Fitness of Members
Medical Supplies
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Fitness of Members
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Medical Supplies
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When planning any expedition, one of the first considerations must be that of safety and general well being. The more remote the location and the more hazardous the activity, the more this is true. When planning any dive - even a day dive at a familiar site in the UK, safety considerations must take priority and all possibilities and scenarios must be considered.
For example: - The Fitness and Experience of the Divers - The Tides and Weather - The Available Equipment - The Depth and Nature of the Dives - The Ability to perform a Rescue in the event of a Diving Emergency - The Ability to perform First Aid and get Medical Treatment
Obviously all planning should be undertaken to minimize the chances of there being any problems, but also, so that if the need arise, that a rescue can be put into operation without wasting perhaps valuable time. Furthermore training should be undertaken to ensure that if any problems do occur, they can be nipped in the bud before they have time to escalate into a major incident.
Whilst emergencies directly related to diving practices are potentially very serious, they are also extremely rare. The use of boats in general, compressors and general camp activities such as cooking are much more likely to result in injury, such as burns, fractures and wounds etc. Any diving expedition must therefore be careful to ensure they have all medical emergencies covered.
This chapter covers the various safety precautions (alluded to above), that the expedition considered. Other precautions relating to general well being, such as nutrition and safe drinking water, that also needed to be considered, are discussed in Field Logistics section.
Divers may have to undergo physical strain under adverse conditions and their reactions in an emergency situation may govern not only the survival of themselves but also that of others. Before anyone can undertake any diving or diver training with the British Sub-Aqua Club (BSAC), they must first have a thorough medical examination and be certified fit to dive. Repeat medicals are required on a regular basis (every 5 years to the age of 40).
The Expedition Diving Officer stipulated that all the expeditionary members, were BSAC divers and therefore in possession of a current 'Certificate of Fitness to Dive'.
To supplement the information given in the medical form, in the event of a medical emergency, a confidential questionnaire was also required to be filled in by each member. The questionnaire requested information on blood group, allergies, and next of kin etc. and was in duplicate form, one to be held in the field, the other in the UK.
It was of particular importance to ascertain whether any expedition members were allergic to drugs, prior to departure, so that they could be catered for when assembling the first aid kits.
Prevention is better than cure etc, so vaccinations are important, however very few are actually needed for Greenland. In fact, only Tetanus was really required though Polio was also strongly suggested. Greenland suffers from the ubiquitous mosquito in its brief summer months, followed by black flies, however these only constitute a nuisance rather than bringing diseases such as malaria.
All team members, by virtue of their BSAC training had a degree of practical knowledge in current resuscitation techniques. Diving is a potentially dangerous occupation and as such it is imperative that all those who dive have a practical knowledge of rescue skills. For this reason BSAC training incorporates lifesaving and resuscitation skills right from the start of diver training - these skills are reinforced and developed at each further stage of diver training.
As mentioned in the Diving section, the lowest qualification held by a team member was that of 'Novice Diver' and even at this level, a diver is taught how to bring a disabled or unconscious diver to the surface in a safe and controlled manner, and when there, how to support the casualty and administer artificial ventilation (mouth to nose resuscitation) if required.
One important aspect of First Aid specific to diving is that of the supply of 100% oxygen (O2) in the event of a serious diving disorder, namely, Gas poisoning, Decompression Illness (the Bends), Cerebral Arterial Gas Embolism (CAGE), and Burst Lung. The immediate supply of O2 as first aid, in such cases often means the difference between death or paralysis or not.
Fortunately, the expedition was able to borrow a small oxygen set, capable of supplying one person for about 20 minutes. This was a personal loan from Rolf Darville, the Naval Diver at the nearby Royal Danish Naval Base at Gr?nnedal. This was a fortunate acquisition because the expedition was not able to ship (either by sea or air), any compressed cylinders, nor fill their cylinders on site with oxygen - which is hazardous and requires specialist equipment, or more importantly, get UK specification O2 cylinders filled in Greenland.
