Medical Care on Board

Every first-aid scenario in this exam starts the same way, and examiners are testing whether you know that, not whether you can bandage a wound. Before you touch a casualty you check for danger — to you, to bystanders, and to the casualty themselves. A person collapsed near unguarded machinery or in an enclosed space is not safely reached by rushing straight to them; you deal with the hazard first, or you risk becoming a second casualty yourself. Only then do you check response, by voice and then by a firm but careful painful stimulus, because how a casualty responds — alert, only to voice, only to pain, or not at all — tells you how urgent the rest of the assessment is and roughly how deep the problem runs.

Airway, breathing, circulation, disability and exposure follow in that fixed order because each threat kills or disables faster than the one after it. An obstructed airway takes minutes to kill; uncontrolled external bleeding takes longer; a fracture, in isolation, essentially never does. So you clear and protect the airway before you worry about a laceration, and you control bleeding before you splint a limb, even when the limb looks worse. This is the whole reason ABCDE exists as a sequence rather than a checklist to tick in any order — it forces you to fix what will kill fastest, first, every time, under stress, without having to reason it out from scratch on a rolling deck at three in the morning.

Once the primary survey has dealt with anything immediately life-threatening, the secondary survey is where you find everything else: a head-to-toe examination looking and feeling for deformity, swelling, wounds and tenderness, combined with a structured history. A simple way to keep the history complete under pressure is to work through six prompts:

• Signs and symptoms — what the casualty feels and what you can see.
• Allergies — especially before giving anything from the medical chest.
• Medications — including anything already taken that day.
• Past medical history — conditions that might explain or complicate the picture.
• Last meal — relevant if evacuation and anaesthesia follow.
• Events leading up to the incident.

The secondary survey is not a one-off snapshot. A casualty who looks stable on the first set of observations can deteriorate over the following hour, and it is the trend — pulse creeping up, breathing becoming laboured, conscious level dropping a notch — that flags a problem long before any single reading looks dramatic on its own. On a ship, where the nearest clinician may be a radio call away rather than a corridor away, repeated observations at a set interval, written down with the time against each one, are what let you and the telemedical service see that trend rather than guess at it.

Radio medical advice exists precisely because you are not expected to diagnose alone. Flag administrations provide, or require access to, a telemedical assistance service — a shore-based doctor, reachable through a coast radio station or a dedicated contracted service, who can talk a ship's officer through assessment and treatment for as long as the voyage requires. It costs the ship nothing to call, and there is no penalty for calling early; the penalty lies in calling late, or in calling without anything useful to report.

What makes that call effective is preparation, not urgency. Before the call connects, you want pulse, respiration rate, temperature, blood pressure and conscious level in hand, along with a concise history from the secondary survey — what happened, what you have found, and what you have already done. A doctor a thousand miles away is working entirely from what you describe; vague answers get vague, cautious advice, and a casualty who might safely be managed on board can end up needlessly diverted, while a genuinely serious case can be under-triaged if the observations given understate it.

The ship's medical chest is not a first-aid box restocked as you see fit; its contents are set against a list the flag administration requires, scaled to the vessel's trading area and the number of persons on board, and it is checked and restocked at intervals rather than only when something runs out. Expiry dates matter here in a way they might not ashore — a drug that has degraded past its expiry is not just less effective, it may be actively unsafe, and a chest holding expired stock is itself a finding at inspection, independent of whether anything was actually used.

Controlled drugs — opioid analgesics and similar medicines with abuse potential — sit in a separate, more tightly governed regime within the chest. They are stored behind a double lock (commonly a locked cabinet inside a locked space, with the keys held by different people), and every single dose is entered in a controlled-drugs register at the time it is given: what was given, how much, to whom, by whom, and witnessed by a second person. A running stock balance is kept, and it has to reconcile — the register, not the cupboard, is usually the first thing an inspector or auditor asks to see, because a tidy cupboard with a poorly kept register is exactly the pattern a genuine diversion of drugs would also produce.

Deciding to get a casualty off the ship is a risk trade, not a reflex. A helicopter transfer looks like the fast, decisive option, but it exposes the casualty to a winching operation in whatever sea state and weather are present, and it exposes the aircrew and the ship's crew on deck to real risk too — it is only available within the aircraft's range of a suitable base, and marginal weather can make the transfer itself more dangerous than the condition being treated. Diverting the ship to the nearest suitable port avoids that risk but costs time, which matters when the casualty's condition is time-critical, and a rendezvous with another vessel — one already closer to help, or one with better medical facilities on board — sits between the two, trading some of the delay of diversion against some of the risk of a winching operation, plus a ship-to-ship transfer of its own.

None of these options is inherently correct; the right one depends on how sick the casualty actually is, how far away each option lies, and what the weather is doing, and that judgement is made by the Master, on the advice of the telemedical or coordinating medical service, not unilaterally by whoever is treating the casualty at the time. The officer's job is to feed that decision with an accurate, trending picture of the casualty's condition — a decision to divert, or not to, is only as good as the information the Master and the shore doctor are deciding from.

Nothing given, done or decided in a medical case is complete until it is written down. Every intervention is recorded with what was given or done, the time, the quantity where relevant, who carried it out, and — just as importantly — the casualty's response afterwards and any advice received from the telemedical service. This is not paperwork for its own sake: a casualty later handed over to a shore medical team, or evacuated, arrives with a written record that lets a doctor who has never met them pick up the case mid-way, rather than starting the assessment again from nothing.

