Bush Doctor 101: Lesson 14 - How not to drop a patient off a ship (after he's survived life-threatening blood loss)

You don't know what you don't know. Read this and you'll know more about how to disembark patients off ships without killing them, and the importance of sleep (and doing good and no further harm).

Dear Family, Friends, Mentors, Colleagues and Jane-Your-Younger-Self,

I hope you are well? We are well.

ABOVE: What disembarking patients off a vessel looks like up close and personal. The tug boat is ahead of us and the ship in the distance is where our patient was.

RIGHT CORNER: Basket attached to a crane which we sometimes use to hoist patients over to the tug boat with, if they cannot walk the gangway or descend the ladder.

ABOVE: A stable patient descending a ladder onto the deck of the boat we went out to fetch him on.

You’ll need to read further about our near miss.

Since my last Substack post, Lesson 13: You Don’t Know What You Don’t Know” where I compared Dive Medicine to Obstetrics, I completed 3 weeks of planned studies in Cape Town learning more about what I don’t know in fields I feel the need to know more in.

And after that you may have noticed I got a mild case of writers block. Probably so much to write and so little time, deer-in-headlights scenario trying to catch up on home life, clinic admin and the like.

But you know how it goes. One sentence at a time. Or when a sentence fails you, one word at a time. Or when one word is elusive, just get up in the morning and brush your teeth and say hi to the kids without being grumpy, which is a good start.

It is pretty much what I tell my patients who are trying to lose weight and start exercise from zero which is really really hard for people who have not exercised for years.

2-5 minutes is better than zero. And you know what I say, all it takes is 15 minutes to change the world (or save a life). Jane-fact.

If you’re still wondering how I could compare Dive Medicine to Obstetrics, a diver is afflicted at depth in water by physics and gas laws, mostly on re-surfacing too quickly or not at all.

A baby is afflicted at depth in amniotic fluid, by physics and gas laws, often on exiting, to quickly or too slowly, or not at all.

Now you can see my Bush Medicine logic in that it’s all the same really. But different.

I would love to tell a hardcore professional diver that they are comparative to an obstetric delivery and see what their cheeks do. Pun intended.

Divers, particularly professional divers, are a “special” breed of people.

Like we sometimes are in the habit of describing something being funny in terms of ha-ha funny and / or weird funny. It’s the same for professional divers being described as “special”. Ha ha special and / or weird special.

Who chooses to work underwater at crazy-ass depths in the dark and the cold with marine life swimming around you which may not even yet be named and identified (at least the Loch Ness Monster is a known entity).

These same divers attached to the surface by a mere umbilical cord of air supply as their life line, which is called a divers umbillical, requiring hours after the work is done to adequately re-compress in order to avoid or treat decompression injuries, baro-trauama and the like.

Just like obstetrics. When all goes well it goes really well. When all goes badly it’s a shit storm of blood, amniotic flood, faeces, controlled and uncontrolled mayhem. There is nothing worse than when the blood just does not stop pooling and pooling.

After my Dive Medicine course at Tygerberg Campus run by Stellenbosch University Cape Town taught my Prof Meintjies (legend in his field), I went and learned shipping safety and security at STC-Southern Africa based in the Cape Town harbor where they offer maritime training for anyone wanting to work on ships and yachts.

Why would I take all the courses necessary for me to work on ships, you may ask, since my dream “Robin Hood” community clinic is firmly land based? Valid question.

Well, because I assist with disembarkation of patients off ships off the south east coast of Madagascar and disembarking patients is part of my job I love because it is dynamic and requires a knowledge of the ocean, the swells, the wind, the ship and their crane or gangway, the patient and their illness and whether they are stable enough to walk down the gangway or require a basket and crane to be lifted over from their ship to our awaiting tug boat, in what is called a vessel-to-vessel transfer (see photos above).

Disembarking patients is thrilling. And sometimes scary. And nothing like obstetrics or dive medicine which is also thrilling and scary in a different kind of way. Much like I would describe “funny” and “special”, but not funny or special ha-ha.

One particular patient springs to mind in the category of thrilling and scary, who nearly died, survived massive blood loss while waiting for us to get to him, and who I could have quite easily killed accidentally due to my fatigue.

He was working in the Engine Room of his ship with his long hair loose and it got stuck in a machine which grabbed his hair with a force that overcame the resistant force of his skin and the machine proceeded to de-scalp him traumatically ripping his subcutaneous tissue like peeling aged oil paint off a concrete wall leaving the edges of his skin clean cut and well defined.