As with any First Aid techniques, the safe administration of O2 requires some training, for this reason it was important that at least two members of the expedition enrolled on a BSAC or equivalent, O2 administration course. Furthermore, in the field the O2 kit was set up for immediate use and all expedition members were given basic training in O2 administration.
Other than O2 treatment there is in fact very little else that can be considered as diver specific first aid. Secondly, as previously mentioned, whilst diving emergencies are potentially very serious they are thankfully rare, injuries from general activities being much more likely. It was therefore desirable that as many members as possible, had a practical knowledge of general first aid.
Most of the team members had previously undertaken some first aid training and the Diving / Medical Officer attended a Health and Safety Executive (HSE) approved, Diver First Aid course, just prior to the expedition departure. The course covering all aspects of first aid. As with the O2 equipment, in the field the contents of the first aid boxes was reviewed with everybody, and emergency procedures discussed.
Whilst first aid training is important to prepare for medical emergencies, it will not necessarily prepare one for all medical matters pertaining to living and operating in remote areas. It was important therefore, for the Medical Officer to obtain such advice from a medical centre. In our case this was from Dr Sarah Freedman at the Imperial College Health Service - who regularly advises on student expeditions.
Other considerations discussed included what first aid and medical supplies to take, and whether or not it would be possibly required to make injections or stitch wounds. The Medical Officer needed to consider the need to remain as self sufficient as possible and in a worst case scenario, the length of time that it would take for the medical services to arrive - in this case about 6 hours. It was decided that injections and stitching would not be required, merely to patch them up and administer pain relief.
Some of the drugs taken are only available on prescription, therefore medical advice was required anyway. We were lucky in that most of the drugs supplied were supplied free by pharmaceutical companies, for such use in student expeditions.
In transporting the supplies, everything was duplicated in case of loss or damage in transit. The following listing of medical supplies and drugs taken, briefly lists their uses, (largely precised from the IC Health Centre notes) and is catalogued here only as a guide to further expeditions. The expedition was relatively lucky in operating from a single base, to which supplies were shipped directly. ie the preparation of first aid and medical supplies was not hampered by the need to be constrained to a size or weight. None the less the kit fitted into a plastic tool box, with carrying handle (dimensions 45x21x21 cm). The expedition also carried a smaller first aid kit and the prescription drugs, whilst in transit to and from the base camp. This kit was also used whilst mapping in the surrounding mountains.
Used for treating infections, such as bronchitis, ear infections, infected wounds and dental infections. They should be taken at evenly spaced intervals over 24 hours. It is important to check for allergies against antibiotics e.g.. penicillin, before they are used. Most antibiotics take a minimum of 48 hours before any improvement in the symptoms is apparent. They should be continued for a minimum of five days, and can be considered as in effective if their is no significant improvement after 3 to 4 days, in which case you can switch to a different antibiotic.
Erythromycin: For persistent sore throats and tonsillitis. A useful antibiotic for those allergic to penicillin. Can also be used for ear infections, sinusitis and skin infections.
Trimethroprim: Particularly useful in urinary infections. Good for ear infections and sinusitis. A useful antibiotic for those allergic to penicillin
Co-amoxiclav (Augmentin): Contains amoxycillin - a type of penicillin, giving it activity against a broad range of bugs. Useful for bronchitis, sinusitis, ear infections and skin infections.
Buprenorphine (Temgesic): Related to Morphine, this should only be used as pain relief with severe injuries, such as fractures. This counts as a controlled drug and required a special prescription to obtain it and then a letter of authority to carry it for use in medical emergencies.
Diclofenac tablets (Voltarol Retard): A non-steroidal anti-inflammatory drug. Good pain killer for soft tissue injuries, such as sprained ankle, bruising and backache. Not to be taken by those allergic to aspirin
Diclofenac cream (Voltarol Emugel): For pain relief of mild sprains, strains, bruises and soft tissue injuries. Not to be used if allergic to Aspirin.
Deep Heat: Menthol based cream for relief of muscular aches and pains.
