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MarineMedicalAcademy
UdoygBhavan,I st Floor,LJnitl4
SonawalaI ane,Goregaon (E),
Mumbai400063.Tel 876 9206,Fax 8769208
email.mmaskI 23@,bom5.vsnl.net.in
 i ]!i':tl'1: ti*r I !i r

corvrEffrs
l. Headand SpinalInjuries.
2. Injuriesof ear,nose,throatandeyes.
3. Minor SurgicalTreatment.
4" Techniques of SewingandClamping.
5. Management of AcuteAbdominalconditions.
6. GeneralPrinciples of Nursing.
a.i
7. l\ urslngcare.
8. MedicalEmergency - SHOCK.
9. Diseases - Communicable.
10. Diseases - SexuallyTransmitted.
I l. AlcoholandDrugabuse.
t2. DentalCare.
13. Gynaecology, Pregnancy andChildbirth.
14. Deathat Sea.
15. Enviornmental controlon Boardship.
16. Disease prevention.
17. Keepingof MedicalRecords.
18. ExternalAssistance.
19. Transportation of ill.
24. Communication.
 APPR.;; ev ' ;r;crprL
MARINE MEDICAL ACADEMY ISSUED : APR2000
1!l EDITION : APR2000
MedlcelCan Courrc
COURSE
SPECIFICATIONS P A O E :l / t

MEDICAL CAREON BOARD SHIP

1 . Sc o p e :

This course covers the training recommendedin RegulationVI/4 read along with
section A-Vl/4-2 of Code A of the STCW ConventionT9TSas amended in 1995.

2, Obiecdve:

On completion of this course the trainee should be able to participate effectively in

Coordinatedschemesfor medicalassistance on shipsat seaand provide the sick and
injured with satisfactorymedicalcarewhile thev remainon board.

3. Entry Standardg:

For admissioninto this coursethe Seafarermust be a holder of certificab of competency

at leastasSecondMab of a Foreign-goingship OR As mab of a home hade ship ( near
coastalvoyage)

4 Course Certificate:

On successfulcompletionof the coursethe traineewill be issueda certificateattesting

that the traineehascompleteda coursebasedon the table of competenceas stated in
SectionA -Vl/4 - 2 of the Code A of the STCWConvention.

5. Course intake limitations :

Courseintakeshould brelimited so that for practicalinstructionsand demonstration

thereare no more than six haineesto eachinstructor.However the total sbength of the
classshould not exceed20 per course.

6. Staff requirements :

All haining and insbucUonsshould be given by properly qualified personnel. The

coursein<harge should be a properly qualified medical doctor whg"is experiencedin
casualty work. He should be assistedby other medical doctorp flnd appropriately
qualified medical support staff like nurse and medical attendant T\g,feacher to taught
ratio should be exceed1:8.
MarinoModicalAcademy Medical Care

HEAI' INJI'RIES

EXAMINATION

Careful enarnination even the most superficial head injuries is essential

as Url are potentially dangerous.

[. Unconsciousness

2. Blood, blood stained fluid or stick5r fluid from ear,

nose, throat.

3. Suspectedopen fracture of skull

4. Paralysis

5. Vomiting or Headache

6. Confused or drowsy acts abnormally

I
7. Pulse below 65/min

TYPES

1. Bruising:- Collection of blood in the tissues under

the skull forming a well defined hard or a diffused soggr
swelling.

2. Wound:- Due to blows to the head the wound will

bleed freely and usually out of proportion to the wound size
surrounding tissues may be swollen and soggl with
raggededgesof the sound.

3. Concussion:- Due to heary blow which posses

shock waves through the soft blain substances.This is
charaterised by loss of consciousnessfor a few minutes, loss
of memory, headache, and sometimes nausea and vomiting.

TYPESOF FRACTURES:

1. Linear:- occur on top and sides of skull due to direct force.

2. Fracture at base of skull:- Due to indirect force transmitted to

base of skull from blows to face & jaws or where casualty falls from
Marine Mdical Acaderny Medical Care

height and lands of feet blood of CSF will be leaking into ear, nose,
throat.

3. DepressedFractures:- Due to heavy flow to the vault with a blunt

object e.g. hammer. Depressed piece of bone causing sevene
bruising and laceration of brain tissue.

Open fractures might cause brain injection.

TREATME.NT:-

1. An ice-bag over bruised area might control bleeding

2. For superficial wounds - direct pressure and stitching might be

required

3. Concussion - rest for 48 hrs.

- Aspirin or Paracetamol for headache

- Report if headachevomiting, drowsiness

4. For serious injuries like fractures and compressionsshift to
hospita-la port or go for RMA at sea.

5. In casesof open fracture:-

Do not in scalp wounds.

Do not press over wounds

Do not try to removefragments of bone.

6. Dressinewound:- cut hair at least 5 cm around wound dab skin

with 1% cetrimide solution and dry with sterile swab. place a
petrolatum gause over the wound. Pat a ring pad over this dressing
before bandaging. Give 6 lakh unite of Procaine benzyl penicillin.
Morphine should NOT be given.

SPINE

A fractured spine is potentially a very serious injury. If you suspect a floc

spine tell the casualty to lie still and do not allow €rnyoneto move him
until he is supported on a hard flat surface.

Always suspect a fracture of the spine if a person has fallen a distance of

over 2 metres.
 I\darineMedical Academy Medical Care

Examinins a spinal iniurvi

1. Ask casualty to move his toes to check for paralyses.

2. Examine for sensation of touch.

3. Ask if there is any pain in back.

- Management:

l. Casualty with fractured spine must be kept still and straight.

2. He can be safelv rolled over on to one side.

-
3, The aim in first aid will be to place the casualty on a hard flat
surface and ask him to lie still.

4. Tie the feet and ankles together with figure of 8 bandage.

5. Use traction on head and feet to straighten him out.

6. A Neil-Robertson stretcher or wooden board can be used.

7. To lift the casualty on to a stretcher a blanket can be use.

8. Lift casualty very slowly and carefully to a height of about Yz metre

just enough to slip the stretcher under the casualty.

9. Adjust the position of the pads to fit exactly under the curves in
the small of back and neck.

10. shift
MarineMedicalAcademy Medical Care

INJI'RIES OF EYTS

Eye injuries - causes:

1. Foreign bodies

2. Direct blow

3. Lacerations

4. Chemicals

5. Burns

EXAMINATION:

Record a full account of injury with circumstances and details of

symptoms.

Examine with the casualty lyrng down with head supported and slightly
baclarrards.

1. Record the general appearance of the tissues around eyes looking

for swelling, bruising or obvious abnormality.

2. Exarrrinethe sclera, conjunctiva and the cornea. Compare eye with

the other.

How to examine:

Sclera:

Hold the eyelids apart asking to patient to look in 4 directions

Lids:

Lower lid can be inspected by gently pulling down the lid with eyes
looking upwards. Upper lid should be averted with eyes looking down.

Cornea:

It is helpful to slant the light across the surface in order to show up any
abnormality. Magnifying glass i.e. also helpful. Any obvious loose foretgn
body should be removed at this stage.
Black eye:

Caused due to btow on or adjacent to the eye, which may result in

complete or partial detachment of retina or bleeding into the eyeball.
Send medical helP.

Corneal abrasions:
pain is felt immediately and the casualty feels there is something in the
eye. Eye ointment should be placed in side the lower eyelid and the
patient ask to blink the eyes.And eye pad is applied for 24 hrs.

Looseforeign bodies:

It can be removed from under the lids with the help of a moistened
cotton wool or a stick or a moistened cotton bud in a gentle manner
taking care not to damage the cornea. Anaesthetic eye drops can be
used.

Foreisn bodies embeddedin the eye:

Small pieces of metal, grit etc. become embedded in the cornea or the
sclera. Don't attempt to removeforeign body yourself. Casualty should be
seenby an eye-specialist.

Wounds of eveballsand eyelids:

Get RMA at once if the eyeball is cot and the eye leaks fluid or jelly. Close
the eyelidsor being then as close or possible cover the eyelidswith sterile
petroleumjelly gauzethen place €rneye pad over this.

Chemical burns:

Wash the chemical out of the eye with copious amounts of water at
least for 10 mins. Bye ointment should be applied to prevent lids sticking
to the eyeball.Apply the ointment every 4 hrs.

Arc eves (welder's flash)

W light in an electric arc can cause sun-burn of the surface of

unprotected eyes. Both eyes feel gritty within 24 hrs and look red. Bright
Ught hurts the eyes. If one eye only is affected it is probably not an Arc
eye.
MarinoMedicalAcadcmy Medical Caro

1. Bathing eye with cold water and applying cold compnesslesto the
lids will give some relief of the symptoms.

2. Darkglasses should be used

3. Condition clears up within about 48 hrs. of no further exposure to

UV or welding occurs.
 EAR INJuRIES
Foreien bodies: Causes 1) sand

2l insect

3) other small objects

Symptoms 1) Irritation

2l Pain

3) Discomfort in ear

Treatment:

l.If object is clearly visible it may be possible to remove it with tweezers.

If this cannot be done no other method should be made. The ear- drum
can be pierced in a attempt to remove objects that are not visible or are
stuck in the ear passage.Also, the object may be pushed further in.

2.If nothing is visible, flood the ear passage with tepid peanut, olive or
sunflower oil, which may float the object out or bring it out when the
casualty drains his ear by lyrng down on the affected side.

Injuries to internal ear:

1. If ear drum has been perforated as a result of skull fracture, there

may be a flow of cerebro spinal fluid. This should not be stopped
by inserting anything inside the ear.

2. The casualty should be placed on his injured side, with his

shoulders and head plopped up; this will allow the fluid to flow
freely.

3. For other injuries, put a dressing over the ear apply a bandage.

4. Do not put cotton wool in the ear.

5. Call for Medical help.

lvlarineMedical Academy Medical Care

NOSE INJTIRIES

Foreigq bodies :

(1) Casualty can blow forergn body out of nostril by

compressing the other nostril and blowing down
the blocked one.

l2l If foreign body is visible and loose, remove with forceps.

Iniuries inside nose:

(U Arrest bleeding - Pinch nose firmly for 10 mins while keeping the
head well forward over a basin. After 10 mins slowly release pressure and
look for drips of blood. Instruct casualty not to blow his nose for next 4
hrs.

If bleeding has not stopped, continue pressing of nose for further

10 mins.

If still does not stop, packing of nose with lubricated strip gau?n
mrght be required. L,eavegauzein place for 48 hrs.

Fractures of nose:Cannot be dealt with on board. The only treatment will

be to stop bleeding.
 MINOR SURGICALTRBATMENT

1t; Abscesses:- An abscessis a localised collection of pus which glves

rise to a painful throbbing swelling usually with fever.

Commonestsites a-re- arm, armpit, neck, groin, and besidethe anus.

General treqtment :- The area round the boil should be swabbed with
cetrimide solution 1% dried and a light dry dressing applied. If a large
boil any hair around the area sirould be clipped short before swabbing.
Give an adequateincision over the area which is eith€r dependent or the
most soft area and drain the pus. If required one will have to use a sinus
forcep to break away pus locules. Dress the wound after putting a pack
of gaugeinside the wouid and should be dresseddaily.

For patient not allergic to penicillin give benryl penicillin 300mg

intramuscularly and start with a standard antibiotic treatment. If patient
has fever he should be put to bed and given either two paracetamol or
aspirin tablets every 6 hours. Dispose off the dressing carefully, sterilize
any instruments or bowls and wash your hands thoroughly.

(2) Cellulitis:- This is a septic skin condition. The skin is red and
swollen. Patient will feel unwell with headache and fever. Nearbv
lymph nodes will becomeenlargedand painful.

Generaltreatmenf- All patients with fever should be put to bed with the
swelledpart elevated.
Specifictreatment:- Benzyl penicillin 30omg Intramuscularly if patient is
not allergic to it followedby standard antibiotic treatment.

