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Emergency sutures in a seaway

Apr 27, 2018

A case study on dealing with a medical mishap offshore

Crewmember Susan suffered a laceration in the back of her head

Crewmember Susan suffered a laceration in the back of her head

Editor’s note: The last thing a voyager wants is a medical problem while underway. Sometimes, however, fate and a rolling sea combine to drop one in your lap. Below is just such a case. The writer, Carol Archer, is the first mate aboard the Swan 100 Virago and has medical experience as an emergency room RN.
 
It is always a time of diverse feelings, leaving Newport for the weeklong delivery to Antigua in the Caribbean. Excitement for the adventure ahead, reluctance in leaving home and friends, trepidation for the first 24 hours of the trip as they are always rough and cold.

Finally, the moment arrived; the boat was provisioned and ready, the cold front moved over the area, the wind turned to the northeast and we were off! For the first eight hours, the seas were lumpy and confused and the winds were strong at 18 to 20 knots. We were sailing a reach at 12 knots and making good time. The crew were adjusting to life at sea and trying to get their sea legs under them and into the routine of ship’s life on a delivery. A heavy roll, however, and a fearful event happened.

I was in my bunk trying to catch up on some sleep when the captain came in to say that one of our crewmembers had fallen and didn’t look good. I leapt up with my heart beating fast, worried as to what I would find. There was Susan, who was sailing as cook, lying stretched out on the floor of the cabin across the hallway from her cabin. She was wedged against the open head door in a semi-sitting position. The crew in that cabin, Ben, awakened by the noise of the fall, said that it seemed like she lost consciousness for a little while, maybe seconds or so.

Medical tools like tooth forceps help arrange the cut for stitching.

Alert and answering questions
I knelt by her side and did a quick assessment. Susan was alert and able to answer my questions, stating that she had just gotten off watch and, while beginning to take off her foul weather gear, the boat had lurched, she lost her balance and went crashing into the next cabin to leeward — a lateral fall of 10 feet! As I looked at her while she was talking, I checked her color, her pulse and respiration, her speech and her grasp of events to assess her level of consciousness (LOC), since I suspected a head injury at the very least.

Without moving her, I palpated her neck, limbs and chest, finding no pain or deformity, and saw that her pupils were equal and reactive to light. I had her sit up, maintaining good head alignment, and palpated the back of her head to discover a large laceration to the occipital area of her skull. While sitting up, still on the floor of the cabin, Susan began to feel light-headed so I had her lay down fully on the floor while I began to gather the needed supplies to attend to her laceration. All the while, the boat was continuing to sail at 10 to 12 knots with a rather uncomfortable motion. Once all the equipment was obtained, with the help of Ben, an EMT, and John, another crewmember, we moved Susan to her own cabin but still on the floor and got her in a more favorable position to begin the cleanup and examination of the cut. I was continually monitoring Susan’s LOC, keeping her talking and making sure she was alert and oriented. It was at this time that the captain came into the cabin to see how things were. If we needed to get Susan off the boat and to a hospital, a return to Newport would take 12 hours, while pressing on to Bermuda was two days. What a decision I had to make! My initial findings were that “at this time” Susan had sustained a head laceration and had no signs of internal head injury. Her vital signs were all within normal limits, she was alert and oriented and fully aware of what happened. Susan herself kept saying that she felt fine — just a little shaken up from the fall and wanted to keep going.

The best-trained on board
As an emergency room RN, I have seen many head injuries come into the ER and know that one minute the patient can look okay and the next they are in shock or developing signs of increased intracranial pressure. I did not want to be in this position but I also knew that I was the best-trained person to make the decision.

I went by my gut feeling. I felt that Susan was remarkably okay, showing no signs of any head injury or musculoskeletal injury at this time. Knowing I had an extensive medical kit on board helped me make my decision.

So I told the captain to keep on going. Did I make the right choice?

Susan on the cabin sole while her scalp was being cleaned and sutured.

Susan had a 6-inch laceration to the occipital area of her head. After thoroughly cleaning the area of the wound, I injected the laceration with 10 mL of 1 percent lidocaine. Then, over the next hour and a half, I put in three internal sutures, six staples and two external sutures, aided by great help from both Ben and John who held flashlights, handed tools and gauze pads, and cut sutures. Once the laceration was cleaned up and dressed as best I could, we helped Susan out of her clothes and into her bunk. A retake of her vital signs at this time showed everything within normal limits. I woke her up every two hours to check her vitals and LOC. Susan always awoke easily and her vitals were stable. Her head laceration continued to bleed slightly as she slept on the area so I changed the dressing often during that first 24 hours. I have to say I did not get much sleep that night!

The next morning, Susan was up and ready to get back into cooking. I managed to have her rest for the day and take it easy before resuming any work. She did as she was told but didn’t like it much. After 48 hours, she returned to the galley, cooking us all amazing meals as if nothing had happened!

I continued to monitor her and change her dressing until we decided it was too hard to keep the back of her head dressed and I finally had her gently wash her hair to remove the last dried blood from the area. Checking the suture line, all looked good — no redness or swelling as one would expect if an infection was starting, and there was no muscle pain from the fall.

Looking back
Now as I look back on the actual suturing of the laceration, I think of how I did not shave away her hair from the area, wanting to save Susan the embarrassment of having a bit of a bald spot for a while. But I wish I had. The situation was very difficult to suture in, with the boat bouncing and heeling, and having her hair in the way made it that much harder — as it also did afterward, when I needed to check on the suture line and apply antibiotic ointment. But in the end, she looked perfectly normal as we pulled into Antigua, something she was very thankful for. Once we arrived I wanted to take Susan for a CT scan just to finalize everything, but she politely refused. Perhaps I should have insisted.

Being the medical person in charge on a boat at sea is a big responsibility; advanced medical help is beyond reach except for what you can carry with you. These days there are a number of companies that put together medical kits for boats and provide emergency online and phone support, and it is comforting to know they are there for you, but you still have to know how your kits work and have a working knowledge of advanced first aid. As Captain Ron says, “If it’s going to happen, it’s going to happen out there!”

Carol Archer was an emergency room RN and now sails on the Swan 100 Virago.

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