marine, Offshore Survey, Remote Systems & ROV.

There are also five regional sections which facilitate work on issues affecting members in their local geographic area – Asia-Pacific, Central & North America, Europe & Africa, Middle East & India and South America.

IMCA C 013

These drills were prepared for IMCA, under the direction of its Competence & Training Committee, by Abermed Ltd.

A spreadsheet is available for downloading by IMCA members or on request from [email protected] for recording completed first aid and other emergency drills in line with this guidance.

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First Aid and Other Emergency Drills

IMCA C 013 – April 2009

Foreword ... 1

Introduction ... 1

1 General Scenarios ... 2

2 Saturation Diving Scenarios ... 23

3 Air Diving Scenarios ... 43

4 Engine Room Scenarios ... 53

5 Machinery Spaces Scenarios ... 56

6 Galley Scenarios ... 58

7 Helideck Scenarios ... 62

8 ROV Spread Scenarios ... 65

9 Pipelay Scenarios ... 66

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IMCA C 013 1

Foreword

A well trained workforce is the backbone of a successful business; procedures, working routines and standard operating processes all ensure that a company’s work is undertaken in a correct manner but these all require a competent workforce to perform to the required standard.

In the armed forces there is a huge emphasis on training which has underlined the saying ‘the more you sweat in peacetime the less you’ll bleed in wartime’. We can apply that to our industry by altering a few words to ‘the more you sweat in preparations the less you’ll bleed in operations’.

The provision of training can represent a significant cost element for a company and shore-based training needs to be complemented by appropriate levels of on-the-job training in order to ensure that the skills gained in the traditional classroom training courses are refined and applied to good effect on-the-job.

This document has been produced to ensure the standard by which first aid drills are undertaken as part of on-the-job training follows current medical and triage*_{guidelines. It also serves to provide credible scenarios by}

which all personnel – not just appointed first aiders – can participate in drills that are appropriate to the workplace. These drills involve all departments on a typical IMCA member’s vessel – on deck, in the engine room, accommodation and within a diving operation. Each scenario is described so that the person responsible for running the drill can set it up correctly. The work party involved then undertakes the drill and a model solution is provided by which the performance of those involved may be judged. This can form the basis of the feedback session during the drill debrief session.

It is intended that this document will be reviewed regularly and other drills will be added or the solutions will be updated if medical practice alters in any way. Likewise each IMCA member may alter the scenarios to suit their particular vessel or worksite needs. It is advisable to involve the member’s occupational health advisers in this programme to ensure the maximum benefit is realised and to maintain compliance with medical guidelines. It is envisaged that members may wish to add scenarios to this document in order to share best practice or to improve the practical aspects of the document. Any member who wishes to add scenarios to this document should forward them to the IMCA secretariat for inclusion in future versions of the document.

John Greensmyth Chairman, IMCA Training, Certification & Personnel Competence (TCPC) Core Committee – Sept 2002-Feb 2009

Introduction

This document has been produced by IMCA to assist with the ongoing competence of first aid personnel onboard vessels. This is not a guidance document; it sets out a range of first aid and other emergency drills which members can use onboard their vessels as part of on-the-job training.

The drills cover a number of different scenarios encompassing a range of activities on a vessel.

Each drill has been written in a way that it evolves. Drill participants are provided with updated information on a real-time basis and the drills set out how they are expected to react.

The drills are designed to provide the reader with a number of pieces of information. Each of them is educational in its own right on the challenges of accidents and medical issues in an offshore environment. These may prompt the reader to look at developing or updating company procedures.

The medical solutions put forward are quite detailed. The drills can be modified to suit particular vessels or worksite needs and the depth of realism expected during the exercise.

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1.1 Scenario 1

A man is found collapsed on the bridge. He is not moving and appears to be not breathing. It is lunchtime on the vessel and the medic is in the canteen, as is the master.

How do you proceed?

He is then successfully resuscitated and is now in the sickbay. He needs to be evacuated. How is this co-ordinated? Can he be successfully transferred to the helipad? Who communicates with the relatives?

The collapsed man is the radio operator. How do you proceed?

Essentials:

i) ABC (airway, breathing, circulation). These are all part of basic life support. This man is not breathing, so needs his airway opened and possibly mouth-to-mouth respiration until the medic can be found and equipment located. This is made less unpleasant by the provision of pop-up face masks, which are inexpensive.

ii) Watch for the neck – this may have been damaged in any fall.

iii) The medic should then check ‘D’ (disability) – i.e. any neurological problems, and ‘E’ (exposure) which is to look for injuries.

You may also wish to consider:

The next problem is contacting emergency medical support and arranging evacuation, particularly if the man is the radio operator and the medic is involved in keeping him stable. Is there anyone else who can operate the radio to call for help?

Thereafter, he needs to be evacuated from the sickbay to the helideck: can this be done whilst monitoring the patient and without causing injury to them?

Who is accompanying the patient to the beach? He needs transferring to hospital – how will this be expedited?

The man is likely to have relatives who will need to be told. Who will tell them, how will they do it and what will they say?

There is likely to be a press response: who will speak to the press? What will they say? It is also important to tell the rest of the crew not to communicate with the press so that a correct version of events, rather than hearsay, goes to the press.

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IMCA C 013 3 1.2 Scenario 2

In heavy seas, a crew member trips and falls down the stairs inside the vessel. He has hurt his arm, which appears to be deformed. How do you proceed?

He now tells you that he has hurt his head as well and seems a little confused. He declines any treatment.

How do you proceed?

The crew member is the captain. How do you proceed?

Essentials:

This is quite common, in that the more obvious injury is treated first and then the more subtle one may come to light later. The medic should ask about other injuries at the same time as the initial history-taking about the arm. The arm needs stabilised in some way, preferably by splinting. It is vital for circulation to be checked, as if it is compromised then it is an even greater emergency. The man needs to be evacuated.