(3) Fish hook removal:- First clean the hook and the area of the skin
around the hook with cetrimide 17osolution or with soap and water.
Two methods for removing fish hooks are describedbelow.

Method I:- hrt a loop of strong thin line round the shank and slide it
down until it touches the skin. Press the eye of the hook down with
one finger until it is flat or nearly flat with the skin and pull on the
line sharply.
Method II :- Used for bigger hooks and for deeper penetration. Inject
lignocaine O.5o/osubcutaneously wait for 5 mts.. Foltowing the curve
of the hook push the barb through the skin until it is seen outside.
Clip off the barb and withdraw the hook following the curve of the
hook.
MarineMedicalAcademy Medicd Care

Minor surglcd treatment, sewing & ctamplng

In case of simple cuts or wounds that never the less require closing, it
may be possible to bring the edges together with strips of adhesive
surgical plaster alone, strapped across a surgical gau?r dressing.

Alternatively, butterfly closureso can be used. Theie consist of two

adhesive patches joined by a n€urow non-adhesive bridge. After
removing the "butterfly closure" from its envelopeand stripping off the
protective backing, the edges of the wound are brought together by
fixing the closure with one patch on either side of the wound and with
the non-adhesivebridge acrossit (seeFig.01).

Make sure that the wound edges are dry before application, or the
closure will not adhere.

Larger wounds must first be covered with a sterile gauze dressing.

Then two broad strips of surgical adhesive plaster are fixed to the
skin, one on either side of the wound. The edgesnearest to the wound
are folded under to form a non-adhesive hem. Using sharp pointed
scissors,a series of small holes is pierced in the folded hems opposite
to each other. When laced with tape or string, the edgesof the plaster
can be drawn together, and this will draw the edgesof the underlying
wound together(seeFig 02).

Closure of wounds by suture

Deep and gaping wounds cannot be closed effectively with adhesive

plaster or "butterfly closures" alone. For these wounds you will have to
consider whether suturing is appropriate.

DO NOT suture unless you can bring together not only the skin but
also the deeper tissue. A dead space will become infected and delay
recovery,and may lead to the loss of the limb or even death. Do not
suture a wound that is over six hours old. Slhea in doubt d,o not
suture.

When you decide that suturing is appropriate, you will require the
following items:
!' A length of silk of thread already attached to a surgical needle
(these are supplied in sterile dry packs, which should not be
opened until you a.reready to sta-rt stitching).
r I needle-holder (Hegar-Mayo)and scissors, previously sterilized by
boiling in water for 2A minutes.
MarineMedical Academy MediealCale

tbs sfsdlized needle-holder and scissors should be placed in the

stenllized kidney dish. Then decide exacdy what kind of repair should
be made. If the cut is linear, for example, how many stitches will be
needed? tf the cut is star-shaped, will one stitch to include the apices
of each skin flap be adequate?

Having decided on the nature of the repair, wash your hands again,
open the sterile pack, extract the needle with forceps and place it in
the sterilized kidney dish.

Pick up the needle with the needle-holder. Grasp the edge of the
wound nearest to you with the toothed tissue forceps, then with a firm
sharp stab drive the needle through the whole thickness of the skin
about 0.6 cm from its edge. Then, with the toothed tissue forceps,
grasp the skin on the side of the wound immediately opposite and
drive the needle upwards through the whole thickness of the skin so
tJ at it emerges about 0.6 cm frorn the wound edge (see Fig. 03).

If the wound is deep and ciean, insert the needle deeply it and the
skin together. Now cut suflicient thread off the main length to tie a
knot, and tie a surgeon's knot, with sufficient tension exerted (and no
more) to bring the cut edges of the skin together. Insert further
stitches as required at intervals of not less than L cm. After tying, cut
off the ends of the knots, leaving about 1 cm of thread free to facilitate
later remove of the stitches (Fig. 04). If the cut edges of the skin tend
to curve inwards into the wound, pull them out with toothed forceps.
As soon as the stitching is completed, paint the whole area with 1olo
cetrimide solution. Next, apply sterile gauze and complete the dressing
as for superficial wounds.

Stitches should be inserted using a curved "cutting" needle so that the

completed stitch is "round" (see Fig. 04).

If you have a diflicult, deep, and tense wounds to close, use a

mattress suture (Fig.05) a mattress suture ensures that the edges of
tJ:e wound are brought together not just on the surface but
throughout together not just on the surface but throughout its depth
and length.

Illote: A local anaesthetic should be necessary for the insertion of one

or two simple stitches; indeed the application of the anaesthetic may,
in such cases, be more painful than the suturing. In more complicated
cases it may be desirable to infiltrate Lo/olidocaine hydrochloride.

A greater or lesser degree of infection of the wound is inevitable after

injury, this means that a certain amount of fluid will be produced in
Marine Medical Academy MedicalCare

the damaged and inflamed tissues, and this should be allowed to

escape. Remember this when inserting stitches; do not put them so
close together that it is impossible for pus to discharge if it forms.
Also, when inspecting a wound after stitching, look closely to cee if
there is swelling or tension on a stitch in any part of the wound,
indicating the formation of pus within the wound. If there is, remove
the stitch and allow the wound to drain freely.

On the seventh day the stitches can be removed and a simple dressing
worn until healing is complete. Remember that leg wounds take longer
to heal than arm wounds. Stitches on the scalp can be removed after
6 days.

The removal of stitches is a simple and painless operation if carried

out gently. Swab the area with 1% cetrimide solution. Grasp one of
the ends of tJ:e stitch witJ: sterile forceps and lift it up, so as to be a.ble
to insert the pointed blade of sterile scissors immediately under the
knot (see Fig. 6a). cut the stitch with and, by gently pulling with the
forceps, withdraw it (Fig. 6b).

Deep and gnpiag woundr that cannot be sutured

If the wound is to be allowed to heal without suturing, lightly pack it

with sterile petrolatum gauze. Then place about three layers of
surgical gauz.e over this and make fast with bandages or elastic
adhesive plaster. Re-dress the wound daily until it is healed. If the
wound is on a limb, the limb should be elevated to encourage draining
and reduce swelling.
Marine Medical Acaderny MedicalCare

=7,i
\*_,
F ' gO l a bulterlly stnp (stin
c l o s u r)e

FrgOl A large wouno coveredwrth a ste,rle

gauze 0ress'ngano acthesrve
plasler
Ttssuelorceps (loolhed) Silk lhtead Rounct strlch

'.*liii
F r Q0 l S l r l C h r n ga w o u n d
F,g OT Cross-sectionol slitchod wound.
Sri166gtshould be ins€rt€d by using curvod
''cuttrngneedle"
so lnal compl€l€ctslilch is
round

Mattresssulu(e
( b e g r nh e f e )

f ; g 0 f , A , . a ( t fe s s s u l u r e

r i g ( o F e ' n o v ' n ga s l r l c n
 Stmple laboratoty tests

Measuremeat of:

l.Urine volume
2.Use and evaluation of urine testing sticks
3.Collectionof blood for smears.

(I) Test for measurement of urine:- In certain illnesses, the urine is

found to contain abnormal constituents when appropriate tests are
performed.
Urine glasses should be washed with detergent solution or with soap
and water and rinsed with water 3 times. First examine appear€rnceof
urine. lnok for cloudiness or haziness. Note any odour present such
as acetoneor ammonia. Check for colour. Normal urine colour varies
from pale straw to quite a dark yellow colour. In concentrated urine it
becomesbrownish. Orangeurine is due to blood in small amounts.

(21Use and waluation of urine testing sticks:- These are called stick
tests. The reagent is attached to the tip of a plastic stick and dipped
into the urine. Then, any colour change on the tip of the stick is
noted.

Clinistir- when dry, the reagent tip is pale straw in colour

compare with the standards on the container after 15 seconds. trf
suga.ris present in the specimen, the reagent area will darken and
' becomepurple.

Ketostir- when dry, the reagent tip is pale straw in colour.

Compare with the standard on the container after 15 second. If
ketones are present in the specimen, the reagent area becomes
lilac and then will darken at higher concentrations of ketones.
MarineMedical Academy Medical Care

ACUTE ABDOUINAL COIIDITIONS

Acute abdominal conditions are the conditions arising suddenly inside

the abdominal cavity. These conditions can go into complications quite
rapidly and therefore have to be managed carefully. The minor abdominal
conditions include indigestion, \rind', mild abdominal colic (i.e.
spasmodic abdominal pain without diarrhoea and fever. Abdominal
emergencies such as appendicitis and a perforated gastric or duodenal
ulcer are high on the list of conditions which should be immediately
shifted to hospital.

Etaminntion of the abdomen:

Ttre abdomen should be thoroughly examined. The patient should be

uncovered from his nipples to the thigh and the groin should be
inspected. Get the patient to take a deep breath and to cough and ask
whether he feels any pain or see if there is a swelling. [,ook for abdominal
movements.If the patient lies still with the abdomen rigid, think in terms
of perforated appendix or perforation of ulcer. Listen to bowel sound.
The conditions, their q4mptoms and probable causes are shown in
the adjoining charts.
 MarineMedicalAcademy MedicalCare

Dirgrrm POSITION ASSOCIATEDSYMPTOMS

No. AND TYPE
OF PAIN
Vomirling Diarrhoea

'All over' None Usuelly not at

abdomen,or first, but
mainly about sometimes
naveland coming on leter
lower half;
s h a r p ,c o m t n g
a n d g o i n gi n
spasms

In upper part Presentand Not at first; it

and under left usually may follow 24-48
ribs, a steady repeated hours later
burning pain

Shootingfrom May be None

loin to groin present
andresticle; but only with
very severe the spasms
agonising
sPasms

Shooting from May'be None

upper part of presentbut
, the right side only with the
of rhe sPasms
abdomento
the back or
righr
shoulder;
agonisrng
spasms
MarineMedical Academy Mcdical Care

ASSOCIATEDSIGNS
PROBABLE
CAUSEOF
THE PAIN
General Temperature Pulse rate Abdominal
conditionof Tenderness
Patient

Not ill; Normal Normrl None: on the Intestinel

usuallywalks contrsry colic
rbout, even if pressurecaSes (pege 160)
doubledup ' the pain

lVretched, Usually Slighrly Sometimes Acute in-

becauseof normal; raised,up to but not severe digestion
nausea,vomit- may be raised 80-90 & confinedto (page 129)
ing and weak- up to 37.8oC upper part of
ness,but soon ( 1 0 0 ' F )i n abdomen
improving severecases

Severeshock Normal or R a p i da s w i t h Overthe loin R e n a lc o l i c

b e l o wn o r m a l shock (kidnev
stones)(page
l 82)

Severeshock Normal or *rpa ,, *trn Just below the Gallsrone

below normal shock right ribs (biliary colic)
(page I42)
MlrincMcdical Acadcsl Medical Care

Dirgrrm POSITION ASSOCIATEDSYMPTOMS

No. AND TYPE
OF PAIN

Vomiring Diarrhoea

Around navel Soon after Sometimes

at first, onset of pain, oncc at
settlinglnter usuallyonly cOmmence-
in the lower once or twice ment of
pan ofthe attack;there-
right side of ifter consti-
abdomen; pation exists
usually
continuous
and sharp, not
alwrys severe

, All over the Present, Usuallvnone

abdomen, bccoming,
usuallysevere more and
and more liequent
connnuous

Spasmodicat lncreasingin None;

first, but later frequency complete
continuous with brown constipation
fluid later exists

In the groin, Nor ar first None, as with

a continuous but later as obstruction
and severe with
pain obsirucrion
MarinoModicrlAcrdemy MedicalCue

SIGNS
ASSOCIATED PROBABLE
CAUSEOF
THE PAIN

General Templrature Pulserete Abdominal

conditionof Tenderness
Parient

An ill prtient Normalat Raisedsll the Definitely Appendicitis

tends to lie frrEtbut time(ovcr85) pfesentin the (page140)
rtill rlwaysriring rnd tending righrsideof
lrter up to to incrcarcin the lowerpart
37.80C retehourby of the abdo-
(100"F);it hour men
maybe raised
morc