Paracetamol: For mild to moderate pain, such as headaches.
Codeine Phosphate: Added to paracetamol it potentiates its pain relief properties
A variety of other mild pain relief drugs, for use with headache, migraine, neuralgia, rheumatic, period and dental pains and symptoms of colds and influenza Anadin Extra (contains Aspirin, Paracetamol & Caffeine) Ibuprofen (Nurofen) Soluble Aspirin (Disprin) Aspirin
Prochlorperazine (Stemetil): Both as tablets, for use with vomiting and nausea, and suppositories, to be used in cases of severe vomiting when tablets have failed, or when vomiting occurs with Temgesic.
Codeine Phosphate: Used as a treatment in cases of persistent diarrhoea.
Loperamide (Diareze): For use with diarrhoea
Antacids: Relief of upset stomachs, indigestion and biliousness. Andrews Liver Salts Milk of Magnesia
Laxative: For constipation. Andrews Liver Salts
Oral Electrolyte: Replace essential body fluids & salts lost during diarrhoea & vomiting. Dioralyte (powder): Commercial flavoured preparation. Sugar/Salt: A simple remedy using doses from a dedicated measuring spoon.
Optrex: Mild antiseptic, for soothing sore eyes.
Normal Saline (Normasol): Washing of eyes.
Chloramphenicol (Chloromycetin) Cream: An antibiotic ointment for use with conjunctivitis, styes and corneal abrasions.
Normal Saline (Normasol): Used to clean skin wounds.
Topical (skin) Steroids: Used to reduce the redness and itchiness of skin complaints. Efcortelan (Hydrocortisone) Cream: Mild Steroid for use with eczema, dermatitis and severe sunburn. Trimovate Cream: Strong Steroid, also containing an antibiotic and fungicide, useful for groin itch, troublesome athletes foot and to clear up slow to heal skin infections.
Daktarin: Medicated Talc for use on fungal infections such as groin itch & athletes foot
Magnesium Sulphate (paste): Useful for drawing out splinters.
Antiseptic preparations: To cleanse and prevent infection in superficial cuts, grazes & broken skin, insect bites, sunburn, blisters and chapped skin etc Betadine: Antiseptic paint & dry powder spray. Not to be used if allergic to Iodine. Savlon cream Sudocrem
Audicort: Ear drops for treatment of otitis externa - an infection or inflammation of the canal between ear lobe and ear drum causing pain and tenderness.
Decongestants Sinutab: Also an analgesic (contains Paracetamol). Olbas Oil & Lozenges Mentholyptus Oil
Cinnarizine (Stugeron): Prevention against motion sickness
Terfenadine (Triludan): Mild Antihistamine: Allergic skin reactions & hayfever.
Silver Sulpadiazine (Flamazine): Non-greasy cream for use on burns to aid healing, if there is a long delay in medical help arriving.
Clove Oil: Tooth Ache
Thermometer
First aid manual
Notebook and pencil
Torch & spare batteries
Safety pins (various sizes)
Gallipot
Forceps Scissors (suitable for cutting drysuits)
Sterile gloves
Pocket mask
Selection of guedel airways
Antiseptic wipes - Sterets
Eye shade
Eye bath
Dental kit - mirror, mouthwash tablets, temporary filling material & tongue spatula.
Space blanket
Inflatable splint
Steri-Strip (various sizes): for Skin Closures
Paraffin gauze dressings (various sizes)
Non-adherent absorbent dressings (various sizes)
Semipermeable adhesive film dressings
Hydrocolloidal dressings
Dressing pads (various sizes)
Dressing packs
Plasters (various sizes)
Micropore tape
Cotton wool
Sterile swabs
Cotton buds
Cling Film - for Burns
Elastic adhesive bandages
Triangular bandages
Finger bandage with applicator
Elastic tubular bandages - Tubigrip (various sizes)
Roller bandages (various sizes)
Crepe bandages
Polyamide & Cellulose contour bandages
A first aid kit is something that a lot of attention should be paid and no expense spared, in the hope that you will never have to use it.