Regarding the head injury, he may well have internal injuries and his airway and level of consciousness need to be checked and monitored regularly. Are there charts to document this?

The patient needs evacuating urgently and transferred to hospital. How will this be expedited? You may also wish to consider:

Given that he is the captain, how will the vessel continue to operate?

Thereafter, he needs to be evacuated from the sickbay to the helideck: can this be done whilst monitoring the patient and without causing him injury?

Who is accompanying the patient to the beach?

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The medic appears to be behaving strangely. He seems very animated, agitated and with a short temper. He does not respond to your questions and seems to be talking to himself.

Essentials:

This is a difficult matter, as the medic is of course the best person to assess this situation!

It would be important for the master to know of the situation, and if the vessel is working for a client it may be simplest to arrange for their medic to make an assessment of the vessel medic. The medic should be taken off his duties meantime and should hand over the keys to the sickbay. Are there sufficient first aiders to cope with medical problems? The emergency medical support should be informed and arrangements made to evacuate the medic, replacing him with another medic.

Who is accompanying the patient to the beach?

The medic will need to be formally assessed, at least by the emergency medical support doctor and perhaps by psychiatrists: how will this be arranged?

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IMCA C 013 5 1.4 Scenario 4

The master appears very anxious and ‘not himself’. There is no obvious reason for this.

Essentials:

This is a sensitive issue, and in the first instance the medic should be involved and discussions should centre on the possible causes of the problem and how to quickly rectify it.

Command of the vessel should be assumed by another member of crew and speaking to shore management is essential.

If the captain is unwell then he needs to be evacuated. He will need to be formally assessed by emergency medical support and perhaps by psychiatrists: how will this be arranged?

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A crew member has just received some very bad news: his partner of some years has told him over the phone that she is leaving him. He is unable to concentrate on the job and seems at a loss for words.

Essentials:

He must be taken off his work in the short term whilst an assessment can be made. This is best discussed with his supervisor. He should see the medic, who will perform an assessment of him and is likely to discuss the matter with the company’s emergency medical support.

Given that he is of little use workwise whilst in that state the company may consider compassionate evacuation. If this is not planned, then a very careful assessment of his concentration needs to be made and of his continuing ability to work: if this is compromised then his safety may be at risk.

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IMCA C 013 7 1.6 Scenario 6

The electrician is doing some work in the laundry behind one of the tumble dryers when he gives a sudden cry and then is unresponsive. His upper body and some of his tools are behind the tumble dryer.

Essentials:

The clues are in the history. He is an electrician, so he was in the laundry fixing something electrical. He has probably electrocuted himself. Given all the metalwork, it will be really dangerous to approach him right away, no matter how tempting it is.

First get help and shut off the power to that room and call the medic. Then check ABC (airway, breathing, circulation). This may be difficult as he is part behind the tumble dryer. Be careful of his body and the tools strewn behind the dryer to avoid injuries.

Once out, check his ABC. Hopefully by then the medic will be in attendance and can take over. You may also wish to consider:

This man, if successfully resuscitated, will need monitoring in hospital for cardiac rhythm problems. He will need urgent evacuation. He may also have suffered entry and exit burns from the electricity.

Another electrician will need to look at the tumble dryer, hopefully to mend it but certainly to make it safe. Thereafter, he needs to be evacuated from the sickbay to the helideck: can this be done whilst monitoring the patient and without causing injury to them?

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A crew member is noted to be ‘high’ and louder than usual. One of his colleagues thinks he might smell alcohol on his breath. He denies this.

Essentials:

He should be taken out of the workplace immediately and confronted with this information. The workplace is not a safe place for him to be.

Depending on what is in the drugs and alcohol policy he should be tested and if intoxicated then he should be dealt with according to the policy.

Does the company have a robust drugs and alcohol policy?

Is testing performed in a proper manner that would stand up to legal scrutiny?

The ability to smell alcohol is very variable. If no alcohol/drugs are found then it is possible that the individual has a mental health problem: in this case a negative test may not be carte blanche to allow him back to work.

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IMCA C 013 9 1.8 Scenario 8

The human resources (HR) department contacts the vessel: there is reason to believe that a crew member’s medical certification has been falsified. The crew member denies this vehemently. How do you proceed?

Essentials:

This is uncommon but easily possible now with developments in scanning and printing technology. The crew member should be stopped from working in the meantime whilst the issuer of the medical certificate is contacted to confirm the situation. The contact details should be on the medical certificate.

Although details about the medical certificate can be ascertained from the medical centre, it is inappropriate to request details of any medical conditions: this puts the medical centre in a difficult situation as regards medical confidentiality.

The HR department is likely to become involved in this at an early stage and will likely discuss it in depth with the company medical adviser.

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The human resources (HR) department informs you that the company medical adviser has discovered new information about a crew member which would invalidate their medical certification. How do you proceed?

Essentials:

This individual should be removed from work. This is a difficult situation but if their medical certification is invalidated then they are unfit to be offshore. They should be returned to the beach forthwith.

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IMCA C 013 11 1.10 Scenario 10

There is a major incident on the vessel: three crew members appear to be dead, with fatal head and facial injuries. They are all foreign nationals. A number of other members of crew are clearly upset and traumatised by events. The client representative and master of the vessel are shouting at each other on the bridge and appear to be almost coming to blows as part of a violent disagreement. The radio operator has called for help and a helicopter is in the air.

Essentials:

Major multiple trauma needs dealing with in a different manner from other trauma. The medic and first aiders must assume a different style of management. The casualties must be assessed rapidly according to a number of different measures.

i) Open the airway. If they are not breathing, they are dead. Move on to the next casualty.

ii) Find those who are viable – i.e. breathing. Go to those who are not moving or complaining and assess those first.

iii) Then move on to the more vocal.

Trauma triage can be performed rapidly in this manner and people are triaged according to their vital signs. A good method is the Cruciform card system.

The medic will then co-ordinate events in conjunction with the first aiders.

