Emergency Protocols — Maritime Quick Reference

Immediate Actions

1. Confirm cardiac arrest: unresponsive, no pulse, no breathing
2. Call for help: activate ship emergency code, request AED and medical team to location
3. Begin CPR: 30:2 ratio, minimize interruptions, swap compressor every 2 minutes
4. Attach AED/defibrillator as soon as available; follow prompts
5. Establish IV/IO access; administer adrenaline 1mg IV every 3-5 minutes
6. Consider reversible causes (4Hs & 4Ts): hypoxia, hypovolaemia, hypo/hyperkalaemia, hypothermia, tension pneumothorax, tamponade, thrombosis, toxins
7. If shockable rhythm: defibrillate, resume CPR immediately for 2 minutes, reassess
8. If lone doctor: secure airway with supraglottic device early, use mechanical CPR device if available

Maritime-Specific Considerations

• Ship motion affects CPR quality; brace patient against bulkhead or secure to deck
• Limited staff: train crew members for compression relay before emergency occurs
• Nearest hospital may be 12-72+ hours away; medevac decision runs parallel to resuscitation
• Document exact time of arrest, interventions, and decision points meticulously
• Termination of resuscitation: consider after 20+ minutes of ALS with no ROSC, no reversible cause identified, and no shockable rhythm. Document rationale thoroughly.

Bridge Phrase

Documentation Requirements

Immediate Actions

1. ABCDE assessment; place on cardiac monitor, obtain 12-lead ECG within 10 minutes
2. Aspirin 300mg PO (chewed), sublingual GTN if systolic BP >100mmHg
3. IV access, bloods if available (troponin baseline), oxygen only if SpO2 <94%
4. Apply HEART-M score: History, ECG, Age, Risk factors, Troponin + Maritime modifier (distance-to-PCI, weather, staffing)
5. Morphine 2-4mg IV titrated for pain unresponsive to GTN
6. If STEMI on ECG: activate medevac pathway immediately; consider thrombolysis if PCI >120 minutes away and no contraindications
7. Anticoagulation: enoxaparin or unfractionated heparin per protocol
8. Continuous monitoring: repeat ECG at 30 minutes and with any change in symptoms

Maritime-Specific Considerations

• Thrombolysis decision: weigh bleeding risk vs. distance to catheterization lab (hours, not minutes at sea)
• Contact TMAS early for shared decision-making on thrombolysis
• Weather and helicopter range affect medevac feasibility; have backup plan for diversion
• Post-thrombolysis monitoring requires continuous 1:1 nursing; assess staffing capacity
• Document decision rationale for thrombolysis or conservative management thoroughly

Bridge Phrase

Documentation Requirements

Immediate Actions

1. Apply qSOFA: respiratory rate ≥22, altered mentation, systolic BP ≤100mmHg (score ≥2 = high risk)
2. Identify likely source: respiratory, urinary, abdominal, skin/soft tissue, line-related
3. Blood cultures if available; do not delay antibiotics for cultures
4. Empiric IV antibiotics within 1 hour of recognition: broad-spectrum per ship medical chest (e.g., ceftriaxone 2g IV + metronidazole if abdominal source)
5. IV fluid resuscitation: 30ml/kg crystalloid within first 3 hours; reassess after each 500ml bolus
6. Monitor: HR, BP, RR, SpO2, urine output hourly, mental status, temperature every 4 hours
7. Vasopressors if available and fluid-refractory hypotension (noradrenaline first-line)
8. Reassess at 6 hours: if deteriorating despite treatment, escalate to medevac

Maritime-Specific Considerations

• Limited IV fluid supply on most vessels; calculate available stock against projected 72-hour need
• 72-hour hold framework: if patient can be stabilized for 72 hours, vessel can often reach port; if not, medevac required
• Antibiotic availability varies by medical chest; know your formulary before the emergency
• Urine output monitoring may require catheterization; ensure supplies are checked and ready
• Contact TMAS within 2 hours if qSOFA ≥2 or clinical concern for septic shock