An extremely Present up to Rapid Very tender, Peritonitis

ill paticnt 39.40c (over I l0) u s u a l l ya l l (page 167)
with wasted ( 1 0 3 " Fo) r and feeble o v e r ;w a l l o f
appcarancc, morcexccpr abdomen
afraid to movc in linal stage tense
becauseof neardeath
prin

Vcry ill Normel Rising Slightly all Intestinal

steadily; over wall of obstruction
feeble abdomen,not (page 160)
h a r db u t
distended

V.rVifi Normal Rising Overthe S tr a n g ul a t e d

steadily; p a i n l u ll u m p hernia
feeble in the groin (rupture)
(page I 58)
Diagram POSITION ASSOCIATEDSYMPTOMS
No. AND TYPE
OF PAIN

Vomiting Diarrhoer

Severeand Rare None

contrnuous
pain, worst in
r h e u p p e rp a r t
of the
abdomen

r0A Lower Sometimcs Usuallynone

abdominal with onset
pain-one or of pain
both sidesjust
abovemidline
of groin
l0B Suddenonset Sometimes None
of lower with,onset
abdominal of pain
painwhich
mav be severe

ll
ll Lower None None

,4. abdomrnal
p a i n .S p a s m s
like labour
pains

V
t2

yd A continuous
discomforrin
pir of rhe
abdomenand
None None

iv\
the crutch.
S c a l d i n gp a i n
on frequenr
unnatlon
 Marine Mcdical Acaderny MedicalCare

ASSOCIATEDSIGNS PROBABLE
CAUSEOF
THE PAIN

General Temperature Pulserate Abdominal

conditionof Tenderness
Patient

Severeshock Normal or Normal at All over; Perforated

ar first, then below normal first, rising . worst over ulcer of
vcry ill; afraid at first; steadilya few site of pain. stomach
ro move rising about hours later Wall of abdo- (page l8l)
because of the 24 hours men rigid
parn later

An ill patient Tends to be Raisedall the Lower Salpingitis

-there may high time abdomen,one (page 124)
be vaginaldis- or both sides
chargeor
bleeding

An ill patienr Normal at Moderately Tenderness Ectopic

may collapse first. May raisedbut in the lower pregnancy
if internal show slight may be rapid abdomen (page 193)
bleedingand rise later and weak if
p a i na r e i n t e r n a lb l e e d -
s e v e r eT. h e r e ing continues
may be
vagrnal
bleeding

Anxiousand Normal Normal or Tendernessin Abortion

distressed. moderately the lower Miscarriage
May show raised.Rapid abdomen (pagc 193)
somecollapse if vaginal
if vaginal bleeding
bleedingis
sevcre

Made Normalbut Normalor Moderate Cysritis

miserableby can be raised slighrly in- tenderness (page I83)
frequent in severe creased in central
painful infection lower
urination abdomen
ldarine Medical Academy Medical Care

Trcatm.enl:

The patient should be confined and nursed. Give him plenty of sweetened
fluid and if he will eat should be given food. The attack may end with the
patient sleeping for up to 24 hours. First, try to calm patient with a glass
(50m1)of whisky. If this proves unsuccessful, physical restraint will be
necessary. In either event, then give chlorpromaaine Somg by intra
muscular injection. This may be repeated after 6 hours if the patient is
still uncontrolled. In addition give diazepam lomg by month and repeat 4
hourly until the patient is calm. Once treatment has started it is
essential that no mone alcohol is given. If in doubt about diagnosis or
treatment get Radio medical advice.

I
I
I

I
I

I
I
Marine Medical Academy Modical Care

Nurstng Care

Nursing care is concerned with the care & treatment of bed patients
till they recover or are sent to the hospital.

- Cheerful, helpful & intelligent nursing encourages the patient to

a positive attitude to his illness.

- Firstly the patient should be put in the ship's hospital or in a

separate cabin.

- Adequate ventilation to be made.

- Check temp, pulse & respiration twice daily.

Clra;ek li"st:

1 . Ensure patient is comfortable

2 . Check Temp, Pulse & Respiration twice
3 . Keepa written record of illness
4 . Specifynormal diet or dietary restrictions
5 . Check the input / output of patient
6 . Remake the bed atleast twice a day

Vita.l signs:
- Temperature
- Pulse
- Respiration
- Blood pressure
- Levelof Consciousness

Temperature:

To be taken twice a day at the same hours or frequent according to

the symptoms. The body temperature is recorded using a clinical
thermometer. The thermometer should be kept for atleast one to two
minutes in the mouth under the tongue.
The normal temp is about 37o Celsius with the range of 63.3 - 37.2oc.
Body temperature is low in dehydration, bleeding & hypothermia.
Body temp is raised in fever & Heat illnesses.
MarineMedical Academy Medical Care

Tfeatment:

The patient should be confined and nursed. Give him plenty of sweetened
fluid and if he will eat should be given food. The attack may end with the
patient sleeping for up to 24 hours. First, try to calm patient with a glass
(50m1)of whislqy. If this proves unsuccessful, physical restraint will be
necessarJr.In either event, then give chlorpromazine Somg by intra
muscular injection. This may be repeated after 6 hours if the patient is
still uncontrolled. In addition give diazepan lomg by month and repeat 4
hourly until the patient is calm. Once treatment has started it is
essential that no more alcohol is given. If in doubt about diagnosis or
treatment get Radio medical advice.

I
I
hlse:

Rrlse rate is the nurnber of heart-beats per minute. The pulse vgries
according to the age, sex & activity.

Normal Pulse rate

2-5 years about 100 / min
5-10 yea.rs about 90
Adults male a5-80
Adults female 75-85

Also record whether the pulse is regular or irregular along with the
volume of the pulse.

Respiratiolr:

Rate varies according to age, sex & activity. It is increased by exercise,

excitement & emotion & decreasedby sleep and rest.

Normal respiratory rate (number of breaths per minute).

Age - 2-5 years 24-28 per minute

5 years - adult progressively less
Adult male 1 6 -1 8
Adult female 18-20

Always count respiration for a full minute noting any discomfort in

breathing-in or breathing-out.

The ration betweenRespiration& pulses 1:4

Blood pressures

Readings are obtained using a sphygmomanometer and a stethostope.

The patient should lie or sit and the arm that is to be used should be
supported.

Washing & cold spoaging:

Patients who a::e confined to bed should be washed all over at least
every other day. Wash the patient beginning with the face. Wash and
dry one part of the body at a time so that the patient is not uncovered
all at once.
After finishing, dust pressure aneas& skin creases with tatc. The bed
linen should be changed as frequently as necessarJr.
 ha spo:ngirryrcold should be applied to any part of the body that is
injured & may bleed in order to narrow the blood vessels & prevent
hemorrhage. cold apptications are also indicated in persons with
certain infections. Ice-packs are frequently used when bleeding is
likely. If paleness or blueness of the skin appears the application of
cold should be stopped for lS mins & then resumed.
&ld moist @mpnessesi often applied to an inflamed (reddenedcye) to
lower the blood flow to the eye. This can be appiied with Cterile
compressesof eye"padsfor a total of l5-20mts.
 SHOCK

Shock is a generalised body reaction to injury and to some acute

illnesses and can range from a feeling of weakness or faintness to
completecollapseor unconsciousness.

Causes:- (a) Commonestcause is loss of body fluid from the

circulation either due to bleeding,burns or
dehydration (Hypovolemicshock)
(b) Due to circulatory failure as in cases of heart attacks
(cardiogenicstock)
(c) Due to severedemotional impact (psychogenicshock)
(d) Due to intense intolerable pain (Neurogenicshock)
(e) Due to severeallergic reactions to foreign proteins,
medicines or insect bites (Anaphylactic shock)
(f) Due to septic conditions after a wound (Septicemic
shock)

Sgmptoms& stgrns:-

The patient - lies still with no heed to surroundings

- complains of chilliness, thirst
- has a faintness feeling
- has blue lips, nails, eyes
- general skin will be Pale, cold and clammy i
- pulse - rapid & weak
- respiration - rapid and shallow. As shock deepens I
it might becomeshallow
- I
may vomit
- I
if untreated may lapse into unconsciousnessand
later die.

Treatment :

1. Primary aim is to treat whatever condition is causing the shock.

2. Give a headlow position or elevatethe feet and the legs.
3. Do not move him unless in a position of danger
4. Stop any blood loss, cover any burns or scalds, immobilise any
fractures
5. Loosen any light clothing for better breathing
6. Keep the patient warm
7. DeaJwith pain, morphine is given if necessary
8. If casualty is consciousgive fluids
9. Move to the place of safety as gently as possible
lO.Placein an unconscious position (recoveryposition) if ABC is normal.
 MarineMedicalAcademv MedicalCare

DISEASES
Communicable diseases

Diseases which are passed from person to person either directly or

indirectly. They are divided into 4 broad categoriesas follows.

a) conragious disease:-communicated by direct contact e.g. - STD's

& erysipelas.

bl Infedions disease:- Transmitted through air by droplet infection

like coughing, sneezing or even talking e.g. influertz.a,meningitis
measles TB etc.

c) Ingested diseases.'- contracted by swallowing fluid or solid

. foodstuff which is infected with harmful agents or parasites e.g.
Typhoid, cholera, dysentery, food poisoning & worm infestations.

d) Parasitic diseases:- spread by bite of an intermediary host, like

flea, louse or mosquito, e.g. yellow fever, t54phus,malaria.

Incubation period:- is the interval of time which elapses between a

person being infected with any communicable disease and appearance
in him of the s/s of that disease.

Isolation period:- Signifies time during whicir a pt. suffering from an

infectious disease should be isolated from others.

Segregation period:- Period during which a pt. who may be incubating

an infectious disease should be segregatedfrom others.

Quarantine period:- means time during which port authorities may

require the ship to be Bloated from contact with the shore esp. foi
serious epidemics like plague, cholera, yellow fever.

Essential ba.sic tttles :

Isolate:- For anybody suffering from a temp without obvious cause

it is best to isolate him until a diagnosis is made.

ii) 9t.ip the patient to make a thorough examination for any signs of
rash.
lvlarineMedical Academy MedicalCare

iii) Put him to bed & appoint someoneto look after him.

iv) Give non-alcoholic fluid.

v) If ternperature exceeds l03of, make arrangements for tepid

sponging.

vi) Arrange for bed-pan & urine-bottle if pt is prostrated.

vii) Seek RMA in case of doubt for diagnosis and the pt is seriously ill.

viii) Treat sympt;ms as they arise.

A If feeble do not attempt to get the pt up

x) When approaching port send a radio messagegling details so that

the health authority can make arrangements for isolation.

Tropical & infections dlseases

CHoLERA
I
Gause.-Infection occurs through infected water & contaminated
uncooked vegetables,fruits, shell fish or ice cream. 1

Tieatment:- Pt should be isolated, complete bed rest, Replacefluid & loss,

i
drink as much as fluid possible for about 2 days.

Tetracycline Soomg6 hrly, If vomiting glve cyclizine lactate 5O mg IM.

heuention :- Travellers to the aJfected area should be inoculated. ft

should be isolated for 4-6 wks until declared free from infection after
'bacteriologicalexamination.

DENGUE FPVER

Cause:Conveyedby mosquito

Treatmenl: Not specific soluble aspirin or paracetanol will relieve some

pain. Calamine lotion for itching, rash.
Marine Medical Academy Medical Care

ENTERIC FEVER (Tlphoid)

cause: by drinking water or eating food contaminated by typhoid germs.

Treatment:

General:-should be kept in bed in strict isolation, until seen by a doctor.