Given possible time delays with getting another helicopter out with doctors onboard, it may be most efficient to get any sick casualties on the helicopter with first aid support and fly straight to hospital, rather than waiting for a second helicopter.

Does the vessel have a multiple trauma plan? Is there a multiple trauma system in place?

Is there a triage area within the vessel? Such areas should be sufficiently large and contain first aid equipment for first aiders, as well as diagnostic equipment. There should also be a board for detailing the injured. The triage area should be as close to the sickbay as possible: very unwell people would be treated in the sickbay, less unwell in the triage area before being moved out to other rooms nearby. A nearby room should also be designated a mortuary.

Are there sufficient qualified first aiders present? Is there a scribe who can keep a log of events and details of the injured/dead? Is the human resources (HR) protocol satisfactory? They are all foreign nationals, how are the relatives contacted?

Have drills been carried out on the vessel but also in conjunction with the other support services – e.g. emergency medical support, coastguard/helicopter companies/HR/contractors/etc?

Do stretcher-bearers know the vessel? Can they lift loaded stretchers from the sickbay or triage area to the helideck? Can the first aiders cope if the medic is themselves injured, or completely occupied in the treatment of very sick people? What would happen if the helideck was out of commission?

What post-incident support do workers have? There is good evidence that a forced debriefing is not beneficial and can even be harmful. However, the offer of psychological support is often very helpful in itself.

Thereafter, they need to be evacuated from the sickbay to the helideck: can this be done whilst monitoring the patient and without causing injury to them? Who is accompanying the crew members to the beach? They need transferring to hospital – how will this be expedited?

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An individual has cough and a fever. He has just come from mainland China.

Essentials:

This is a difficult issue. Many people can suffer from these symptoms but there is the rare possibility of avian flu. If this is the case then it is possible that they could be infectious to the rest of the crew. The difficulty is one of separating what are very common symptoms from those that might be lethal.

It is difficult to pass it on from bird to human and people who have close contact with infected birds are the ones who are most at risk. At the time of writing, there is little chance at all of it passing from person to person in its current form: however, if it mutates then that might be possible. A vaccine is still being developed. Another possibility might be tuberculosis which can be contagious in the open form and needs urgent treatment.

The best advice is to isolate the individual and then contact the emergency medical support for the most up to date information. Other sources of information are the World Health Organization website (www.who.org) and the Centers for Disease Control and Prevention (CDC) website (www.cdc.gov). Emergency medical support will be able to advise on the risk and on further treatment.

This is probably more of a public relations (PR) than a medical problem: the crew will be very concerned. The master and the company should consider liaising with medical adviser to advise on the level of risk and then issue advice.

An important element of response to either problem is to isolate the patient and then to make sure that a list of the contacts is created: initially the close contacts, e.g. the ones who share a cabin with the crew member and those who share a workspace with them, and then more distant contacts, which would comprise the rest of the crew. This sort of information is vital and invaluable to public health doctors and the company medical advisers who would be taking the matter further in the wider context.

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IMCA C 013 13 1.12 Scenario 12

A life support supervisor (LSS) falls down the stairs into sat control. He is unconscious and is lying at an unusual angle.

Essentials:

ABC (airway, breathing, circulation). Don’t forget neck/spinal injuries!

The man should be recovered (carefully) to the sickbay on a spine board and then assessed by the medic for any neurological problems. A good neurological method for recording the conscious state of the patient – the Glasgow Coma Scale (GCS) or similar – should be used. Thereafter the man should be examined for any other injuries.

The emergency medical support should be contacted urgently. This individual needs evacuated to hospital for definitive treatment.

This man’s work will need to be taken over by another member of staff. Do you have sufficient crew to enable this?

Thereafter, they need to be evacuated from the sickbay to the helideck: can this be done whilst monitoring the patient and without causing injury to them?

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The sickbay has been broken into, and some drugs may have been taken. How do you proceed?

Essentials:

The area must be sealed off and drugs accounted for: it would be important to start with the controlled drugs and other drugs of abuse. It is possible that if these have been consumed that individuals may now be under the influence of drugs and constitute a safety risk. Another possibility is attempted suicide and this should be considered as well.

The medic should be aware of the potential risk to health in an individual who has taken drugs.

This is also quite clearly a criminal matter and the police should be informed immediately: they will be able to give advice on how to proceed.

How accurate is the vessel’s stock record? Is it likely to pick up missing medication?

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IMCA C 013 15 1.14 Scenario 14

There has been an outbreak of gastroenteritis on the vessel. One man was affected three days ago and now six others have come to the medic complaining of vomiting and diarrhoea. Several members of crew are becoming alarmed. There is a routine crew change tomorrow by helicopter.

How do you proceed?

Essentials:

These individuals should be isolated. The most common cause of infectious diarrhoea is viral. One of the most common of these are the noroviruses, which can be passed on by faecal-oral spread, by contamination (such as cutlery) or by aerosol from vomiting.

The isolated individuals should not share a cabin with an unaffected individual, as they will surely become infected.

Most of these infections will subside after 24-48 hours. Thereafter the individual may well continue to be infectious for 48 hours after the symptoms have stopped. Thereafter they can go back to work.

The galley needs to be deep-cleaned, as do their cabins after they are well.

Of VITAL importance is to ascertain that there are no caterers involved: before they return to work stool sampling should be undertaken to make sure that they have fully recovered.

The difficult issue is what to do in the next few days: exposing new workers coming in on the next helicopter runs the risk of them getting it too. It may be worth sitting tight and letting the cleaning and isolation do their job before introducing new crew into the equation.

An equally difficult issue is management of the rest of the crew and their relatives. There may also be a press response, which will need management.

Given past experience, there is likely to be a press response: who will speak to the press? What will they say? It is also important to tell the rest of the crew not to communicate with the press so that a correct version of events, rather than hearsay, goes to the press.