The record also protects the ship and the officer who acted. If a treatment decision is questioned afterwards — by the casualty, by an inspector, or in the course of an investigation — a timed, signed record showing what was known at the time and what advice was followed is what demonstrates that the decision was reasonable given the information available, rather than something decided after the fact. Afterwards, the medical chest is restocked and the controlled-drugs register reconciled and re-checked before the next use, closing the loop the same way the incident was opened: with an entry that can be checked.

The two scenarios below are worked the way an oral examiner expects: read the situation, gather what is actually known, reason through the priority in order, and state the decision the way you would have to defend it in the exam room.

Worked example 1

Primary survey after a collapse on deck

During a night watch on a bulk carrier underway in open sea, the duty AB is found collapsed on the weather deck near the mooring winch. He does not respond when a crew member calls his name, and a laceration on his scalp is bleeding steadily. The Officer of the Watch calls the Chief Mate, the ship's designated first-aider, to attend.

Given

Casualty unresponsive to voice, found alone on deck Steady bleeding from a scalp laceration Vessel underway, sea state moderate, deck wet No witnesses to how the fall happened Ship's hospital and medical chest are two decks below

1. Before touching the casualty the Mate scans the immediate area for continuing danger — wet deck, the ship's roll, nearby mooring gear — since a second casualty helps no one.

2. Response is tested next.

   AVPU=Alert, Voice, Pain, Unresponsive =Unresponsive here

   By voice and then by a firm but careful painful stimulus; no reaction to either places him at the bottom of the AVPU scale, so this is treated as a reduced-consciousness casualty, not a simple faint.

3. With danger and response checked, the Mate moves to Airway.

   Because the fall was unwitnessed, a head or neck injury cannot be excluded, so the airway is opened with a jaw thrust rather than a head tilt, and the casualty is not rolled or dragged clear until this has been considered.

4. Breathing is confirmed present but rapid and noisy &mdash.

   A partial airway problem in its own right — so the jaw-thrust position is held rather than moving straight to the head wound.

5. Only once airway and breathing are secured does circulation get attention.

   Firm direct pressure controls the scalp bleeding, which looks dramatic but is not what will kill him first.

6. Disability and exposure follow &mdash.

   Sequence followed=Danger -> Response -> Airway -> Breathing -> Circulation -> Disability -> Exposure

   A rapid check for other injuries and for cooling, since a semi-conscious casualty on a wet deck loses heat quickly and shock will worsen the picture. The whole assessment has followed one fixed sequence.

7. With the casualty stabilised and spinal precautions maintained.

   The Mate gathers pulse, respiration, temperature and conscious-level trend before contacting the radio medical service, because the advice given back will only be as good as the observations supplied.

AnswerDanger and response assessed first; airway opened with a jaw thrust and spinal precautions maintained throughout; breathing and then bleeding addressed before any secondary survey; radio medical advice requested only once trended observations are ready.

The trap: going straight for the visible scalp wound — the bleeding looks urgent, but an obstructed airway in an unresponsive casualty kills first, and moving him before airway and spine are considered can turn a head injury into a spinal one.

Worked example 2

Evacuation decision with a suspected acute abdomen

A ro-ro vessel is three days' steaming from the nearest port of call, in open ocean. A 34-year-old engine rating develops severe, worsening right-sided lower abdominal pain overnight, with a low-grade fever. He is otherwise fit, has no known allergies, and last ate 14 hours ago. The Master, as the vessel's medical authority, must decide how to respond.

Given

Severe, worsening right lower abdominal pain, onset overnight Low-grade fever; pulse and breathing otherwise stable No known drug allergies; last meal 14 hours ago Vessel is three days' steaming from the nearest port Helicopter range does not reach the vessel's current position Ship carries a controlled-drug store of injectable opioid analgesia

1. The pattern — localised.

   Worsening pain with fever in a previously well casualty — is consistent with an acute abdomen such as appendicitis, which the Mate cannot diagnose on board but must recognise as a red flag needing outside input rather than watchful waiting alone.

2. Before requesting telemedical advice.

   The Mate takes and records full observations — pulse, respiration, temperature, blood pressure, and a description of the pain's site, onset and progression — because the shore doctor's advice is only as good as this data.

3. The instinct is to relieve the pain quickly.

   But strong analgesia can blunt the very signs — tenderness, guarding — that a later examination would need to judge how the condition is progressing, so the telemedical service is consulted before, not after, giving anything from the controlled-drug store.

4. Once advised.

   Controlled-drug entry=substance, quantity, time given + given by / witnessed by + casualty's response

   If an opioid analgesic is given it is drawn under double lock, the dose and time logged and countersigned by a witness, and the casualty is reassessed afterwards with the result recorded — the register entry is what an inspection, and a receiving hospital, will actually look at.

5. With helicopter transfer ruled out by distance.

   The remaining options are to alter course for the nearest port capable of surgical care, or to hold course and monitor — a choice the Master takes on the telemedical service's advice, weighing the near-certainty of a worsening surgical problem against the time cost of a diversion.

6. Given a deteriorating.

   Likely-surgical abdomen and no faster option available, continuing the original passage plan on the basis that the casualty is “stable for now” is the wrong call. Deviation is agreed with the advising doctor, and the owner/operator is notified of the course change.

AnswerTelemedical advice is sought with full observations before any analgesia is given; any controlled drug administered is logged and witnessed; course is altered towards the nearest port with surgical facilities on the doctor's advice, since helicopter transfer is out of range.

The trap: giving strong analgesia early out of sympathy, before the telemedical service has heard the observations — it can mask the deterioration that justifies the diversion, and an unlogged or unwitnessed dose from the controlled-drug store is a finding in itself.