The pt's urine, stool and vomitus should be disposed off as they are
highly infectious. Pt should scrub properly after toilets. The attendants
also scrub properly. The pt should be encouraged to drink as much as
possible.

Specific:Get RMA. Amo4ycillin 5OOmg 6 hrly for 2 wks.

heuention: by strict isolation. Also typhoid inoculation (Tlphoral) can

give some protection.

INFLUENZA- Acute infectious disease

Cause:gerrn inhaled through nose or mouth often occurs in epidemics.

s/s; onset is sudden. Almost like common cold. Later shivering,

bodyache,breathlessness,palpitations headache,fever.

General treatment- standard isolation

Watch for signs of pneumonia, breathlessness,
chest pain, bluish lips,
Give plenty of water to drink
Give light nutritious diet

Specific treatment- no specifictreatment

2 paracetamol / aspiring tablets every 4 hrs until
temperature is normal.

MALAR,IA

Recurrent fever caused by germs introduced into the blood stream by the
bite of Anopheles mosquito" This mosquito is common in marshy places
where if breeds by layrng its eggs in water.

S/s;

Fever, debility, nausea, vomiting, headache, bod5rache,coma, death.

MarineMedicalAcademy Medical Care

(21 Temp. pulse, respiration to be taken 4 hrly.

(3) If body temperature rises to 104oF and above, cooling should be
carried out by Tepid sponging, ice packs or cold wet compresses
may be applied to the forehead, arm-pits and groins. Iced drinks
should be given.
(4) Fan to be used to increase air movement and evaporation from
skin.

Specific Treatment:

(1) Chloroquine phosphate 25omg - 4 tabs at once

OR Chloroquine sulphate 2o0mg - 4 tabs at once
(21 2 tabs six hours later
(3) 2 tabs every 24 hrs for 3 days.
(4) For chloroquine resistant malaria (Far east & Southern America)
give Quinine sulphate 600mg twice daily.
If treatment continues for more than l0 days get Radio Medical
Advice.

Y-ELLOWFEVER

Cause; virus transmitted to humans by a mosquito. Endemic in Africa,

Central & South America.

heuertion:

(1) Travellersto these areas should be inoculated.

(2) Many countries require a valid International Certificate of yellow fever

inoculation for those who have been to such areas.

General Treatment :

(1) Bed rest in a room free of mosquitoes.

(21 Increasefluid intake
(3) For high fever - tepid sponging
Ice packs on forehead, arm pit, groins fanning to
improve air circulation.
ldarine Medical Academy Medical Care

Prcuention : (1) Avoidance of mosquito bites

(21 Prevention of infection

Avoidanceof mosquito bites: within 2 miles of a malaria

(a) Doors should be kept closed at all times after dusk

(b) Use insecticide spray.
(c) Persons going out shoulcl wear long slewed shirts and
trousers
(d) No pools of stagnant water should be allowed to develop,
where mosquitoesmight breed.

In ships which are not air conditioned:

(e) Fine wire mesh over portholes, slqylightsetc.

(fl Screeninglights to avoid attracting mosquitoes.
(e) Fixing mosquito nets over beds.

heuention of infedion :

(1) Progmanil hydrochloride 100mg everyday should be given to

persons over 9 yrs of age. Starting one day before entering
and during stay in malarial area and continued 40 days after
leaving the area. Half the dose for children below 9 yrs. No
side effects.
(21 Chioroquine phosphate or sulphate - if in a.reas where
malarial parasites are resistant to Progmanil.
Dosage- adults & children over 9 yrs - 1 tab twice weekly
Children below 9 yrs - 1 tab twice weekly.
Treatment should start I week before and upto 6 weeks after
stay in malarial area.

(3) Maloprim - for malarial parasites highly resistant to

chloroquine.

Dosage: persons over 10 yrs - I tab once weekly

Personsbelow 10 yrs - % tab once weekly
Treatment should start 1 wk before and upto 6 wks after
stay in malarial area.

CieneralTfeatment:

(U Bed rest in cool place

fu{arinehdedicalAcademv \!, !. ..-

SEXT'ALLY TRANSMITTED DISTASES

Frevention:

There is no protective inoculation against them.

Preventivemeasures recommended are:

(t) Rubber sheathes (Condoms)- should be made easily available to crew

members
(2) Passing urine and washing genitalia immediately after sexual
intercourse
J) Enquiries should always be made about the sexual contacts of anyone
found to be suffering from any STD. The contacts should alw,?,"yp: F;
advised to seek advice & treatment. ,,:::,1 ' .tl. l t'..i

URBIHRITISI

Inflammation of the lining of the pipe which leads from the bladdeitri thei
top of the penis.

S/s: (1) Itching at the opening with a scalding pain on passi4g.urig,g..,..;,

(21 Thin milky discharge which progressively becomes thick dnd
greenish yellow.

htse; (1) Gonoccocal 2) Non-gonoccocalurethritcs.

:" :.i''':' '
rwatnbnt.t'
'l ' :
. , 1 ,, r ' " j
r i . . , . ii , . - , 1 ,.],' t . .' :

(U Co-trimox azxile l+4O mg twice daily for 3 days

. i'!r' ; ''; '' thtrt: ',". 960 fng twice daily for 5 d-ay"
' ,,
( 2 ) ; . r : ' X r uA6l c d l o l , : : : i i " : , .;i
isit*, $exuafeCtivitJ,"fofbtdden
tiit advisedby D&tor.

BAIAITfIIS: ''
-,.-::l f't.l
i::iir..f;t,;t

Infectidf 6f,:dr€arunder the' foieskin' and:'arbdnd ifie' head'of penis which

usually causes redness, mottling and a discharge. _
. . r,:..i,.".1ir
* {,,{i{ir;:;
nrir{T

Trestmenl :
qri{
t 1) shiwrwnltrete 2v/ocieam- local application
 (2) Before-application wash the afiected area with soap and water and
dry with tissuepaper.
(3)Avoid scxualcontact until condition clears.

OEIIITAL UI,CERS:

An ulcer ls a raw arce on the sldn, often accompanied by a discharge of

pu8.

Caugcsof genital ulcers

(1) Syphilis (comrnonest)

(2) Chancroid
(3) Hcrpes genitalis

I S}PHILIS

Caused bg: a germ - Spirochaete of qphilis.

Mdp of fiansmlssdorusexual intercourse or kissing.

Sqtr?s& Sg:mptoms:

First Stage -hard chancre which shows itself 2-4 weeks after infection
which begin as a small pimple on or around the genitalia.
usually painless. The pimples breaks down and forms an
open sore around which the flesh ie. Usually thick and tough
making the underlying tissue hard. Gtands in the gro.-in
usually become enlarged like rubbery lumps and are
painless.

Second Stage-begins 6 weeks after an untreated hard chancre has

appeared. Headache, slight fever, rash or body face & limbs.
Highly contagrous stage - disease can spread thro'contact.

Third Stage- develops after a period of years.

Tleatment:

No treatment with an antibiotic should be given on board except under

direct instruction of a medical ofiicer.
II Chon rvid / tufi sore

Bacterial infection contracted during sexual intercourw. 3-5

days after sexual contact a small blister appears on the head
of the genis. The blister soon breaks to form a roughly oval
or rounded.

III Herpes Genitalis

This common infection by herpes virus causes ulceration similar to that

produced by cold soreson the lips and around the mouth. The head of
the penis on the inner surface of the foreskin are aJfectedby a patch of
redness on which pin head sized blisters from and later become septic.
The blisters invariably break to form multiple shallow ulcers.
I
In contrast to chancroids, herpetic ulcers remain superficial, their I
edgesare not well defined and if is unusual to find much painful I
enlargement of the groin lymph nodes. t

I
Herpes genitalis is often a recurring condition so always ask if there
has been a similar attack in the past.
I

I
he-clinical treatment of genital ulcers: I
Aim - To absorb any discharge and to prevent discomfort by the
application of an unmedicated dressing.

Dressing can be dry a lubricated with a smear of petroleum jelly.

The dressing may be changed as often as necessarJr.

Genital ulceration may be highly infections, so wear polythene gloves

and use instruments when handling the genital area and the dressing.
After applying a dressing, burn the old one, boil the instruments and
scrub your hands.

On no account should a genital ulcer be treated by local applications of

antiseptics, creams, ointments, or other medications.

If the ulcer is painful, give the patient paracetimol zuitable aspirin.

MarineMedicalAcademY MedicalCare

AIDS

The Acquired Immune Deficiency Syndrome (AIDS), recognized as a

disease in 1981, has become a major public heath concern throughout
the world. In western Europe and north America, the disease has been
observed mainly in male homosexuals, while in central, eastern and
southern Africa and in some countries the Caribbean, it is seen primarily
in hetrosexuals. Other risk groups a-re recipients of biood or blood
products, intravenous drug abuses, and partners or offspring of infected
persons.

This condition is caused by the Human Immune-deficiencyvirus (HIV),

which has been found in various body fluids of infected persons.

Mode of Transmissron;

All infections appear to result from contact with

(1) Se m en
(21 Vaginal and cervical secretions
(3) Blood or blood products
(4) Vertical transmission - from mother to child.

There is no evidence that the virus is transmitted through casual contact

with an infected individuai e.g. at the workplace. The risk of infection to
health workers is verv low.

Stbns & Sgmptoms:

Following a latterly period of between 6 and 6O months about 2o-25o/oof

infected individuals may develop a non-specific condition known as AIDS
related complex.
(1) Fatigue
{21 Low grade fe'"'er
(3) Night sweets
{4) Generalized enlargement of lymph nodes, hand and not painful
t5) Persistent diarrhea
(6) Weight loss of more than 10%

Some 2o-25o/oof the infected persons may develop the full clinical picture
of Acquired immuno deficiency syndrome within 5-10 yrs after infection.
In addition to the severe weight loss or diarrhea lasting for more than a
month, patients may suffer from
Marine Medical AcademY MedicalCare

(1) Pneumonia's caused by various organisms

(21 Skin ulceration
(3) Meningitis
(4) Other severeinfections
(5) Malignant vascular tumors in the skin
(6) WhiG patches of yeast infection on the mucosal surface of the
mouth (thrush), usually extending into the pharynx.

Tleatment:

To date there is no therapy that can restore the immune functions of a

patient with AIDS. Treatment for AIDS patients consists of specific
the.apy for the opportunistic diseasesoccurring in the individual case.
Refer to specialist at the next part of call.

heuention of sentallg transmitted diseases:

Being outside their normal environment and often in circumstances that

allow for promiscuity, sailors are at special risk of contracting STD S

(1) Avoidance of casual and promiscuous sexual contacts

(21 Mechanicalcarrier - condom
(3) In women, use of diaphrogen in combination with a spermicide
cream offers some protection.
t4) In risk situations the male partners should urinate at once after
possible exposure.
(5) Each partner should subsequently wash his or her genital and
other possibleinfection areas.

Use of Condom:

A condom or rubber is a thin elastic covering that forms a protective

sheath over the penis. If properly used it should prevent infection during
intercourse, unless the point of contact with an infected lesion is beyond
the area covered by the condom. The condom comes rolled before use.
The tip of the condom should be held by pinching it between the fingers
and the rest of the condom unrolled to cover the entire penis. The
pinched part forms a pocket to hold the ejaculate. As soon as the male
has had an orgasm, the penis should be withdrawn from the vagina
before it softens, becauseloosening of the condom may exposethe penis
to infection. The condom is removed by grasping the open end with the
fingers and pulling it down quickly so that it comes off inside out. The
MrrinoModicCAcadcnty Medical Car€

condom should be discerded without further handling in caee it contains

infectious material.
ItdarineMedical Academy Medical Care

ALCOHOL AND DRUG ABUSE

Deaths of seamen are recorded every year either as a direct result
of the excessivedrinking of liquor or related accidents.

Minnry drunleenness:-it is characterised by poor muscle control,

difficulty in walking and talking and to perform functions. Face is
flushed and eyes are bloodshot'. The person may be in a happy,
excited mood or Iighting drunk or depressed.