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Documentation Requirements

Immediate Actions

1. Scene safety: ensure area is safe; use PPE; move patient only if immediate danger
2. A - Airway: protect c-spine, open airway, suction if needed, jaw thrust if unconscious
3. B - Breathing: assess rate, depth, symmetry; decompress tension pneumothorax if suspected (needle, 2nd ICS MCL)
4. C - Circulation: control catastrophic haemorrhage (direct pressure, tourniquet for limb); establish two large-bore IV lines; tranexamic acid 1g IV if within 3 hours of injury
5. D - Disability: GCS, pupil size/reactivity, blood glucose, brief neuro exam
6. E - Exposure: full body check front and back; prevent hypothermia (foil blanket, warm fluids)
7. Splint fractures, dress wounds, reassess every 15 minutes
8. Packaging: spine board or scoop if spinal injury suspected; secure for ship movement and potential helicopter winch

Maritime-Specific Considerations

• Damage control: focus on stopping bleeding and preventing contamination, not definitive repair
• Blood products rarely available on ships; crystalloid and tranexamic acid are your resources
• Ship movement complicates procedures; have crew brace patient and equipment
• Helicopter stretcher packaging has specific requirements; confirm with SAR coordination
• Falls from height and crush injuries are common maritime mechanisms; assess for spinal injury and internal bleeding

Bridge Phrase

Documentation Requirements

Immediate Actions

1. Assess neurovascular status: radial pulse, sensation over regimental badge area (axillary nerve), finger movement
2. Analgesia: IV morphine titrated or Entonox if available; consider intra-articular lidocaine (20ml of 1%)
3. X-ray if available (rule out fracture); if no X-ray, proceed to reduction if clinically clear anterior dislocation
4. Procedural sedation: midazolam 1-2mg IV + fentanyl 25-50mcg IV titrated, with monitoring and resuscitation equipment ready
5. Reduction techniques (try in order):
   • Cunningham technique: patient seated, massage biceps, trapezius, deltoid; gentle, no traction
   • External rotation: elbow at 90 degrees, slowly externally rotate
   • Stimson technique: patient prone, arm hanging with weight
6. Confirm reduction: palpable clunk, improved pain, restored range of movement
7. Post-reduction: neurovascular check, immobilize in sling, post-reduction X-ray if available

Maritime-Specific Considerations

• Cunningham technique is ideal at sea: no force, patient seated (works with ship movement)
• Procedural sedation requires dedicated monitoring person; confirm nursing availability
• Crew members: return-to-duty criteria must account for safety-critical roles (e.g., no climbing, no lifeboat drill until cleared)
• If reduction fails after 2-3 attempts, immobilize and arrange port disembarkation

Bridge Phrase

Documentation Requirements

Immediate Actions

1. Determine evacuation urgency: immediate (life-threatening), urgent (6-12 hours), or scheduled (next port)
2. Contact TMAS for clinical support and evacuation recommendation
3. Prepare SBAR-M handover (see template below)
4. Check with bridge: current position, distance to coast, weather forecast, sea state, helicopter range (typically 150-200nm)
5. Notify captain with clear recommendation: medevac vs. diversion vs. continue to port
6. Prepare patient for transfer: packaging, documentation copies, medication supply for transit
7. If helicopter: clear deck, brief crew on winch operations, wind direction, remove loose objects
8. Prepare handover documentation pack: medical summary, vitals trend, medications given, allergies, passport copy

SBAR-M Template

Maritime-Specific Considerations

• Helicopter operations limited by: range (~200nm), wind speed (>50kt often grounds operations), sea state, night operations, fog/visibility
• Diversion cost is significant; captain needs clear medical justification documented
• Multiple agencies may be involved: MRCC, coast guard, P&I club, company fleet medical director
• Time-critical decisions: thrombolysis vs. medevac-to-PCI is a common maritime dilemma

Documentation Requirements

Immediate Actions

1. Confirm death: absence of pulse, breathing, and pupillary response for minimum 5 minutes of continuous observation
2. Record exact time of death (or time death confirmed if unwitnessed)
3. Notify captain immediately: "Medical, Bridge. I am confirming a death onboard."
4. Do not move the body until scene assessed (foul play must be considered in any unwitnessed death)
5. Photograph scene and body position if circumstances are suspicious or unclear
6. Complete death certification documentation per flag state requirements
7. Body preservation: move to cold storage (morgue cooler or food cooler designated for this purpose); if unavailable, air conditioning on maximum in a secured cabin
8. Secure personal belongings; inventory and witness sign