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A man who has been on the vessel for one month goes home on shore leave. He has had a persistent cough for six weeks. He telephones the vessel after seeing his own doctor. He has been told that he has tuberculosis (TB) infection. How do you proceed?

Prior to working on the vessel he was on a training course with 30 other people for a day at a hotel. How do you proceed?

Essentials:

Tuberculosis is becoming an increasing problem. For the purposes of this discussion, TB management falls into two basic types, dependent on the type of TB – open or closed. Closed TB is when the individual is infected with TB and is unwell with it but not infectious. This individual needs to be treated by his specialist for the condition and will be unfit for a relatively short period whilst this is going on.

Open TB is altogether a different problem. Open TB is diagnosed when the individual is coughing up spit (or ‘sputum’) in which are TB bacteria. It can take a few weeks for the TB bacteria to grow in a lab culture of this spit and so the individual should stay off work until this is confirmed or refuted. Sputum containing TB bacteria is infectious and the individual will need treatment, during which time they will be off work. Treatment can take several months. If they are still infectious after that then they can be off even longer. Contacts will also need to be screened. (For example, the current view on land in the UK is that individuals who are infectious should have their household contacts screened first. This means that Public Health will contact them and arrange X-rays for them in about 6-8 weeks. If any of these are infected, then the net is cast wider and less intimate contacts are then contacted and screened.)

On an oil rig or vessel, then the people with whom the individual works and lives with for half their life are considered close contacts and so it is they who are contacted and screened in the same manner. If any of them are infected, then they would be treated. With offshore this can become a huge logistic issue. This is made easier by the fact that oil installations keep a close watch on their persons onboard (POB) and have multiple lists from which to draw information.

In the first instance it is better to issue a statement for the crew, in conjunction with the medical adviser, to the people with whom he shared a vessel and let them know of the situation and the possible need for testing at a later date. This should preserve the individual’s confidentiality. Thereafter there is no further action until more information is obtained over the next few weeks from the patient’s doctors, and the company’s energies are best directed at making up a list of those likely to have been in close contact (i.e. working with them on the vessel).

As regards the training course, this is a red herring. It would be extremely unlikely for an individual to be able to pass on TB in that length of time. However, should they prove to be infectious and other crew members are infected too, then it may be that further screening is warranted: in this case keeping details of who was on the course are prudent.

This is almost certainly going to hit the press and it would be prudent to have public statements ready. Crew should be advised to direct any queries from the press to the press officer for the company.

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IMCA C 013 17 1.16 Scenario 16

A man has been found dead in bed in his cabin. There are no obvious signs of what has happened to him.

Essentials:

ABC (airway, breathing, circulation) initially and call the medic immediately.

If it is clear that the man has been dead for some time then resuscitation need not be attempted: however, otherwise it should be.

If the medic is able to confirm death, then he should and inform the emergency medical support. The police will also need to be informed and will take on the matter themselves. The area must be kept secure for their investigations.

The rest of the crew will of course be affected by this and pastoral support should be offered. This can be through the company or their medical advisory support.

Informing the relatives must be done sensitively: this may well be a task for the police or for a joint effort with police and human resources (HR) department.

A press statement should be carefully worded and released. The crew should be advised to redirect any queries back to the public relations (PR) representatives of the company and not try to answer questions themselves.

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A welder has noticed a pain in his eye and is in a lot of pain. He has managed to switch off the equipment but is still on deck.

Essentials:

The medic should be informed. The welder should try eyewash solution initially.

It is likely that this man has suffered from either a foreign body in the eye (mostly when fettling/grinding and likely to be metal fragment) or arc eye.

It is possible for foreign bodies to enter the eye even if safety glasses are worn, so this must be considered. If this is a possibility they need to go to an accident and emergency department for testing with specialist equipment as metal fragments can produce permanent rust rings in the eye, affecting vision.

If arc eye is suspected, then the welder will experience severe pain and may need guiding to the medic. The medic has been trained in eye examination and can apply fluorescein to look for foreign bodies under a blue light – they show up green. If arc eye is suspected then the individual is likely to need their eye patched, for approximately 24-36 hours. They also receive antibiotic ointment, which also serves to act as a lubricant for the eye. Arc eye is ultraviolet damage to the eye and if uncomplicated can recover rapidly.

Are working areas well stocked with eyewash solution? Are they in date and the seals intact? Is there a system to check this? On occasion, particularly in hot countries, eyewash bottles have been tampered with in an attempt to drink the contents (in fact the contents are quite often saline – salty water – so can taste disgusting!).

If the welder has suffered arc eye, how did this happen? It is difficult for this to happen if they were wearing their welding goggles, so to prevent recurrence (in other people: it tends to be a formative experience for the sufferer!) it should be investigated.

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IMCA C 013 19 1.18 Scenario 18

A caterer slips on the bottom step of the galley store. They are in some pain and having some difficulty in weight-bearing.

Essentials:

This may be a broken ankle. The medic should be summoned and will want to examine the caterer back at the sickbay, thereafter bandaging it as necessary.

There are certain criteria which ‘earn’ an X-ray of the area, including inability to weight-bear immediately and tenderness in some areas around the ankle: these may indicate a greater likelihood of a broken bone. If this is the case, then the individual should be evacuated for X-ray. Thereafter what happens to them depends on how they are: if mobile and no swelling or pain, then they can go back to work – if pain or swelling they will need support bandaging and may perhaps not be able to go back to work.

Are there any measures that increased the risk of the slip? Check the layout of the steps and the surface quality. Is there spillage of anything that might make the step slippery? Is the caterer’s footwear up to the job?

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A crew member returns to the vessel after a night out on the town. He has bruising to his face and is limping. He cannot give a coherent explanation as to how he came by his injuries and is vague. He smells of alcohol.

Essentials:

There are a number of issues here – alcohol, medical (from injuries) and possibly criminal.