Dead drunk:- When a large amount of alcohol is taken serious

poisoning may develop. This may lead to respiratory or heart
f,ailure. A man who is 'dead drunk' lies unconscious with slow
n-oisybreathing, dilated pupils, a rapid pulse and some blueness of
the'lips. His breath will smell of alcohol.

Tfeatment:- If person is conscious water to be given. If 'dead'

drunk, don't give anything and monitor his condition.

For hangover give plenty of fluids, paracetamol tablets and if

necessa-rJr
magnesiu m trisilicate compound 260mg.

DRUG ABUSE
Different types of drugs are abused by the seafarers like cannabis,
ma-rijuana etc. Prolonged use of drugs results in the following
conditions.
- Unexplained deterioration in work performance
- Unexplained changes in the pattern of behavior towards
others
- Changes in personal habits and appearernce,usually for the
worse
- Loss of appetite
- Inappropriate behavior
- Needlespunctures on skin of arms and thighs or septic
spots which are due to unsterile needles
- Jaundice through the use of improperly sterilized syringes
and needles.
MarineMedicalAcademy Medical Care

If you have suspicions, malre enquiries of other cnewmembers.

Tteatment:- Remove any drugs from the patient and try to identify them
and their sounce. Always obtain Radio Medical Advice. If the patient is
unconscious, give the appropriate treatment.
MarineMedicdAcdemv MediealCare

Baslc Dental CFre

ktnclpla of cd hyglcae

Good dental care has to be maintained so that the teeth & gums
remain healthy.

The main aims of good dental care should be to prevent gum disease,
cavities of the teeth & injections in the oral cavity. The basic dentd
care consists of, .

U Bmshing teeth at least 3 times a day espdcially after meals. Ttre

brushing of teeth should bc done thoroughly inside out & above
downwards. The tooth-brustr used has to be soft. The brushing
strould be gentle.

2l Flossingthe teetlr regularly once a week.

3l Gargling the mouth dter every meal. For gargling mouth wagh
solutions like listerine can be used.

4l For removing particles, use of tooth-picks should be provided.

5) Regular dental check-ups should be carried out.

6) Gum disease, infections should be treated with antibiotics.

 kegnancy and Femde Dlsorders

Delayed Menttruatlon

Pregnancg: The cofirmonest causes of delayed menstruation in a

healthy woman whose cycle has preciously been regular if she has
been sexually active and menstruation is two weeks overdue she
should consult a doctor for pregnancy testing when convenient.

Other causes.' of delayed menstruation are an irregUlar cycle, mental

or physical stress and disease. In every case, the previous menstrual
history should be recorded.

Bleedlng durlnrr Prernrancv or Suspected Prennancv

Pregnant women should not be at sea. Suspect pregnancy if the

patient:

1. Has missed one or more periods.

2. Has morning sickness nausea or vomiting.

3. Thinks her breasts are larger and heavier than before.

4. Thinks her nipples with the surrounding pigmentation have

darkened.

5. Has to urinate frequently.

The abdominal swelling is rarely noticeable before the 16ft week of

pregnancy.

Bleeding duriag first 6 months:

A threatened of inevitable miscarriage. The patient should be put to

bed and kept there until the bleeding stops as if may in threatened
miscarriages. If the bleeding does not stop and is accompanied by
pain, miscarriage is inevitable.

Bleeding during the 7h to 9tb month of Pregnancy:

This is likely to be the onset of labour (childbirth) or an abnormal

position of the after birth (placenta) in the womb (uterus). In either
case the woman should go to bed and stay there until she can be put
ashore immediately. No drug apart from paracetomol, should be
given to a pregnant woman except on the advice of a doctor.
 MarineMedicalAcademy MedicalCare

Ectoplc Prqnracyt

An ectopic pregnancy occurs when a fiertilized eg beingS to develop

outside the womb - often in the tube leading from an ovarJr to the
womb. About 1 per 100 pregnancies are ectopic.

Ttre growing egg may split the tube within 3 weeks of a normal
menstrual period or at any time upto the 8h week of pregnancy.

Slglr ead r5roptonr:

1. Usually one menstrual period will have been missed before pain or
bleeding or both appear.
2. Moderate to severe pain in the abdomen accorntrtanied b5ra orrall
amount of irregular vaginal bleeding.
3. Tlee blood is often dark in color like coffee ground.
4. A little pain and vaginal bleeding - miscarriage.
l.ot of pain and vaginal bleeding - ectopic.

When the tube sptts a blood vessel may be damaged causing severe
internal bleeding with very abdominal pain and collapse.

Miscarriage:

The usual time for miscarriage is around the 12e week of pregnancy.
About 2oo/oof pregnancies tend to end in miscarriage.

In threatened mlscarrlage the women notices slight bleeding and

discomfort similar to normal menstrual pain. She should be put in
bed and kept at rest under observation until her symptoms ccases.
Thereafter she should rest for several days and be excused all
strenuous duties until she sees a doctor at the next port. If pregnancy
' is confirmed she should be paid off ship.
If the pulse rate rises either with or without severe bleeding, give
ergometrine 0.5 mg intra muscular remove all pillows and nurse the
patient flat in bed. This injection may be repeated 2 hours later if the
pulse rate is still high and bleeding continues. If bleeding continues
and patient is restless and distressed give morphine 15 rng may be
given.

Chttdbirth
Although pregnant women should not be at sea, one may sometimes
bson board ship and cornsrence labour during the voyage.
Marine Medical AcadunY MedicalCare

If full term pregnancies most births are normal but some without fore
warning can give rise to medical and surgical problerns threatening
the lives of both mother and child.
Premature birth ie more likely on board. The earlier the birth, the
greater the danger to the life of the child.
A child is born normally about 40 weeks after the mother becomes
pregnant.

Onset of child birth:

When a women goes into labour she start having pains at intervals in
the lower part of her back and abdomen. At this stage seek Radio
Medical Advice and keeP in touch.

The labour pains become stronger and more frequent over a number
of hours, until they occur every minute or so. About this time, there
'show', which consists of a small amount of blood
will probably be a
and mucus tricking from the vagina. The birth process has now
started to take place. Usually in a short time, but sometimes only after
several hours, the bag of water in which the infant is enveloped in the
womb bursts, and quite a large amount, 250 to 500 ml (L12 pintto I
pint), of a stici<y watery fluid will escape from the vagina. The woman
should be encouraged to empty her bowel and bladder at the
beginning of labour. It is also important that the bladder is kept empty
thiough labour. The separate stage of descent and delivery of the child
may last from half an hour to several hours.

Preparation for birth

A suitable cabin should be made ready in good time. If possible it

should be large enough to allow access from both sides and from the
foot of the bunk. If the ship's hospital is to be used, any other patient
should be moved out to other accommodation. Alternatively, if the
patient cannot be moved, or if the hospital has recently been used for
i patient suffering from an infectious illness, the confinement should
be made as clean and as hygienic as possible. It should be kept warm
but not too hot at a temperature of around 2Io c (700F). a waterproof
sheet should be put across the bunk immediately under the top sheet
in order to protect the mattress.
Then assemble:

. A plentiful supply of hot water, soap, flannels and towels,

r Bed pan,
. Sanitary towels (not tampons),
. Sterile receptacle for the afterbirth,
. Plastic bag in which to store the afterbirth,
. 4 pieces of tape each about ten inches long,
MarineMedicd Acaderry MdicalCare

. Surgical scissors,
. Cotton wool,
r 2 small sterile dressings,
. bandages, dressings, and swabs
. certrimide,
r in a kidney dish, a syringe pack and ergometerine O.5o/o.

All unpacked instruments and the tape must be sterilised by boiling

for at least ten minutes. In addition it wil be necessar5rto have ready
for use, a clean soft blanket in which to wrap the child, a suitable box
with clean sheets for the mother after the biith.

The attendant(s) at the birth should be in good health and not

suffering from coughs and colds or any infectious disease, diarrhoea,
or any skin disease. Before doing anything for the mother or baby, the
attendant(s) must wash and scrub their hands, wrists and foreanns
thoroughly with soap and water, and should, if possible, have freshly
laundered clothes or a freshly laundered overall or gown to wear.

The birth
The mother should be in her bunk by the time the labour pains are
occurring every ten minutes or so. Temperature, pulse and respiration
rates should be taken and recorded every hour. If the mother has had
a child before, it will probably be unnecessary to give much advice,
but if it is a first child, she will naturally be more apprehensive, and
may ireed to be encouraged frequently and told that she is doing well.
Make her as comfortable as possible, preferably on her side, with the
head supported on a pillow, and her side, with the head supported on
a pillow, and her knees drawn well up. She should be kept warm, and
can be given a warm drink, if necessary, but no alcohol. The mother
should bot be left alone for long periods. Preferably somebody should
be with her particularly during the later stages of labour when the
pains can be quite severe and she may become distressed. Advise her
not to bear down or to push with the pains in the eady stages but
rather to breathe quickly so as to lessen their effects. Premature or too
rapid an expulsion of the baby's head may tear the vagina.

The baby usually emerges head first and nothing shoul<i be done at
tJ'.is stage other than to clear any membrane from the baby's nose and
mouth so that it can breathe and to check as the neck appears that
the cord is not wrapped around it. If it is, pull it over the back of the
head down to the front to free it. If the cord is tight around the neck,
knot the tapes tightly, about an inch Apart, round the cord, cut
between these witb the surgical sciscfiFs *rnd separate the severed
ends ftom around the babyb a€ck tFitfuro Ot).
 MedicalCare
MarineMedical AcademY

clear of the
As soon as the baby is completely born it should be lifted
p"ttittg o/rr the tord, which is still attached to the
mother without -*"k"-",rre
placenta. Again, that the bay's nose and mouth are not
then hold it
iovered Uy anyttring which would stop it from,breathing,
a few seconds to
firmly bui very eer;tly upside down (Figurg 021' for
etc' if it is
attow any fluid 6 ar*itr tut if the baby's throat and nose
it upside do-*t
,rot U.""it ing, give it a sharp slap on its back and hold
breathe,
io, few sec-onis more. Thi; will usually ensure ttrat it does
" mouth with your mouth
but if it does not, cover the baby's nose and
puff: of- air.
and give gentle artificial respiration using very small
side, where
When"the 6aby is breathing, lay it down, preferably on its
you can *rt"h its progresi and, with sterile swabs soaked in sterile
water, clean the babY's eyes.
pieces of tape
Then when the cord has stopped pulsating, tie two
5 cm (2
,Ofr,fy around the cord; one pilce oflape shouid be tied about
2y" WI (1
in"cfres;from the baby's abdomen, and the other piece about
cut between the
inch) further along tlie cord towards the mother; then
two ties. Fut a dressing on the baby's abdomen over the stump
"t"iil" next five
of the cord, and wrap ttre child in a soft blanket. During the
if it is, tie the
rninutes, check wheiher the baby's sturnp is bleeding;
third piece of tape around the cord (Figure 03)'

Actious after tYing the cord

your
You should deal with the baby as quickly as possible, so that
quietly,
attention can be directed to the mothlr. She should be resting
of tl.e
and there may be a siight loss of blood mixed w'ith the remains
fluid from the bag of water, which need cause no concern. If, however'
part of
bleeding is exces",sive,you should. put one hand--on the lower
wiil be recognised as a
the abdomen and feei for the womb, which
Try
1ump, rising up from the pelvis, about the size of a small coconut.
to keep the womb hard by gentle massage. About 15 to 20 minutes
more
after tire birth of the baby, the mother wilt probably have some
pains and the afterbirth (placenta) will be expelled naturally with some
ttooa. The placenta is a-fleshy-looking object, like a flat cake, about
cord
15 to 20 cms (6 inches to 8 inch"") itt diameter, with the
of the
attached to its centre. Do not attempt to hasten the expulsion
and
afterbirth by puiling on the cord. ThJ cord, placenta, membranes
should be placed in
pieces of material wttictr come out of the mother
can be
ihe plastic bag, sealed ald stored in a refrigerator until they
to a hospital or doctor for
taken with the mother and child
examination.
After the e4pulsion of the placenta, prepare an injection of ergometrine
injection
0.5mg and give this in o.s mg .Ild gitt" this intramuscular
MarineMedicalAcadernv MedicalCare

into the upper other qua&ant of the buttock. This injection will make
the womb conEact and lessens the danger of hemorrhage.