Maritime-Specific Considerations

• Flag state law determines death certification requirements; know your vessel's flag state procedures
• P&I club must be notified within hours; captain handles this but doctor provides medical details
• If crew member: employer notification, repatriation of remains, consular contact
• If passenger: next-of-kin notification (captain/hotel director role), disembarkation arrangements
• Preserve all clinical records, medication charts, and nursing notes as legal documents
• The doctor may be asked to provide a preliminary cause of death; note this is not a formal autopsy finding
• Emotional impact on crew: consider welfare support and informal debrief

Bridge Phrase

Documentation Requirements

Immediate Actions

1. Outbreak threshold: ≥2% of passengers or crew with acute gastroenteritis (AGE) symptoms (vomiting and/or diarrhea) within 72 hours
2. Activate outbreak management plan: notify captain, hotel director, housekeeping supervisor
3. Isolate symptomatic individuals: cabin isolation for minimum 48 hours after last symptom
4. Enhanced cleaning protocol: 1:10 bleach solution (5000ppm) for all public areas, handrails, elevator buttons, bathroom surfaces
5. Collect stool samples from first 5-10 cases for laboratory testing at next port
6. Close buffet self-service; implement plated service if cases exceed threshold
7. Increase hand sanitizer stations; post signage for hand hygiene
8. Track cases using line listing: date/time of onset, cabin number, symptoms, crew/passenger, dining assignment

Maritime-Specific Considerations

• CDC VSP reporting required for vessels in US waters: report at ≥2% GI illness threshold
• Port health authority notification required 24-48 hours before arrival in many jurisdictions
• Crew cases are operationally critical: food handlers must be excluded until 48 hours symptom-free
• Environmental health team (if available) should audit galley and water systems
• Consider delaying embarkation/disembarkation day deep clean if outbreak is active
• Communication plan: captain's announcement, guest letter, FAQ for reception desk

Bridge Phrase

Documentation Requirements

Immediate Actions

1. Scene safety first: ensure you have security backup before approaching; maintain escape route
2. Rule out organic causes: hypoglycaemia, head injury, intoxication, infection, medication reaction, hypoxia
3. Risk assessment: danger to self, danger to others, danger to vessel safety
4. De-escalation: calm tone, open posture, give space, offer choices, acknowledge distress, avoid confrontation
5. If de-escalation fails and immediate risk exists, consider chemical restraint: haloperidol 5mg IM + lorazepam 2mg IM (reduce doses in elderly)
6. Physical restraint only as last resort, with security team, using approved restraint techniques; monitor continuously
7. Contact TMAS for psychiatric support; consider telemedicine psychiatric consultation if available
8. Ongoing monitoring: 1:1 observation if suicidal ideation, 15-minute checks minimum otherwise

Maritime-Specific Considerations

• Ship's master has ultimate authority for vessel safety; medical team advises, captain decides on confinement
• Duty of care: the doctor must continue to provide medical care regardless of patient behavior
• Legal documentation is critical: every decision to restrain, confine, or medicate must be justified in writing
• Disembarkation at next port may be necessary; coordinate with company, port agent, receiving hospital
• Alcohol-related presentations are extremely common; distinguish intoxication from psychiatric crisis
• Cabin safety check: remove sharps, medications, glass items; consider supervised accommodation

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Documentation Requirements

Immediate Actions

1. Estimate weight: ask parent, or use Broselow tape / age-based formula (weight kg = [age + 4] x 2 for 1-10 years)
2. Pediatric ABCDE assessment: be aware of age-appropriate normal vital signs
3. Equipment sizing: ETT = (age/4) + 4 uncuffed; suction catheter = 2x ETT size; NG tube = age-based
4. IV access: attempt peripheral IV x2, then IO (proximal tibia) if unsuccessful within 90 seconds in critical cases
5. Fluid resuscitation: 20ml/kg normal saline bolus, reassess, repeat up to 3 times (60ml/kg total in first hour)
6. Drug doses (always weight-based):
   • Adrenaline: 10mcg/kg (0.1ml/kg of 1:10,000) IV/IO
   • Paracetamol: 15mg/kg PO/PR
   • Ibuprofen: 10mg/kg PO (over 3 months)
   • Amoxicillin: 25mg/kg TDS
7. Contact TMAS early: pediatric emergencies at sea are high-anxiety, low-frequency events
8. Document all calculations showing weight and dose working