You may have noticed that scalp wounds bleed. A lot.

Large de-scalp wounds bleed even more. Take my word for it.

When I say “de-scalp”, I mean that his hair got tangled in a machine that quite literally pulled his scalp off his skull (cranial bone) from the front of his hairline at the top of his forehead, to the nape of his neck (in case you don’t know what it’s like to peel paint off a wall).

Over the years during which time I have gained experience in the shipping industry, I have made it my standard operating procedure to ask ship captains for photographs of patients because sometimes I feel they underestimate the extent of the injury when they write the injuries down in an email to me.

If I (as a non-medical but direct person that I am) were to write the request for medical assistance as the captain of a vessel I would write it as follows:

HELP! We require very urgent medical assistance for a crewman who has sustained a complete de-scalping injury and who is continuing to bleed profusely (the room is covered in blood) where all his scalp has been removed exposing the skull bone. We have saved the scalp for re-attachment.

The message I tend to get from non-medical less direct people than me goes something like this:

We require assistance for a crewman who has sustained a skin injury and is bleeding from the area.

Which fails to mentioned that the entire scalp is detached which they have put in plastic bag next to his bed, the room which is covered in blood.

The fact that the ship is 6 hours from the specified anchor point (the “anchor point” being a GPS point about 8 nautical miles off shore) where their vessel would meet the assisting medical team who would proceed to the said anchor point by tug boat to disembark the patient.

It’s funny (ha ha) because when I was working in the Public System in South Africa I worked in Edendale township and invariably at 2am someone would come to our Emergency Room with chronic back pain which has been longstanding for the past 3 years plus.

As a junior doctor I would sit in front of the patient with my fatigued Chimpanzee brain (reference The Chimp Paradox) screaming, “WHY? WHY NOW?”. And I would more than likely underestimate the patient’s problem in the hope of giving some basic painkillers so I could go and get some much needed rest having hit exhaustion hours prior.

The answer would be obvious, at 2am there were fewer queues, and they had probably tried other Emergency Rooms and had not go the meds and relief they wanted, or they had and now the meds were finished.

Whether it was really a back ache or an addiction to painkillers or both, at 2am in the morning having worked 18 hours already I was less than enthused to be empathetic.

I’m not proud of myself but it is what it is. You try and walk in a doctors well worn call shoes for so many hours and then make your judgement.

Pilots are required to rest after 8 hours of flying and less than 6 hours sleep for anyone causes people to make the same poor judgement errors as if they were drunk. Have I made my point?

For those who go to an ER at an ungodly hour for chronic back pain (or chronic any pain) when you can go during daylight hours when your treating doctor has hopefully slept more, I would question your treating doctor’s accurate diagnostic capability in any wee hours of any morning after 8-16-24 hours with not even a toilet break in a government toilet with no toiletpaper.

On the other hand, I have learned that when a ship contacts me for a sick patient on board, whereas in the past I may have underestimated the gravity of the situation, I have learned that they have often underestimated the gravity of the situation.

I’ll give you an example in the shipping industry where a case has been slightly underestimated.

I was contacted to remotely consult (by phone) a patient who slipped and fell down stairs, which is not uncommon because ships are lurching and stairs can become slippery. I was informed he was “not doing so well” with a severely broken ankle and profuse bleeding from the said fractured ankle.

As per our hallowed medical protocol, life before limb, I asked them to stop the bleeding by direct pressure or tourniquet with elevation and I asked for photos of the patient’s injuries. The photo showed a patient lying on the ground, deathly pale, with the ankle at right angles to the lower leg.

But what was more peculiar from the photograph which was focused on the obviously broken ankle, was that the patient appeared to have head injuries, which had not been mentioned in the information I was given. The patient died shortly after the photos were sent. Or perhaps before. It was hard to tell.

A 2nd example, I received the photos I had asked for, regarding a patient who had also fallen down stairs (as I said, common IOD on ships) and I was again informed about a leg injury. The photos I received was of what looked like a minor leg injury with a haematoma (bruise) on his shin / lower leg that did not look life threatening in the least. Almost as an after thought the other photos were sent, of severe head injuries, swollen purple eyes and a few minor lacerations.

I digress.

Going back to our de-scalped patient and neither wanting to underestimate or overestimate his condition I asked for photos of the injury.

To even the untrained medical eye the room looked like a blood bath, with fresh bright red blood everywhere.