The mother should now be washed, given a clean sanitary towel and a
clean nightdress, and the bed remade with clean sheets. If the birth
has caused any external tears, get RAI)IO MTDICAL AXInCt about
the need to stitch any of them. Afler the mother has been made
comfortable she should be given a warm drink and allowed to hold the
baby to the breast for a short while. She will then probably want to
sleep.

Someone must stay with the mother for at lest an hour in case sterts
to hemorrhage. In which case get RADIO MEDICAL ADVICE.

Probleme durlng the bltth

If during the birth there is any departure from the normal get RADIO
MEDICAL ADVICE.

Subsequent managemeat
I
The care of the mother and of the baby should be handed over to a
hospital or doctor on shore as soon as possible, but in the absence of
skilled help and until they can be put ashore the following regime
should be adopted. The mother's temperature should be taken nlght I
and morning and if there is any rise of temperature ab<yve 37.8oC
(100oF')give penicillin V 500 mg at once followed by 250 mg every 6
hours for 5 days. If the mother is allergic to penicillin grve
erythromycin. A full course must be given. If the tennperature remains
normal, however, and the nlother feels well, she should be encouraged
to get up for a time each day after the first 24 hours. She should have
a normal diet with plenty of fluids, including milk. During the first few
days of convalescence, a watch should be kept on her bladder and
bowels. She may have a little di{frculty in urinating at first, due to the
stretching of the muscles and general soreness of the area. This is
usually overcome with encouragement and reassurance.

Attempting to urinate while sitting in a warm bath rrill often help

initially. If the bowels tre not open after three days, a mild la<ative
should be given.

The baby should be put to the mother's breast soon after birth, and at
frequent intervals there after. The milk flow is usually established by
the second or third day. Both breasts should be used at each feed,
and seven to ten minutes at each breast should be allowed. For the
first few days of 1ife, a baby usually loses weight, but birth weight
should have been regained by the tenth day.
The baby should be washed after 24 hours. Prepare a bowl of warm
water, some toilet soap and a clean flannel. Lay the baby on a towel
and gently wash the scalp, face and body so as to remove the white,
war-like material which covers it. Leave the area round the cord
unwashed, keep it dry by covering it with a sterile dressing. After
carefully during the baby by patting it genfly with ttre towel, the cord
should be redressed qrith a new sterile dressing. The dressing should
be renewed every two or three days. Normally the cord shrivels up and
comes away in about ten days.

Tragedte:

If the baby is dead or definitely badly malformed, get RADIO

UTDICAL AI)VICT.
MarincMsdicd Acade,mv lvtedicalCare

H e a dd e l i v e r s" l a c ed o w n . , 'i . e ,
l o o k i n ga l o n gb a b y ' ss h o u t d e r

H e a d t h e n r o r a l e s t o f a c e b a b v ' sf r o n r
Suppon head gently

U m b r l i c a lc o r d m a y b e
aroundhead or neck - see texl

',
D e l i ver yol a oaby.
Marine Medical Academy Ivletlkal€arc

Drarn baby'3 th/oal and nose Hotd carslullY,

b a O y r s c o v s r a d I n a s l r P P € I Ys l r m e

l m m e d i a t e l ya l t e r b i r t h

Tie and cut the umbilical cord.

Marine Medical Acaderny MedicalCare

IIT CAST OT DEATH AT SEA

TVO IUPIORTATITITIoAES:

1. RELIEVE PAIN IN LAST STAGES

2. DIGNITY OF DECEASED TO BE PRESERVED

SIGJVIS& SrffinOUS OF DEATIIT

1. HEART STOPSBEATING
2. BREATHING STOPS
3. EYES DULL, PUPILS- WIDELY DILATED AND
NOT REACTINGTO LIGHT.

UISTA,iEN DEATTTI'Y CASES ON

1. LARGE DOSES OF SEDATIVES

2. SEVERE SHOCK STATE

1. NATURAL0LLNESS)
2 UNNATURAL (INJURIES)

RECORDOF ILLNBSSSHO(/,D BE MAINTAINDD

FCIR.WQUIRIESLATER.
 MedicalCare
Marine Medical AcademY

PROCEDURT AI'TTR DEATTI

1 . TAKE PHOTOGRAPHSTO ILLUSTRATEFIOW DEATH OCCTTJRBED

2 . CLOTHES& AND ALL BELONGINGS-

STRIPPED86PRESERVEDIN LABELLED
PLASTICBAGS AND HANDED OVERTO
AURHOzuTIESARE WET _ THSY SHOULD BE
RECIEPTAFTER DELIVERY

3. EXAMINATIONOF BODY:

> RACE
> SKIN COLOUR
> APPROXIMATEAGE
> HEIGHT _ MEASURED WITH BODY FULLY
STRAIGHTENEDOUT
> DEVELOPMENTOF BODY - WHETHER
FAT, THIN, MUSCULARETC.
> HEAD & FACE - HAIR LENGTH & COLOUR
- COMPLEXION
COLOUROF EYES
. SHAPEOF NOSE
. TEETH _ SOUND,
DECAYED,MISSING
. DENTURESSHOULD BE
REMOVED, CLEANED
AND PLACED WITH
OTHER ARTICLES
> BIRTH MARKS, MOLES, TATTOOS,SCARS
> NOTE CIRCUMCISIONOF DONE
> IF BULLET INJURY _ NOTE BLACKENING
AROUND ENTRYWOUND & BIGGER EXIT
WOUND
> CHECK FOR BROKEN BONES

NOTE:ALL OBSERVATINALNOTESTO BE
AND ENTzuESMADE IN OFFICIALLOG-BOOK
COUT.ITNNSIGNED

DISFOSAL OF BODY

1. RETENTIONFOR POST-NORTEMEXAM. OR BURI.ALAT

SHORE _ WHENEVERPOSSIBLEOR FOR THE SAKE OF
RELATIVES
 WASH, SCRUB, DRY BODY

COMB HAIR

> STRAIGT{TENLIMBS, TIE ANKLES

> II.ITERLOCKFINGERS OVER THHIGHS

> PLUG RECTUM WITH COTTON WOOL

> EMPTY BLADDER WITH CATHETER OR IF

NOT POSSIBLETIE FIRM KNOT AT ROOT
OF PENIS

PLUG NOSE WITH COTTON WOOL

PUT BODY IN BODY BAG AND KEEP IN

COLD STORE OR IF NEAR PORT I,,AY

2. BURIAL AT SEA

> IN NATURAL DEATH OR

> IF NO FOUL PLAYIS SUSPECTEDOR

> IF NOT POSSIBLETO PRESERVEOR

> IF REQUESTED B'!r NEXT-OF-KrN

PROCEDURE:

> PREPAREBODY FOR DISPOSAL

> BODY SHOULD BE SEWB INTO A SHROUD

AND SUFFICIENTLYWEIGHTED DOWN TO
ENSURE RAPID SINKING AND PERMANEI.IT
SUBMERSIONIN WATER

> THERE SHOULD BE 3 OR 4 SLITS IN THE

SHROUNTO ALLOW GASES OF
DECOMPOSITIONTO ESCAPEAI{D PREVENT
FLOATING DUE TO TRAPPEDAIR

> BURI.ALSHOULD NOT TAKE PLACE IN

SOUNDINGS IN AI.IY PART OF THE WORLD
> AFTERPREPARATION BODY IS PI.,ACEDON
AN IMPROVISEDPI,ATFORMRESTINGON
THE SHIPSSIDE RAIL

> RELIGIOUSRITESPERORMED
> AT THE WORDSOF THE COMMITAL,AND ON
RECIEPTOF A DISCREETSIGNAL,THE
INBOARDEND OF THE PI,ATFORMIS
RAISEDAND THE BODY IS ALLOWEDTO
SLIDE FROMUNDERTHE ENSIGNINTOTHE
SEA

> RECORDIN THE OFFICI.ALLOG.BOOKTHE

EXAC"TTIME & PLACE OF BURI.AL
Marine Medical Academv MedicalCare

Environmental Gontnol On Board Shtp

Hygleoc:

Main principles of ship board hygiene & health education aboard

ships.

Some necessary precautions should be taken to preserve the health of

those aboard ship & to prevent the spread of disease when it has
occurred. Since injection is the most common cause of disease it
should be prevented by proper hygiene.

Geoeral cleanliness otr board shtp:

Cleanliness of both, persons & environment is essential. Frequent

monitoring by the master & senior officers will help to keep the crew
aware of necessity to maintain cleanliness clothes should regularly be
boiled or soaped in disinfectant. Proper insecticides should be used for
destnrction of plying insects such a flies & mosquitoes. Insecticidal
powder is used for body, clothing bedding for destruction of tugs, fleas
& body like Articles can be sterilized by boiling water or steam Boiling
has to be done for at least 10 minutes.

Dis'infestation & De-rattiag:

Disinfestation means destruction of rats, mice & insects of all kinds

which may or may not carry disease to humans. This can be done by
using insecticides & pesticides which are approved by the pesticides
safety precautions scheme. Liquid insecticides are used for
destnrction of flying insects such as flies & mosquitoes, & non-fl;ring
insects such as cockroaches, bugs & ants. Insecticide powder is used
bn clothing' bedding etc. for destruction of bugs, fleas & lice.
Deratting has to be done on regular intervals. There should be
adequate amount of rat traps on board.
Annex V of MARFOL 73178
(Including amendmentsl

Regulations for the

heuention of Pollutton
turbage from Ships

Regulation 1

Regulations

The purpose of this Annex:

l) Garbage means all kinds of victual, domestic and operational

waste excluding fresh fish and parts there of, generatbd during
the normal operation of the ship and liable to be disposed ol
continuously or periodically except those substances which are
defined or listed in other Annexes to the present convention.

2l Nearest land. The term "from the nearest land" me€urs from the
baseline from which the territorial sea of the territory in
question is established in accordance with internationj law
except that for tJre purpose of the present convention, ""from
the nearest land"" off the north-easrern coast of Australia shall
mean from a line drawn from a point on the coast of Australia
shall mearr from a line drawn from a point on the coast of
Australia in

Latitude 11o00's,longitude, L42oOg,E

to a point in latitude 10035's S, longitude 141055'E,
thence to a point latitude 10000'S, longitude 142000'E,
thence to a point latitude 9010'S, longitude 143oS2'E,
thence to a point latitude 9000'S, longitude 144030'E,
thence to a point latitude 13000'S, longitude 144000, E,
thence to a point latitude 1So00,S, longitude 146000'E,
thence to a point latitude 18000'S, longitude 147000'E,
thence to a point latitude 21000'S, longitude 153000'E,
thence to a point on the coast of Australia in
Iatitude 24o 42'S, longitude 153o15, E.

3) Special area means a sea area where for recognised technical

reasons in relation to its oceanographical and ecological
MarincMedicd Acaderny MedicalCare

condition and to the particular character of its trallic the

adoption of special mandator5r methods br the prcrrcntion of sea
pollution by garbage is required. Special aneas shell include
those listed in regulation 5 of this Annex.

Ra3drtlos 2

eWhutfuon
Unlcss e:rpreacly provided otherwise, the provisions of this Alnex
Bhall apply to dl ships.