So what did we use? Thankfully very little: -
Decongestants - Minor analgesics: Headaches etc - Plasters: Minor cuts and blisters - Antiseptic Paint and Cream: Minor cuts and blisters - Diclofenac Tablets and Cream: Fractured Coccyx
The latter injury which occurred at the very end of the expedition, (to the medical officer whilst trying to scout around some Musk Ox!!), did not require hospitalization.
Safety does not just depend on having good first aid training and suitable medical supplies, but rather, on good forethought on possible problems and good planning on how to avoid these problems. Below is a listed a number of precautions taken by the expedition.
Diving As mentioned above, first aid for serious diving emergencies such as decompression illness is the administration of Oxygen, however such illnesses can only be resolved by the use of a recompression chamber. There are however no recompression facilities in Greenland, the nearest to us being in Canada. This was a serious affair for several reasons, not least because the greater the time before treatment the less likely there will be a good prognosis and also because any increase in altitude as might be expected in an air evacuation, is likely to aggravate the damage. It was essential therefore that everything was done to minermize the chances of getting a 'hit' - more so than on any regular dive trip.
For this reason all dives were planned using BSAC 88 tables. Tables assume rectangular dive profiles - which is rarely the case - and therefore offer some safety margin over dive computers which take this margin and give it to you as extended bottom time.
All dives were planned as No-Stop dives, ie dives requiring no compulsory in-water decompression stops. Though stops are normally not a problem, the greater the time spent decompressing, the greater the chance of getting a 'hit' within the tables. This is important also if you consider the context that high work rates, such as might be expected when carrying out surveys etc, increase the circulation and therefore the amount of Nitrogen taken up on a dive, possibly more so than is considered in the mathematical models on which the tables are calculated.
Continuous diving over several weeks can also result in a nitrogen build up in some (slow) tissues, which may result in a bend. It was therefore considered necessary to take a day off diving every fourth day.
Other than over-extending depth/time constraints, decompression illness may also be the result of a rapid ascent, as may be brought on when a diver runs out of air. This in turn being caused by bad practice or equipment failures, such as regulator free flows. For this reason all divers carried a redundant air supply as well as their main supply - in the form of a pony cylinder with a separate regulator.
Secondly, it was important that where possible all regulators were tested and environmentally sealed prior to departure. This was particularly important with the modern high performance regulators that were used, as these are more likely to free flow due to their greater air flow rates.
The practice of testing that the regulators were giving an adequate air supply, only after immersion in water at the start of the dive, rather than on the surface prior to diving, was also implemented. This cuts down on water entering the second stage, which in itself may lead to a free flow.
When operating a boat in open sea it is very important to be able to contact others in the case of emergency, similarly this is the case when operating from an isolated valley, both scenarios applicable to us.
Communication in such cases is usually down to emergency flares or marine VHF radios, both of these have innate problems.
Within the fjord itself however, the use of radios was no problem and they were routinely used to assist in the surveying etc. The radios used for surveying were Maxon GSX 3410, operating on 169.31250 MHz and with an output of 3 watts.
In able to use these radios, it was first necessary to make an application to obtain a license from the authorities, in which the possible frequencies that we could utilize were listed. It was also necessary for at least one person to hold a 'certificate of competence in radio telephony'. This application took us several months to obtain.
Insurance etc In the UK Divers are very lucky - there is a well oiled rescue service to call upon in the event of an emergency. Divers with Decompression Illness etc are whisked away to recompression facilities, and everything is paid for by the state. Overseas this is rarely the case, especially when it comes to payment. As nearest recompression facilities were in Canada, insurance to cover medical services including a medical evacuation was therefore a must.
Greenland, whilst not part of the EEA medical agreement, does none the less have a reciprocal health care arrangement with the UK, in which UK residents are entitled to emergency care on the same basis as local people. In our case this would have meant use of hospital facilities at the naval base at Gronnedal.
Antibiotics
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