Maritime-Specific Considerations

• Most ship medical centers are not stocked for pediatric emergencies; know your equipment and drug limitations
• Pediatric BLS ratios: 15:2 for healthcare providers (2-person), 30:2 for lone rescuer
• Febrile seizures are common in children on cruise ships; manage supportively, reassure parents
• Medevac threshold is lower for children; escalate early
• Parent communication: be honest, use plain language, explain what you are doing and why, include parents in care where safe to do so

Bridge Phrase

Documentation Requirements

Cylinder Duration Formula

Duration (minutes) = (Gauge pressure PSI x Cylinder factor) / Flow rate (L/min)

Cylinder factors: D = 0.16, E = 0.28, M = 1.56, G/H = 3.14

Quick Reference Table

Times assume full cylinder at 2000 PSI. Reduce proportionally for partially filled cylinders. Always have a backup cylinder identified.

Maritime-Specific Considerations

• Count your total oxygen supply at the start of every voyage and after every use
• Calculate: can you oxygenate this patient at the required flow rate until you reach port or medevac?
• If oxygen will run out before definitive care, this changes your medevac threshold
• Piped oxygen systems (if available) have finite reservoir; confirm capacity with engineering
• Nebulizers consume 6-8 L/min; factor this into burn-rate calculations

Bridge Phrase

Initial Notification

Requesting Course Change or Speed Increase

Medevac Request

Status Update (Stable)

Death Notification

Communication Principles

• Lead with role identification: "Bridge, Medical" every time
• State what you know, what you need, and what you recommend
• Avoid medical jargon with non-medical bridge officers; use plain operational language
• Give timelines: "I will update in 30 minutes" sets expectations and reduces interruption
• Document all bridge communications with times in the medical record

Immediate Actions

1. Remove trigger if identifiable (stop infusion, remove sting)
2. IM adrenaline 0.5mg (0.5ml of 1:1000) into anterolateral thigh — do not delay
3. Lay patient flat with legs elevated (sitting if respiratory distress)
4. High-flow oxygen 15L/min via non-rebreather mask
5. IV access — fluid bolus 500ml-1L crystalloid rapidly
6. Repeat IM adrenaline every 5 minutes if no improvement (up to 3 doses)
7. IV hydrocortisone 200mg and chlorphenamine 10mg IV
8. Nebulised salbutamol 5mg if bronchospasm persists
9. Monitor for biphasic reaction: observe minimum 12 hours (24 hours if severe)

Maritime-Specific Considerations

• Check adrenaline stock: multiple doses may be needed; audit remaining supply
• Biphasic reaction can occur 4-12 hours later — continuous observation needed at sea
• No allergy testing onboard; document suspected trigger meticulously
• Airway equipment check: supraglottic airway, surgical airway kit as backup
• If refractory: consider IV adrenaline infusion (requires careful monitoring)

Bridge Phrase

Documentation Requirements

Immediate Actions

1. FAST assessment: Face drooping, Arm weakness, Speech difficulty, Time of onset
2. Document exact time of symptom onset or last known well time
3. ABCDE assessment, check blood glucose (exclude hypoglycaemia)
4. Do NOT give thrombolytics — cannot differentiate ischaemic from haemorrhagic without CT
5. Blood pressure management: only treat if >220/120 (permissive hypertension)
6. Position: head of bed elevated 30 degrees, nil by mouth until swallow assessment
7. IV access, IV fluids (avoid dextrose), continuous monitoring
8. Contact TMAS immediately for guidance
9. Initiate medevac request — thrombolysis window is 4.5 hours from onset

Maritime-Specific Considerations

• No CT onboard means you cannot safely give thrombolytics — this is a critical capability gap
• Time is brain: every minute of delay matters; medevac decision must be immediate
• Document neurological status serially (GCS, pupil response, limb power)
• Aspiration risk: strict nil by mouth, suction available
• If within thrombolysis window AND evacuation feasible: prioritise speed of transfer