Rqulrtloa 3

Ddsposalof gatbage outside specinl anms

(U Subject to the provisions of regulations 4, 5 and 6 of this Annex:
(a) the diopoeal into the sea of all plastics, including but not
limited to synthetic ropea, synthetic fishing nets and
plaotic garbage bags is prohibited:
(b) the disposal into the sea of the following garbage shall be
made as far as practicable from the nearest land but in
any case ie prohibited if the distance from the nearest
land is less than:
(if 25 nautical miles for dunnage, lining and packing
materials which will float;
(t4 12 nautical miles for food wastes and all other
garbage including paper products, rags, glass,
metal, bottles, crockery and similar refuse;
(c) Dieposal into the sea of garbage specified in subparagraph
(b[iil of this regulation may be permitted when it has
passed through a comminuter or grinder and made as far
as practicable from the nearest land but in any case is
prohibited if the distance from the nearest land is less
than 3 nautical miles. Such comminuted or gpound
garbage shall be capable of passing through a screen with
openings no greater than 25 mm.

Rqulrtton 4

Spelcia.!rquiremenlrs.for disposal of garboge

(U Subject 'r.othe provisions of paragraph (2) of this regulation, the
Cisposal of any materials regulated by this Annex is prohibited
from fixes or floating platforms engage in the exploration,
exploitation and associated ofrstrore processing of sea-bed
 mineral resources, and from all other shipe when alongside or
within 5OOm of such Platforms.
(21 Ttre dieposal into the sea of food wastee may be pcrmi-tted 1hen
they have been passed througtr a comminuter br grinder from
fixed or floating platforms located'more than 12 nautical
"n"h
miles from land and all other ships when alongside or within
500 m of such platforms. Such comminuted or ground food
wastes shall be capable of passing through a screen with
openings no greater than 25mm.
MarineMedicalAcadernv MedicElCsrE

Rcguletloa 5

Disposal of garbage within special aneas

For the purposes of this Annex the special areas are the
Mediterranean Sea area, the Baltic Sea area, the Black Sea area, the
Red Sea area, the "Gulfs area", the North Sea area, tJle Antarctic area
and the Wider Caribbean Region, including the Gulf of Mexico and the
Caribbean Sea.

Subject to the provisions of regulation 6 of this Annex:

(a) Disposal into the sea of the following is prohibited:

i) All plastics, including but not limited to synthetic ropes

synthetic fishing nets and plastic garbage bags; and

ii) All other garbage, including paper products, ralts, glass

metal, bottles, crockery, dunnage, lining and packing
materials;

(b) Except as provided in subparagraph (c) of this paragraph disposal

into the sea of food wasters shall be made as far as practical from
land, but in any case not less then 12 nautical miles from the
nearest land;

(c) Disposal into the Wider Caribbean Region of food wastes when
have been passed through a comminuter or grinder shall be made
as far as practicable from land, but in any case not less than 3
nautical miles from the nearest land. Such comminuted to ground
food wastes shall be capable of passing through a screen with
openings no greater than 25 mm.

Rqulatlon 6

Receptlotts

Regulations 3,4 and 5 of this Annex shall not apply to:

(a) the disposal of garbage from a ship necessary for the purpose of
securing the safety of a ship and those on board or saving life at
sea; or;

(b) the escape of garbage resulting from damage to a ship or its

equipment provided nll reasonable precautions have been taken
before and after the occurrence of the damage, for the purpose
of preventing or rninimi,ring the escaPe; or
MarineMedicalAcadernY MedicalCar€

(c) thb accidental loss of synthetic fishing nets, provided that all
reasonable precautions harrc been taken to prevent such loss.

Rquletloo 7

Rcaeptlon faclHtlcs

The government of each Party to the Convention undertakes to ensure

the irovision of facilities at ports and terminals for the reception of
grtb",g", without causing undue delay to ships, and according to the
needs of the ships using them.

Reguletton 8

Placands, garbag e management plnns

and. garbag e rccord-keePing

fl) (a) Every- ship 12m or more in length overall shall display
placards whiih notiff the crew and passengers of the
disposal requirements of regulations 3 and 5 of this
Annex, as applicable.

(b) The placards shall be written in the official language of

the state whose flag the ship is entitled to fly and, for
ships engaged in voyages to ports or offshore terminals
under the jurisdiction of other Parties to the Convention,
in English or French.

(21 Every ship of 400 tons gross tonnage and above, and every ship
which is certified to carry 1.5 persons or more, shall carry a
garbage management plan which the crew shall follow. This
pUtt provide written procedures for collecting, storing,
"ft*t
processing and disposing of garbage, including the use of the
equipment on board. It shall also designate the person in charge
of carrying out the plan. Such a plan shall be in accordance
with the guidelines developed by the Organisation* and written
in the working language of the crew.
Every ship of 400 tons gross tonnage and above and every ship
which is certified to carry 15 persons or more engaged in
Voyages to ports or offshore terminals under the jurisdiction of
other Parties to the Convention and every fixed and floating
platform Cngaged in exploration and exploitation of the sea-bed
shall be provided vrith a Garbage Record Book. The Garbage
Record Book, whether a,s a part of the ship's official tog-book or
MarineMedicalAcadernv MedicalCare

otherwise, shall be in the form speeilied in the appendix to this

Annex;

fa} each discharge operation, or completed incineration, shall

be recorded in the Garbage Record Book and signed for on
the date of the incineration or discharge by the oflicer in
charge. Each completed page of the Garbage Record Book
shall be both in an ollicial language of the State whose
flag the ship is entitled to fly shall prevail in case of a
dispute or discrepancy;

(b) the entry for each incineration or discharge shall include

date and time, position of the ship, description of the
garbage and the estimated amount incinerated or
discharged;

(c) the Garbage Record Book shall be kept on board the ship
and in such a place as to be available inspection in a
reasonable time. This document shall be preserved for a
period of two years after the last entry is made on the
record;

(d) in the event of discharge, escape or accidental loss

referred to in regulation 6 of this Annex an entqr shall be
made in the Garbage Record Book of the circtrmstances
of, and the reasons for, the loss.

(3) The Administration may waive the requirements for Garbage

Record Books for:

(al any ship engaged on voyages of I hours or less in

duration which is certified to carry 15 persons or more; or

(b) fixed or floating platforms while engaged in exploration

and exploitation of the sea-bed.

(4) The competent authority of the Government of a Party to the

Convention may inspect the Garbage Record Book on board any
ship to which this regulation applies while the ship is in its
ports or offshore terminals and may make a copy of any entry in
ttrat book, and may require the master of the ship to certi$r that
the copy is a true copy of such an entry. Any copy so made,
which has been certilied by the master of the ship as true copy
of an entry in the ship's Garbage Record Book, shall be
admissible in any judicial proceedings an evidence of the facts
stated in the entry. The inspection of a Garbage Record Book
and the taking of a certified copy by the competence autJrority
 under this paragraph shall be performed as expcditiously as
possible without causing the ship to be undrrly delayed'

(5) [n the case of ships built before 1 July 1997, thie regulation
sha[ apply as from t JulY 1998.
Marine Medical Academ MedicalCare

DISINT'ECTION AND SITRILIZATIOIT

Of the many causes of diseasis, infection by living organisms is the

commonest and an understanding of their mode of spread is necessary if
healthy living and working conditions are to be maintained.

Infection can take place directly from person to person or it may be

conveyedindirectly in air, water or food by parasites.

Potable WateI

Fresh water should be from causes of infection and be bright, clear

and virtually colourless. It should be aerated that is, it should bubble
when shaken, otherwise it has an insipid taste.

F.resh water storage taaks

The water tanks are coated internally with an anti corrosive

inaterial, which will not contaminate the water. It is recommended that
tlre tanks should be emptied annually for inspection and maintainance
after which they should be thoroughly scrubbed and flushed out, and the
whole water system should be disinfected by chlorine.

Anyone entering any potable or washing water tanks should wear clean
clothing and footwear and should not be suffering from skin infections,
diarrhoea, or any communicable disease.

Dlrlafection of fresh water tanks by super chlorlnatlon,

The chlorine compounds that are used for disinfecting are :

(1) Chlorinated lime
(21 High test hypo chlorite
(3) Commercially prepared sodium hypo chlorite solution.

Determine the volume of water necessary to lill the tanks and

distribution system completely and the amount of chlorine compound
required. The latter can be calculated from the manufacturer's
instructions or from the table or formula shown below.
 und required
High-test Sodium
Capacity of Calcium Hypochlorite
Chlorinated lime
system Hypochlorite solution
(including 7Oo/o 5o/o IOo/o
tanks and
pipinsl
For each: Kg Kg Litres Litres
1,000 litres o.2 0.08 1 0.5
1Otonnes 2.O 0.8 10.1 5.0

Qlrlorinated lime

Place the required amount of chlorine compound in one or more clean,

Ow Uuctets. Add a small amount of water to each bucket and mix the
lime into a thick paste. Dilute the paste by adding wann water gradually,
and stirring .ottit"trtly, until there are about 6 litres of solution in each
bucket. Allow the solution to stand for 3O mins, so that the undissolved
particles will settle to the bottom. Decent the clear liquid (the clear
solution) and, if necessary,filter it through muslin on cheese-clothprior
to putting it into the tank.

Fligh test calcium Hvpochlorite

Place the required amount of the compound in one or more clean, dry
metal buckets. Add fresh water and stir until the powder is dissolved.

Sodium Hypo chlorite solution

No preparation is required.

Procedure:

Introduce the chlorine solution into nearly empty fresh water tanks and
immediately fill them to overflowing with fresh water. The turbulence of
the incoming water will ensure adequate mixing.
Open the taps and outlets of the fresh water distribution system
and allow water tb flow until you can smell chlorinated water till all
outlets are completely flushed with chlorinated water.
The chlorinated water should be allowed to remain in the storage
tanks and the distribution system preferably for twelve hours but not
less than 4 hours.
Marine Medical Academy MedicalCare

.F/oses:

Hoses when caried on board for the purposes of transferring water from
shore mains supply on water barges should be used solely for this
purpose. They should also be suitably marked and after use, should be
drained and capped at both ends. The hoses should be stowed away from
the deck in a place free from contamination.

Disinfection of hoses should be carried out as a routine measure every 6

months with a chlorine solution of 100 mg/litre. This should be allowed
to stand in the completely filled hose for a period of at least one hour.

Taking water on board:

Before taking on water check the delivery-cocks on the shore and the
receiving point on the ship are properly cleaned. Examine the hose to
ensure that it is clean. Ensure that the ends of the hose do not drag
across the deck.
I
Remember that a light, clear, sparkling water may easily contain either
deadly organisms such as cholera, or harmful minerals such as lead. It is I
recommended that chlorination of water outlined as following be ca:ried
out in all vessels.

Routitla ttzatment otfiesh utater bg chlortne:

All fresh water taken from shore or water barge for drinking or washing
should be chlorinated on loading to ensure a residual free chlorine
content at atl outlets throughout the ships freshwater distribution
system.

If chlorine test facilities are available, samples of treated water should be

taken at tap and shower outlets at intervals, preferably using outlets that
would otherwise not be used in order to reduce the presenceof standing
water in the system.

It should be remembered however that if drinking water supplies pass

through charcoal filters close to the outlets, there will be no free chlorine
at these points.
 Water making plant:

All water made from sea water by low pressure evaporators or reverse
osmosis plant, requires to be treated by means of an automatic
chlorination unit adjusted to give the required concentration on delivery
to the storage tanks.

Mairtennnre of distribution sg stem:

The various elements of the freshwater system which might include sand
filters, evaporates, reverse osmosis plant, softeners etc should be
inspected, cleaned, flushed out, back washed, recharged or items
replaced where appropriate, in accordance with the maker's instructions
anO it is recommended that a fresh water system. Maintenance log be
kept itemising each principle unit in the system-

Food:

It is essential to avoid contamination in the food preparation area. Raw

food should be kept separate from cooked products. The food handler
must wash between handling different foods and especially after
handling raw meat and poultry, cooked food should be manipulated by
tools and not by hands, and work surfaces and equipment must be
cleanedthoroughly and disinfected efficiently.