The captain may wish to check out the breath alcohol. The medic should see the man as well: he may well have injuries that are not initially obvious: the fact that he has facial bruising and is incoherent may mean that he has a significant head injury. This might mean a trip to the local accident and emergency department. However, he may be merely drunk or being evasive. There may be a need for further monitoring of the man overnight to ensure that he is not worsening.

Do you have a robust drugs and alcohol policy and procedures? Does it allow for ‘with cause’ testing? Are crew aware of this? Is the tester trained and proficient in the testing process?

The criminal element is one to consider: is there a possibility of assault (either to the crew member or by them). Careful notes should be taken, particularly by the medic of any injuries in case of possible ensuing litigation. Never underestimate the power or usefulness of contemporary notes!

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IMCA C 013 21 1.20 Scenario 20

A crew member has been onboard for three weeks when he develops a high temperature, shivering and shaking and feeling generally unwell. He has had to travel through West Africa to reach the vessel.

Essentials:

This may well be malaria and urgent assistance should be sought from the emergency medical support by the medic. Thereafter they will risk-assess the likelihood of this being the cause. There are a number of other causes of this, general infections of other origins being one. The malaria test cards can help in the diagnosis. If they are suffering from malaria, then instituting treatment as recommended by emergency medical support is necessary, and evacuation should be arranged: the emergency medical support will help with this and the patient should be directed to an infectious diseases specialist. Malaria should be suspected in an individual up to one year after travel to an infectious area.

Some employers provide a letter to each employee to carry with them: it will help their own doctors (or any doctors they might meet) to include malaria as a possibility should they become unwell.

Employees should always take antimalarials as recommended by their travel medicine specialists. Does your company ensure that individuals are taking them and using other measures to reduce the risk of malaria? Does your company carry drugs for treatment of malaria and the instant test cards?

It is possible that there may be a press response: who will speak to the press? What will they say? It is also important to tell the rest of the crew not to communicate with the press so that a correct version of events, rather than hearsay, goes to the press.

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A painter is spray-painting on deck. It is his first day on the job. He is concerned that the spray paint compressor is not working, so he sprays it on to the tip of his glove. It is immediately painful. He takes off his glove but can only see a pin-prick wound on the tip of his finger, so carries on working. However, when he stops for a cup of tea his finger looks a bit swollen and his hand is also throbbing.

Essentials:

This is a really easy accident to have, particularly in a junior member of staff, and is a classic preventable incident. He may well have a high pressure injection injury: the spray guns work to high pressure and the entry wound can be really small. However the volume of substance injected can be surprisingly large. The injected liquid then tracks down between the tissue planes or layers, down the finger and into the hand. It could even go up the arm. It needs surgery, to open up and ‘explore’ the finger and possibly the hand, with a view to washing it out. The assessment of the need for surgery needs to be done urgently by a specialist, so the man will need evacuation. The paint (or other substance depending on the job – another common one is mineral oil) can be very corrosive and end up with internal scarring and loss of function of the hand.

This is clearly an education issue if a deliberate act. How well are the staff trained in preventing such an accident?

Occasionally it can also occur with equipment failure: This has occurred on land with a high pressure water jet used for cleaning of naturally occurring radioactive material (NORM): the individual needed an operation (done in a special operating theatre) and Geiger counters were used to make sure that there was no radioactive material left in the individual’s arm afterwards. That was due to faulty equipment. How often is the equipment checked? Do staff know how to connect it safely?

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IMCA C 013 23

2 Saturation Diving Scenarios

2.1 Scenario 1

A diver is working on clearing an area of debris on the seabed at 130m. The debris partly consists of fishing nets, including buoys. The diver decides to puncture a buoy with a hammer and chisel. The buoy is still at 1 atmosphere and implodes, pulling the diver’s hand into the implosion. His arm is now very sore and his watch was wrenched off in the implosion. The other diver was not close enough to become injured in the implosion.

However, their hats begin to fill up with water.

Both he and the other diver are stunned by the implosion and only wake up when water begins to cover their mouths. They are at some distance from the bell.

The implosion was heard by the diver in the bell, who now starts to get ready for a recovery effort.

Essentials:

The important first step is recovery to the bell. If the divers are sufficiently alert they will be able to turn on their free-flow valves and head for the bell themselves: otherwise it might be the bellman who has that task to do. Recovery to the bell of one diver is exhausting: two will be more than doubly so. If the divers are still not competent, can the bellman recover an unconscious diver back into the bell? Is there equipment within the bell to help with this? Is there sufficient space within the bell for two unconscious or semi-conscious divers? Is there resuscitation equipment within the bell to resuscitate one or two divers? Is there sufficient room to resuscitate a diver? In addition, the bellman may have a difficult decision to make between the two divers as to which one to resuscitate. As a rule of thumb, the more viable diver is the one who should be resuscitated with the limited resources available. First step – open the airway. If there is no breathing, then move on to the next casualty. If neither is breathing, then check a pulse: if one has a pulse, but is not breathing then the bellman should concentrate on that one.

Once back in the boat, how easy is it to transfer an unconscious diver from bell to chamber? Thereafter there will be more help available from the other divers and also some input from the medic, who can at the least peer through the windows and give advice, or perhaps even go into the chamber itself to assist.

What facilities exist for psychological support for the divers or other crew members? There is good evidence that forced debriefing is detrimental, but the offer of support has been found to be useful and can prevent or reduce the risk of long-term absence.

(28)

A diver has stomach pain and is feeling unwell. He is at 100msw in saturation. He starts to vomit and is unable to keep anything down.

At this stage this could be a number of different things. It is obviously impossible to isolate him: this is what would ideally be done were he on the surface. As it is possible that he has gastroenteritis, strict hygiene should be exercised.

There is a high likelihood of him becoming dehydrated as the chamber is warm.

The medic should be contacted and should give advice to the diver medics within, who will be able to examine the sick diver and feed back this information to the medic, who should discuss with the diving medical support doctor. If he is unwell he will need to start decompression and will need an intravenous drip.

You may wish to consider:

Does the dive spread have monitoring equipment?