The skull bone was bare, the edges of the skin defined, the blood was fresh, the patient fortunately looked conscious. I like to be a glass/body-half-full-of-blood kinda gal. My patient in a photo looking conscious was my glass half full. Although we all know that photos can lie and tell half truthes.

All through the night I worked with the captain and crew by phone and email instructing how to stop the bleeding, manage his pain, manage his fluids.

I got them to sit the patient up elevating his head, and wrap a bandage around his de-scalped skull, while putting as much direct pressure as he could tolerate on the skull to stop it bleeding.

No one could establish an intravenous line to replace the fluids he had lost (which looked like a few litres judging from the photos.

His blood pressure was 80/60 and pulse of 120/min), so I instructed them to give the patient fluids by mouth, 100-200ml per hour x 10 hours = 1-2 litres, because I knew that the patient would not be received at a hospital (and thus be required to be nil per mouth for any surgical intervention) within 12 hours due to their distance of 6 hours from our mutual anchor / meeting point, our remoteness of Fort Dauphin Madagascar to any First World hospital with a blood bank and surgical facilities who could manage this particular case, as well as the hours of planning involved with getting an international air ambulance from South Africa to fetch the patient.

Added to the fact that our harbor cannot operate between sunset and sunrise, so the earliest we could get to the patient off the vessel was at first light the following day.

The vessel arrived at the anchor point just after dark in the evening and I could see the vessel from our shore, knowing that my patient was on board fighting for his life, and all I could do was send emails and stay in contact with the captain and his crew, who were doing an absolutely awesome job at stopping the bleeding, positioning him, medicating him, and replacing fluids by giving him sips of water to drink through the night.

The weather report for the following day said some rain which ran the risk of canceling the whole operation because it increased the risk of accidents for all involved.

After spending most of the night arranging the Air Ambulance medi-vac logistics and keeping tabs on the patient via the captain by email, we arrived at Port d’Ehoala (our harbour in Fort Dauphin) at first light and arrived at the anchor point about an hour later, which is the time it takes to travel by boat to meet at the anchor point 8 nautical miles off shore.

I boarded the vessel to assess the situation first hand and determine how we were going to disembark our patient who had thankfully made it through the night, but who’s blood pressure was still very low (80 systolic) with a fast pulse (tachycardia), looking pale and whoozy. The bleeding seemed to have stopped, though all bandages were soaked, they seemed to be drying meaning no fresh blood was seeping through.

I dared not remove the now caked-with-blood bandages in fear of dislodging any clots and restarting the bleeding. I estimated by the extent of his pale skin that his haemoglobin (red blood cells which are responsible for carrying oxygen) was less than 6g/dl. A blood transfusion would most certainly be required. But if we were no longer losing blood, we were going to be ok for the time being.

I put up bilateral intravenous lines, and got his blood pressure up to between 90-100 systolic just enough for him to feel less dizzy when sat up, purposefully not aiming for a higher blood pressure in case his increased blood pressure blew off clots and started further bleeding.

We initially put him on a trauma board stretcher which we were going to lower over the edge of their ship onto our tug boat.

Everything was in place for this, we had placed the patient on the stretcher, we had secured him with the spider harness which is a set of velcro straps attaching him to the wooden stretcher, and ropes had been tied to the trauma board stretcher to lower him down off the side of the ship onto the awaiting tug boat.

Rain started falling and someone murmured that we might need to cancel the operation. I was in my medical box and at that point rain was not our biggest problem, keeping the patient stable was.

As our patient was pivoting on the edge of his ship strapped to the stretcher I looked at the system we had put in place and something (my Chimp brain?) told me something was not right with our system, but I couldn’t figure out what.

By that stage I had been working through the night and it had taken me about an hour to get up intravenous lines, attach him to the stretcher, give him time to get his blood pressure up, carry him out to the deck from his blood bathed room, and get to the point of teetering on the edge of a ship towering at least 6 meters above our awaiting tug boat.

All eyes were on me to do the count down, the patient was balanced on the edge of the ship ready for us to do the controlled tip and descent with him on a stretcher feet first to the awaiting tug 4-6 meters below.

I again checked the system, having learned rope access systems in my paramedic days which were many years (20 years to be more precise) away from where I now stood on the deck of a ship ready to lower my patient to safety and medi-vac’d on to South Africa.