Vegetables:

. Al1 vegetables should be thoroughly washed in clean running water.

Wherever practicable, boil vegetables before senring. Where vegetables
are to be eaten raw, it should be soaked for 2 minutes in a solution of
3.5gm stabilised chloride of lime to 5 gallons of water followed by at least
2 through rinsing in potable water.

Fruit:

Fruits such as apples, tomatoes, grapes, dates that is not generally

peeled, is a frequent source of diarrhoea. Before eating them should be
treated in the way recommended for raw vegetables.
Marine Medical Academy MedicalCare

Canned foods:

Each tin should be carefully examined before being opened. Never accept
or use tins which are rust5r,dented, damaged or blown.

Badeia infood:

Bacteria require moisture and warmth for growth the most favourable
temp. for growth is normal body heat, although most will thrive at 15oC
to 450C(59.p and 113"F).

Unpreserved foods should therefore be stored in a refrigerator or freezer.

When perishable bulk food packs are opened for use, any unused portion
should be resealed and returned to the refrigerator or freezer.

When removed from the cold for cooking, food should be thoroughly
thawed, carefully prepared and heated to a minimum temperature of
g3.c (145"F).

It should be served and eaten at once or kept above the minimum

cooking temperature if there is to be any delay in serving. Inadequate I
defrosting before cooking food, particularly meat and poultry, may me€rn
that the centre does not reach the minimum temp. to destroy bacteria. !
This is a common source of food poisoning. Frozen meat and poultry
which have thawed out should not be refrozen before being thoroughly i
cooked.

All cooked unconsumed food should be cooled rapidly and stored in a i

refrigerator for up to 48 hrs or in a freeznr if it is to be kept for a longer
period. Any food to be recooked must be heated thoroughly to the
temperature necessary to kill bacterial contamination.

Cateing staff : Personal hggienic

The staff should be supplied with, and should wear, clean clothing when
handling food. There should be ample supplies of soap, towels, nait -
brushes, and hot water available for washing hands.

Food handlers should be free from communicable diseases. Anyone

suffering from septic skin condition, typhoid fever or dysentry and who
may have become a carrier of the disease, or who has suffered from an
unexplained or unusual illness, should not be allowed to prepare or
handle food or utensils until cleared for such duty by a doctor.
ldarine Medical Academy Medical Care

MTDICAL RTCORDS

Medical Records are for Diagnosis/treatment/Radio Medical advice.

- Date
Full name of patient.
Date of birth
Nationality
Seafarer's Reg. No.
Name of ship
Ship owner
Ship's representative on shore.
DI.AGNOSIS
Date when patient was first examined.
Details of examinations:-

(a) In case of illness:-

On set- sudden/slow
List of all signs and symptoms
Course of present illness.
Past history of any illness/Injury or operation
Family history
Social/occupational history
Medicinestaken by the patient
Habits of Alcohol/drugs etc
Results of examination
Temp/ pulse/ respiration
Appearance
List of all medicines given to patient

(b) In caseof injuries:-

Exact way of injury
Time of injury
Complain in order of appearance
Important past history
Medicinestaken beforeirUury
Alcoholic history
Time and depth of unconsciousness in case of
head injury
Respondto command/painful stimulus
Pupil enlargement
Paralysis/ unusual movement
ldarine Medical Academy Medical Care

Exarnination of temp/pulse/respiration, general

condition injuries, approximate quantity of blood
lost.

- Treatment given with response

- Anyfurtherreferences/opinion/treatmentreinjured
- Is illness contaglous
Is he fitlunfit for work?
- Is bed rest necessary?

- Recommended to be r Repatriated
. Hospitalised
. Should be accompanied
Place:-
Date:-

Signature of Doctor
 RADIO MTDICAL AI'VICE
THIS IS AVAII,,ABLEBY - RADIOTELEGRAP}IY
RADIOTELEPHOI{Y
DOCTORON NEARBIYSHIP.

EXCHANGE OF INFORMATION SHOULD BE IN LANGUAGE

COMMONTO BOTH PARTIES.

CODED MESSAGESSHOULD BE AVOIDED.

ALL INFORMATION POSSIBLE SHOULD BE PASSED ON TO THE

DOCTOR AND ALL HID ADVICE AND DIRECTIVES SHOULD BE FTJLL
RECORDED ON PAPEROR TAPED.
THIS RECORD CAN BE USED FOR VERIFICATION.

NOTIFYTHE SCALE OF YOUR MEDICAL CHEST.

IN SOME CASES IN ORDER TO PRESERVE CONFIDEI'ITIALITY, IT

MAY BE NECESSARYTO WITHHOLD PATIENTS NAME, WHICH CAN
BE SUBMITTED LATER IN WRITING TO COMPLETE THE DOCTORts
RECORDS.

IIIFORMATIOIT TO BE READY WTIEIITREOUESrING R.U.A.

A) rN cAsE oF ILLNESS:

1
I""'ffi*T;:TSHIP
- NEARESTPORT
. OTHER POSSIBLEPORT
LOCAL WEATHER

2' :ou"'iliritffi?'"'ffiffiff''l'"*I'Nr
- RANK
'
JOB ON BOARD
- oou
3' : *'3H"ff-3i'l'3ilR','rror
. LIST OF ALL SIGNS AND SYMPTOMS
- COURSEOF PRESENTILLNESS
PIII - ILLNESS,INJURY, OPERATION
MarineMedicalAcadernY MedicalCare

: HISroRr
36?^" / occuPArloN
MEDICINES TAKEN BY PATIEI'IT
-
HABITS ALCHOL, DRUGS ETC.
R+l rE
4 Y'"'f'Hm#??#, Pur-"' r*

_
.ENERALF-::ii:,
EXAM. OF LOCAL 'ART ?'E >?ip r\ | \L\r.Jf._Rngor,-,
- INVEST.DONE L-.53V,V'IET

5. DLAGNOSIS: PROVISIONAL
DIFFRENTIAL
SPECIFIC

6. TREATMENT: LIST OF ALL MEDICINES

GIVEN TO PT. SINCE ILLNESS
BEGAN

7. PROBLEMS- ON WHICH YOU NEED ADVICE

8. OTHER COMMENTS

9. COMMENTSB]TRADIO DOCTOR

B) IN CASE OF INJURY

1. ROUTINE PARfiCULARS ABOUT SHIP

2. ROUTINE PARTICULARSABOI.JTPATIENT

3' :{ISroffiS'#iYtF?o'u*
. TIME
- COMPLAININ ORDER OF IMPORTANCE

: ilftr"Jtllr rAKEN
BEF'RE
TNJUR'
. ALCOHOLIC HISTORY
. TRANSIENTLOSS OF CONSCIOUSNESS_ TIME &
DEPTH.
RESPONSETO
COMMAND OR PAINF'UL STIMULUS, PUPL
ENI.A.RGEMENT,PARALYSIS/ UNUSUAL MOVT.

4'
Tt"'#"31?H; / REsp.
Marine Medical Academy MedicalCare

. GEN. CONDITION

- LOSS OF BLOOD - QTY.

TESTS DONE

5. TREATMENT
- FIRST AID GIVEN
- ALL MEAL WITH DOSE AND TIME
. RESPONSETO MED.

6. PROBLEMS ON WHICH YOU NEED ADVICE

7. OTHER COMMENTS

8. COMMENTSBY RADIO DOCTOR

 COUUT'NICATION

saTcou
(SATELLITECOMMUNICATIONEQUIPMENT}

COMMUNICATIONVIA SATELLITETO AI.IYPORTWORLDWIDEBY

USINGA TWO DIGIT CODE.

CODEFORR.M.A.IS 32+

e.g. A SHIP IN THE ATL,ANTICOCEANWOULD FQLLOWTHE

FOLLOWING
PROCEDURE:

> DIAL NORWEGLANCOAST EARTH STATION(I"ANDSTATION)

> CODE FOR R.M.A. (Advice) - 32+

> CODE FOR R.M.A. (Assistance) - 38+

> DIRECTLYCOMMUNICATEWITH R.M.A.-NORWAY

CEITTRO ITALIANA RAI'IO MEDICAL

lcRrMl
A NON - PROFITORCANISATIONBASED IN ITALY,WORKINQ24
HRS, MAKESAVAII.,ABLEDOCTOR'SPROFICIENTIN MARINE
MEDICAL EMERGENCYTHROUGH

> TELEFAX
> TELEX

INFORMATIONABOUT CIRM CAN BE OBTAINEDFROM FOLLOWING

BOOKS:

> ADMTRALTYLrST OF RADrOSTGNALS(ALRS)-VOL. I OF I UNDER

.ITALY'

> LIST OF RADIO DETERMINATION& SPECTALSERVICES

STATIONS- UNDER 'ITALY'
Marine Medical Academy MedicalCare

Medlvac Servlce bY HeltcoPter

The normal procedure is as follows:

Contact the shore radio station, ask for medical advice and they will
normally transfer your call to a doctor. Give the doctor all the
'information
you can so that he can make an assessment of the
seriousness of the situation.

After the link call is over the doctor will advise the coast ffuard service
on the best method of evacuation the coast guard will make necessarJr
arrangement and keep in touch with the ship.

When helicopter evacuation is decided upon:

(1) Ships position should be given the bearing (magnetic or true)

and distance from a fixed object should be given if possible.

(21 Give details of your patients condition. Details of his nobility are
especially important as he may require to be lifted by stretcher.

(3) Inform the bridge and engineroom watches.

(4) Hehcopters are frtted with VHF and/or UHF Rf. If

communication between ship and helicopter cannot be effected
on VHF it may be possible to do so via a lifeboat. Alternatively a
massage may be passed via a Coast Radio Station.

(5) The ship must be,on a steady course gving minimum ship
motion.

(6) An indication of relative wind direction should be given. Flags

and pennants are suitable for this purpose. Smoke from a galley
funnel may also given an indication of the wind.

(7| Clear as large an area of deck (or covered hatchway) as possible

and mark the area with a large letter 1{'in white.

(S) All loose articles must be securely tied down or removed from
the transfer area.

(e) Use a distinctive distress signal, which can be seen by the

helicopter eg. Orange coloured smoke signal carried in the life
boat.
(10) On no account must the winch wire be allowed to foul any part
of tJ:e ship or rigging

(11) The winch wire must be handled only by personnel wearing

rubber gloves.
(l2l The survivor is placed in the stretcher, strapped in sugh _a
manner that it is impossible for him to slip or fall out and both
stretcher and crewman are winched up into the helicopter.

(13) Obey instructions of helicopter crew.

Preoaration of the patlent for esa,cuatlon:-

Place in a plastic envelope the patient's medical records, together with

any necessary papers, so that they can be sent with him.

Add to the medical record note of any treatment given to the patient.

If possible ensure that the patient is wearing a lifejacket if possible

before he is moved to the stretcher.

Shio to sbip transfer of doctor or oatient:'

This is a seamanship problem, which demands high standards of

competence for its safe and eflicient performance.

Keep clear of the overhang of bows or stern, especially if there is any

sea running. Also beware of any permanent fendering fitted at sides.
The general rule is that the ship with the higher freeboard will provide
illumination and facilities for boarding and will indicate the best
position.

For your own safety, make sure you are seen and your actiong are
communicated to the Master of the larger ship and out promptly on
his instructions.

Conmunicating with Doctors:-

A letter should always be sent with any patient who is going to see a
doctor. The crew member will be a stranger to the doctor and there
might even be a language di{frculty.

A written communication in a foreign langUage is often easier to

understand than a spoken one.
Marine Medical Academv MedicalCare

The letter should include:

(1) Routine particulars about the crew member
- name of ship, poft, name of agent, owner.
(21 A systematic s5mopsis of all that is known about the pereon,
including copies of any information from doctors in previous
ports.

The doctor is requested to write back to the Master on the form.