Are the divers proficient in administering treatment of this type, including putting in drips, administering intramuscular pain relief, etc?

(29)

IMCA C 013 25 2.3 Scenario 3

A diver crushes his hand in machinery on the seabed, at 100msw. He is clearly in a lot of pain and is still on the seabed.

The first action is to extricate the diver with the minimum of further damage to the hand. Once he is recovered to the bell, an examination should be undertaken to ascertain the damage to the hand. An essential part of that is to check the blood flow to the fingers to make sure it is not compromised – do this by pressing gently on the fingertip until it goes white: the colour should return in less than two seconds. As the nerves run up the sides of the fingers, these can become damaged too – so check by rubbing the tips and comparing sensation with any undamaged fingers.

Once back in the chamber, the diver medic should look at the injuries to assess them and relay to the beach to diving medical support, who will give advice. The injury should be dressed and splinted as best as possible and, if the skin is broken, antibiotics should be started. The hand will need checked periodically: particularly to make sure that the dressings are not too tight: therefore sensation and circulation should be checked.

The diver will need pain relief: ideally orally but intramuscular if necessary. The diver will need decompression and probably surgical review as soon as possible.

(30)

A diver nips his finger tip closing the chamber door. The skin is broken but there don’t appear to be any broken bones.

This will need to be assessed on a case-by-case basis. Without casting aspersions on the occupants or their cleaning regime, saturation chambers are dirty places. There is little ventilation, it is hot and humid and there is a relatively high oxygen concentration, which means that bacteria which are widespread in the environment but normally harmless can cause problems. It is normally a good idea to have a low threshold for starting antibiotics.

Under these circumstances it is best discussed with the diver medic and emergency medical support for advice. In addition a decision needs to be made about future fitness to dive on this period of saturation.

Is there sufficient expertise to clean and dress a wound that has occurred in saturation? The tetanus status should be ascertained.

(31)

IMCA C 013 27 2.5 Scenario 5

A diver becomes confused shortly after a bell run. He is now in the saturation chamber but is keen to get out, despite it being at 50m. The other divers are now becoming concerned about him.

This is a difficult one to manage. Clearly he cannot come out of the chamber!

It is unclear what the problem is: given the circumstances there is a good chance that he has suffered a cerebral bend and the usual neurological decompression illness (DCI) protocol should be followed, even if it is in doubt. The diving medical support needs to be contacted and the treatment discussed. There are a number of other causes that could be responsible for his behaviour. Acute confusion is probably the best medical description for this situation and so a diagnostic ‘sieve’ needs to be run through: this of course would include decompression sickness but also would need to include stroke, infection, toxicity, etc.

Another cause might be mental illness but it is unusual for it not to be preceded by unusual attitudes and behaviour (always clearer in retrospect!).

If he becomes more confused and violent, is there sufficient skill in the chamber to be able to deal with this? Is the supervisor skilled in treating decompression illness?

(32)

A saturation diver complains of back pain after a bell run. He is unable to stand up straight. He is still in the bell.

Much more common on the vessel than in saturation, but still possible. It would seem that the diver has suffered acute back spasm, or perhaps even a lumbar disc prolapse (.i.e a ‘slipped disc’): this can sometimes occur after a period of hard working and all the muscles will be in spasm, preventing movement.

The diver is therefore in a tricky position, in the bell and having to go through a narrow opening which would normally demand reasonable flexibility.

The diver will need assistance from the other divers. It may be prudent to administer him some anti-inflammatories and muscle relaxants prior to moving him: this should be in conjunction with the medic and diving medical support doctor. Thereafter if it is possible, then he should be put on a spine board or other rigid stretcher and manhandled from the bell into the chamber where he can be examined more fully. ‘Red flags’ are symptoms which indicate that it is at the more severe end of the spectrum and is actually compressing the nerves. These include: loss of sensation in the buttocks/leg and loss of control of the bowels/bladder. Also worrisome can be pins and needles down the legs. These symptoms can mean that the nerves in the spine are being compressed and this needs urgent surgical advice.

Most cases, however, are ‘simple’ mechanical back pain (as opposed to ‘complicated’ back pain, i.e. complicated by nerve root irritation as described above): anti-inflammatories and muscle relaxants, along with keeping the back mobile and exercised, are recommended. Lying on the bunk for days on end is not helpful in this case: exercise is more useful.

Given this man’s history of not being able to straighten up, he should be decompressed: even if he makes a full recovery there is further risk of this recurring and if this happens in the water then recovery will be much more difficult.

(33)

IMCA C 013 29 2.7 Scenario 7

A diver returns from diving and removes his suit. His wrists and hands are very inflamed and the skin is blistered. It is very painful.

It is not immediately clear what has happened here but it is possible that he has suffered burns from substances in the water. The severity of this chemical burn is unusual. The suit should be very carefully washed and assessed for damage.

As for the diver, attempts should be made to ascertain what the chemical was. The treatment will be copious irrigation of the area. The blisters should be carefully dressed and, if the skin is broken, antibiotics considered. Analgesia should be discussed with the medic.

This has multiple side-issues: why were the chemicals present in the first place? Is there a leak? Is it clear what chemicals are present in the water: are there chemical datasheets and supporting documents on which to base a management plan? In addition, is the discarded diving suit likely to cause a problem? In the bell, it may be releasing vapour into the atmosphere.

(34)

A diver returns from a dive. He has been working at a heavily contaminated worksite with copious hydrocarbon residue. On his return he notices that the others in the bell suddenly become confused and drowsy. He removes his hat and immediately becomes the same himself.

It is likely that they have succumbed to hydrocarbon toxicity, which is rapid. Hopefully the remaining diver has the presence of mind to reattach his hat and flush it with clean gas. He can then assist the other divers in the bell. The bell itself should be flushed with clean gas and the offending equipment washed to get rid of the hydrocarbon residues.