Bridge Phrase

Documentation Requirements

Immediate Actions

1. ABCDE assessment; position upright if tolerated
2. High-flow oxygen: start at 15L/min via non-rebreather mask
3. Perform oxygen burn-rate audit immediately: cylinders × volume ÷ flow rate = hours remaining
4. Identify cause: asthma, COPD exacerbation, pneumonia, pulmonary oedema, PE, pneumothorax
5. Nebulised bronchodilators: salbutamol 5mg + ipratropium 0.5mg
6. IV access, IV hydrocortisone 200mg if suspected asthma/COPD
7. If pulmonary oedema: IV furosemide 40-80mg, GTN infusion if available
8. Consider CPAP if available and patient cooperative
9. Continuous SpO2 monitoring; target SpO2 94-98% (88-92% if known COPD)

Maritime-Specific Considerations

• Oxygen is finite: reduce flow rate to minimum effective as soon as possible
• Calculate: can oxygen supply sustain the patient until evacuation or port?
• CPAP uses high oxygen volumes; weigh benefit against supply endurance
• No ventilator, no ICU, no blood gas: clinical assessment and SpO2 are your tools
• Staffing: high-flow oxygen patient needs 1:1 monitoring; plan nurse rotation

Bridge Phrase

Documentation Requirements

Immediate Actions

1. Remove from cold environment; handle gently (rough movement risks cardiac arrest)
2. Remove wet clothing; insulate with dry blankets, sleeping bags, space blankets
3. Horizontal position — do NOT allow patient to stand or walk
4. Core temperature if available (rectal preferred; tympanic unreliable in cold)
5. Mild (32-35°C): passive rewarming, warm fluids if conscious
6. Moderate (28-32°C): active external rewarming, warm IV fluids (38-42°C)
7. Severe (<28°C): high risk of VF; gentle handling, active rewarming, prepare for CPR
8. If cardiac arrest: CPR with extended intervals; warm before pronouncing dead

Maritime-Specific Considerations

• Circumrescue collapse: patients can arrest during or shortly after rescue from water
• MOB protocol: coordinate with bridge for rescue, prepare medical centre
• Expedition landings: hypothermia risk from wet zodiac transfers in polar regions
• "No one is dead until they are warm and dead" — prolonged resuscitation may be appropriate

Bridge Phrase

Documentation Requirements

Immediate Actions

1. ABCDE assessment; IV access
2. Pain assessment and analgesia: IV morphine titrated (do NOT withhold analgesia)
3. Nil by mouth; consider nasogastric tube if vomiting or distension
4. IV fluids: aggressive crystalloid resuscitation if signs of sepsis/dehydration
5. Abdominal examination: peritonism, guarding, rigidity, absent bowel sounds
6. If peritonitis suspected: IV antibiotics (ceftriaxone 2g + metronidazole 500mg)
7. Serial abdominal examinations every 2-4 hours
8. Urinalysis if available; contact TMAS for guidance

Maritime-Specific Considerations

• No imaging, no surgery, no interventional radiology onboard
• Appendicitis, perforation, bowel obstruction all require surgical intervention you cannot provide
• Antibiotics buy time but do not replace surgery
• Decision point: "hold and observe" vs. "divert immediately"
• Audit antibiotic stock for 48-72 hours of IV therapy

Bridge Phrase

Documentation Requirements

Immediate Actions

1. Remove patient from water; ensure scene safety
2. ABCDE assessment; monitor for anaphylaxis
3. Jellyfish: rinse with vinegar (box jellyfish regions); remove tentacles with tweezers
4. Fish spine injuries (stonefish, stingray): hot water immersion 45°C for 30-90 minutes
5. Sea snake bite: pressure immobilisation bandage, immobilise limb, keep patient still
6. Wound care: irrigate, explore for retained spines/barbs, prophylactic antibiotics
7. Pain management: local anaesthetic, IV/IM analgesia as needed
8. Tetanus status: document and manage per guidelines
9. Monitor for systemic envenomation: nausea, weakness, paralysis, cardiovascular collapse

Maritime-Specific Considerations

• Species identification helps treatment: photograph the creature if safe
• Antivenom may not be onboard; check medical chest inventory
• Box jellyfish (Chironex, Irukandji) can cause cardiac arrest; have adrenaline ready
• Sea snake envenomation: progressive paralysis; early medevac is critical

Bridge Phrase

Documentation Requirements