During my mostly sleepless night I had organized an air ambulance to arrive (with pouches of blood) from Johannesburg South Africa with their medical team so that we could do our first ever ship-to-air-ambulance transfer. The air ambulance was waiting on the runway for us to arrive from the ship.

Suddenly one of the ship Engineers shouted “STOP!”.

I was so relieved, because despite my angst I was ready to give the go-ahead to let the patient tip over the edge on the trauma board stretcher, but something was telling me there was a problem and I couldn’t figure it out.

We pulled the patient back to the safety of the deck and the Engineer pointed out that we only had 1 point of contact by rope which was to the trauma board it’s self.

In rope rescue we are taught always to have 2 points of contact, one to the stretcher, and one to the patient.

Essentially by not having a point of contact with the patient, our patient was at risk of sliding off the trauma board out under the spider harness.

We were seconds from tipping the trauma board stretcher which had been balancing on the edge, to potentially allow the patient to free-fall to his death 6 meters below onto the deck of the awaiting tug boat.

Within a few minutes we changed the plan, now with his blood pressure up to around 100 systolic he could stand with assistance, and we decided to put him in the ship basket, which is an inverted cone shaped basket made with webbed rope coming to a point above the basket, the patient assisted by 1 person on each side, to be lifted by the ship’s crane over to the tug boat (see photo above to see the basket).

All’s well that ends well and with the assistance of 2 fellow crewmen we managed to disembark our patient safely onto the tug boat, transported him by ground ambulance to the airport where he was received by the air ambulance crew from South Africa.

Apparently the case was written up in a shipping and medical insurance journal and transmitted amongst the marine industry and the disembarkation was declared being a complete success.

I went directly home after the Air Ambulance took off, took a shower to wash the blood off me, and slept for 12 hours, and only after reflected on what could have been, and shuddered.

What could have been is him dead on the deck of the tug boat.

But, like many accidents are a series of small events that all accumulate to create a catastrophe. Fortunately one Engineer out of everyone standing on deck looking on, knew rope work and had slept more hours than I had, to identify the problem and we averted a tragedy. Go us.

The patient went on to South Africa to undergo over 6 months of plastic surgery, millions of rands (over a million dollars) of medical bills, and returned home with a scalp fashioned from partial thickness skin grafts. South African medicine rocks.

What is the moral of the story?

You don’t know what you don’t know so make a point to fill in your blanks with quality information. Go on a shipping safety course, or if your kids don’t know what to do send them on a shipping safety course (STCW - Standards of Training, Certification and Watchkeeping for Seafarers), it was great and will never be a waste of money.

ABOVE: C.J. Le Roux - HOD of STC Southern Africa, Cape Town - having an adult education college like this in Madagascar would create jobs and be AWESOME. It was very professional, well run, and well worth the money to obtain all the necessary courses to work safely on vessels and yachts.

If anyone wants to help me set up a Marine Training College in Madagascar, message me!

ABOVE: Our water safety course, in the case we are ship wrecked. The pool was around 14 degrees. I’m the odd yellow tuby out in a yellow bouyancy suit. The others in blue overalls ignorantly chose not to use the suit. The yellows laughed on. Without our teetch chatering.

ABOVE: Fire Fighter Training at Pulse Training Northlink College, Belhar Campus Cape Town. Great course, introducing us to basic fire fighting techniques and safe use of equipment.

I know more about dive medicine, shipping and safety after after my 3 weeks in Cape Town in May.

You know now that you shouldn’t let your hair or your child’s long hair near any rotating mechanism (like go-cart wheels and the like, which is where else I have seen this type of injury).

He and those he worked with now know that he should not work with loose long hair.

Sleep (7-8 hours minimum) is like oxygen, without it we die. Fast or slow, you get to decide. Less than 6 hours of sleep causes us to function, reason and judge like a person under the influence of alcohol (fact).

If you need any convincing re my last data point, lack of sleep also causes men’s testicles to shrink, it can cause infertility, high blood pressure, increased glucose, increased insulin, obesity, metabolic disease, strokes, heart attacks, cancer and death.

Doing yourself good an not further harm. Sleep. 7-8 hours. No less. Non-interrupted.

Now there is something you might not have known but now you do.

Kind and mad regards,

Mad Madagascan Mum & Medic,

Jane

ABOVE: Myself and Christoph, my nurse who was assisting me with a disembarkation of a patient off a ship. We’re both suffer from seasickness. I’ve learned ways and means to cope. He hasn’t :) (This was before, when we are both looking happy and hydrated)