(35)

IMCA C 013 31 2.9 Scenario 9

A diver returns from a dive with injuries to the back of one of his hands. He was cleaning debris away from a dive site and brushed the back of his hand against some rough metal. The wound is bleeding but is very dirty, contaminated with oil.

The first step is to ascertain the severity of the injury. This is best done in conjunction with the diver medic onboard, who can look at the wound. The wound will need irrigation as much as feasible and dressing. If extensive then it will need a surgeon to look at it. It is important to ascertain whether there is any blood vessel damage (by checking the tips of the fingers) and loss of sensation.

(36)

A diver develops diarrhoea and vomiting shortly after going into sat. He does not feel too well and so lies down. He does not recall eating anything ‘dodgy’, but did remark that his young son had suffered from diarrhoea and vomiting about four days previously.

The other divers are wondering what to do.

There is a good chance that this is a norovirus. Viral gastroenteritis is very common and can be passed on easily. It does not bode well for the other members of the chamber!

Ideally, this diver should be isolated, but clearly this is impractical. The infection can be passed on by faecal-oral spread (a hygiene issue), by contamination (such as cutlery) or by aerosol from vomiting. The vomiting from norovirus is legendary, in that it can produce projectile vomiting for several feet. The other hallmark feature is that there is only very rarely a feeling of nausea before the vomiting starts.

Most of these infections will subside after 24-48 hours, but the incubation can be two to three days. There are therefore two possible choices: keep the divers in saturation and let them all catch it, suffer from it for 24-48 hours, and recover: they will be able to go back to work two days after symptoms have resolved. The alternative is to decompress the infected diver with one attendant and hope that the others in the chamber have not yet become infected: the chamber will need deep cleaning, and it is possible that the divers will become infected: if nothing has happened for two days then their chances of having become infected are low. Difficult choices indeed!

The next problem, if the first choice is followed, is what to do with the diver once they have been decompressed. If they are not too deep, then it is still possible that they might be infectious: in that case the diver should be isolated for another 24 hours, to a maximum of 48 hours after the symptoms stopped. It is unlikely that he will be an infectious risk thereafter.

(37)

IMCA C 013 33 2.11 Scenario 11

A diver is heard to swear loudly on the communications system when on a dive. The supplied hot water is too hot. He returns to the bell. He is in a lot of pain and his skin has already started to blister. It is painful and red.

Burns are not common these days but do still happen. As with any burn, the severity of it should be checked, in conjunction with the diver medic. Because it has started to blister, this might suggest that it is fairly severe. It will be very painful.

In the first instance he should have it doused in copious amounts of cold water. The burns need to be dressed and, if the blisters are burst, antibiotics may be warranted. He will need adequate analgesia and then will most likely need decompressed. If he only gets minor burns then he may perhaps be able to return to diving without being decompressed.

(38)

A diver spills a pot of tea over his thighs when removing the tea tray from the medical lock. His thighs form blisters immediately. He is in a lot of pain and resisting examination by the other divers in the chamber.

The diver needs to have the area deluged with cold water immediately to prevent further damage. The diver then needs to be examined to ascertain the damage: that it is blistered suggests that at least moderately severe, and could be worse. The diver medic should be contacted to give further advice and assist with medications, etc.

The burns will need dressed and, if blisters are burst, will probably need antibiotics. He will need pain relief and decompression.

(39)

IMCA C 013 35 2.13 Scenario 13

A diver is loosening a bolt on pipework when it comes off at great speed, hitting him in the chest. It transpires that the pipework was under pressure.

He is winded, but recovers quickly. About two minutes later he begins to feel pain where he was hit and wonders if he might be slightly breathless.

This man needs to be recovered to the bell: with presence of mind he will probably already have made his way there. A careful examination of the chest is necessary, including listening to make sure that there is air entry to all areas of his chest and looking for any wounds. Some types of spirometry machines work in a compression chamber and can be useful in assessing lung function. If he continues to be breathless then he will need more qualified assessment, and for this it might be prudent for the offshore medic (if feasible) to enter the chamber for a short period to assess the diver and report back to the diving medical support. Thereafter careful monitoring for 24 hours will be necessary: and after speaking to the diving doctor responsible, he may perhaps return to diving. However if there is continued concern then he may well need to be decompressed – and will continue to need close monitoring during this.

How did the pipework come to be under pressure and the diver not know about it? Where did communications fail?

(40)

A diver is assisting with pressure testing. A dye has been instilled into pipework to test it and high pressure applied. It is clearly leaking from a flange. The diver starts to screw the bolt in with a spanner when it loosens suddenly and the flange comes off, striking the diver on the arm. The diver is stunned but able to summon help. The pipe is still leaking copious amounts of thick dye.

The rescue diver will need to recover the diver to the bell, whatever condition he is in. The pressure will need to be switched off.

The diver will need to be assessed in the bell for injuries. He has been struck on the arm and this may well be broken. If so, the arm will need splinting and he will need pain relief and eventual decompression. However, always start with ABC (airway, breathing, circulation), and then look for injuries thereafter.

(41)

IMCA C 013 37 2.15 Scenario 15

There has been an explosion onboard, resulting in a major incident necessitating abandonment of the vessel. There are divers in saturation but none in the water; one of these has been injured in the explosion. It is unclear what his injuries are but he is conscious and able to talk to the other divers, who are clearly anxious about the situation.

In this respect the divers are practically on their own: they must marshal themselves to escape to a hyperbaric lifeboat.

Are the divers able to transfer an injured diver up to the lifeboat? Can this be done with a diver who has spinal injuries? What facilities exist in the hyperbaric lifeboat for treatment of a sick diver (or in a normal lifeboat, for other crew, for that matter)?

(42)

A diver appears to lose consciousness in the water. The other diver tries to awaken him but it is clear that he is unrousable.

Before approaching the unconscious diver, the other diver should first ascertain that it is safe to do so. After that is ascertained, there is no other option but to recover the diver to the bell and see what the matter is. On doing this, ABC (airway, breathing, circulation) are the first things to do, and will dictate what happens next. The diver ought to go back to the chamber for further investigation of the cause. Possibilities include syncope (i.e. a faint), also a seizure, hypoglycaemia (low blood sugar), heart problems or problems with inhaled gas, amongst others. It would be unwise to allow them back to diving without finding out what has happened and this may well include decompression.

(43)

IMCA C 013 39 2.17 Scenario 17

A diver becomes increasingly breathless and suffers chest pain during decompression. The pain is on one side of his chest. He is finding it more difficult to speak.

Check ABC (airway, breathing, circulation). All of these are likely to be still reasonably good in this man’s situation. The next thing to do would be do would be to listen for breath sounds on either side of his chest. If they are reduced on one side then there is a possibility that he has suffered from a pneumothorax. Feel for the trachea (windpipe) – you should be able to fit a finger down each side between trachea and clavicle (collar bone). Check whether it is deviated to the side. If this is the case then urgent treatment is needed – there is a good chance of this being tension pneumothorax. First unless it is impossible, contact the medic urgently and the diving medical support. Advice will follow. Put the diver on oxygen, so he receives twice the partial pressure that he would be receiving in the chamber mix.

For the sake of example, if the trachea is deviated to the left, and there are reduced breath sounds on the right, then there is a tension pneumothorax on the right – i.e. the trachea will be pushed out of the way of the expanding lung on the right side. The chest might also be ‘hyper-resonant’ – i.e. when you tap (i.e. ‘percuss’) the chest, it will sound like you are tapping a drum – as opposed to the hollow noise you would normally get when tapping the chest.

If it is a tension pneumothorax, this can be relieved by putting a needle into the chest to relieve the pressure, on the side where the pneumothorax is. Do not do this without first discussing it with the medic and divingmedical support for clearance to do this, as it can in itself cause a collapsed lung.

Use a large-gauge Venflon cannula with a large (preferably 50ml) syringe attached. Feel for middle of the collar bone and slowly insert the needle just below this. Aim down at an angle of 45 degrees with the patient sitting up. If the diagnosis is right then the syringe will fill up with air. If not, try pulling on the plunger of the syringe to aspirate any air inside. Withdraw the needle part of the Venflon and leave the clear sheath of the Venflon in place. Continue aspirating until no more air comes out, then tape it in place and plug the cap. Continue monitoring the patient – if the diagnosis was correct they are likely to improve dramatically. Discuss further with the medic and diving medical support, as during continued decompression this problem may well recur.

(44)

A diver collapses and stops breathing whilst in the chamber. He had suffered from some chest pain prior to the collapse.

Check ABC (airway, breathing, circulation). If he is not breathing, start the basic life support algorithm …

Unresponsive? Not breathing normally?

Seek help Open airways Call emergency number

30 chest compressions 2 rescue breaths 30 compressions

Basic life support algorithm

… and do not stop, whilst monitor/defibrillator are moved into the chamber. Do you have defibrillators that can be used in saturation (the most common problem is battery damage in compression)?

Then the defibrillation protocol needs to be started. If the diver is in a shockable rhythm, then no time should be wasted in defibrillating them. Given the large amount of metalwork in the chamber, bystanders and operator of the defib should take particular care that they are clear and not likely to receive electric shocks.

Unresponsive? Open airway Look for signs of life

CPR 30:2 Until defibrillator/ monitor attached

Call resuscitation team Assess

(45)

IMCA C 013 41

The medic should be on hand outside the chamber to communicate with the diving doctor and to supply the medications to inside the chamber.

For administration of medication, the diver will need an intravenous drip. Choose a large-bore cannula and then prepare the area – have all your equipment ready. You will ideally need – gloves, a sharps container, the cannula, adhesive tape, tourniquet, a syringe and a saline flush to flush the cannula with.

Apply the tourniquet to the arm and pull it tight – the veins should stand up. Pick a vein in the arm which you can feel rather than see. It should not be pulsatile – that is an artery!

Make sure the area is clean of oils/dirt and then insert the needle along the line of the vein at a shallow angle. If you are in, then the little window at the back end of the drip will show blood. Push the sheath into the vein and withdraw the needle. Take off the tourniquet but apply pressure at to the arm just above the cannula to stop blood coming out, and then take the cap off the needle and apply to the end of the sheath. Open the cap on the top of the cannula and gently flush in the saline – about 2ml should be enough. Close the cap. Then tape it in position.

Next get fluids set up. Get a bag of fluids, insert the sharp end of the giving set (i.e. the tubing) into the bag and push – the fluid should flow into the reservoir chamber. Allow fluid to flow down the tubing until it comes out the end. Make sure there are no bubbles in the fluid and then remove the cap from the cannula and screw in the giving set. Control the flow of fluid by using the little wheel on the tubing. Hang up the bag. If the diver remains unconscious and is unable to maintain his airway, he may well need to be intubated. Check the airway is open and get a good position. Pre-oxygenate by bagging with a mask and oxygen, and make sure that all your equipment is ready.

The list is: laryngoscope, endotracheal (ET) tube, 10ml, syringe, cloth tapes (to tie it later), bag, mask and oxygen, and connectors.

Open the airway, put the laryngoscope in the mouth to the back of the tongue and between it and the epiglottis and lift upward. Do not lever on the teeth. You should see the vocal cords. Slip the tube in between the vocal cords – if you can’t then try for 30 seconds max then go back to bag and mask until you can have another go. If you are struggling then use forceps to push it through, or a wire introducer up the middle of the tube. Inflate the balloon cuff on the ET tube and then listen to the chest in both axillae (i.e. under each arm) and over the stomach whilst pumping the bag, to make sure that you have air entry in both sides of the chest and not in the stomach. If the tube is in place, tie in position with the tapes. Because the diver is in saturation then he will need to have water in the balloon cuff, not air, as this will expand as decompression takes place and may cause damage.