Fall from a ladder: bilateral hand numbness on a rolling deck
During heavy weather on passage, a 24-year-old deck cadet loses his grip on a vertical ladder and falls about 2.5 m onto the steel deck. He is conscious and talking. He says his back and neck hurt badly, and he complains of tingling and numbness in both hands and cannot grip your fingers with either hand. He is wearing a hard hat, which is still in place, and there is no visible bleeding. He is lying on his back and the vessel is rolling about 15 degrees. He asks to be helped to sit up and taken to his cabin. Breathing is 22 per minute, pulse 100 and regular, and his skin is pale and clammy. A Neil Robertson stretcher and a vacuum mattress are stowed two decks below. The next port is 26 hours away, and a helicopter is reported to be 90 minutes away if requested.
1. He asks to sit up and be walked to his cabin. What is your answer and your reasoning?
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Refuse, politely and firmly, and tell him why. The mechanism - a 2.5 m fall onto steel - is enough on its own to suspect spinal injury. Add midline neck and back pain plus tingling, numbness and weakness in both hands, and this is a suspected cervical spinal cord injury until proved otherwise. Sitting him up or lifting him by the arms could turn a stable fracture into permanent cord damage.
Kneel or lie beside him, tell him not to move his head or body, and place your hands on either side of his head to hold it in line with the spine (manual in-line stabilisation). Keep talking to him so he stays still and does not try to help. Brief the crew firmly: nobody sits him up, nobody pulls him, nobody removes his hard hat without instruction.
He may only be moved for a life-threatening reason - vomiting with airway compromise, or to evacuate - and then by a coordinated team log roll with one person controlling the head, onto a board or vacuum mattress. Call the master early: this is a potential helicopter evacuation, not a cabin case.
2. Do you remove his hard hat? Explain your decision and how it would change.
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Leave it on. A correctly fitted hard hat that is not obstructing the airway and is not forcing the neck into flexion does not need to come off, and removing it is itself a manoeuvre that moves the cervical spine. The straps should be left alone rather than cut in a way that lets the helmet shift.
The decision reverses if the airway is at risk. If he vomits, becomes unresponsive, or the helmet is pushing his head forward and blocking breathing, the airway wins over the spine. Then remove it only with two rescuers: one kneels at the head and holds in-line stabilisation from below with forearms along the deck, the other releases or expands the helmet and eases it off slowly while the head is held, then hands over to a collar or continued manual stabilisation. If you cannot remove it safely and he is vomiting, log roll him as a team with the head controlled. Never remove a helmet single-handed by pulling on the straps.
3. Describe the immobilisation, the observations you would take and the evacuation argument you would put to the master.
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Immobilise on the vacuum mattress rather than the Neil Robertson stretcher: it conforms to the body, supports the head and reduces pressure damage on a rolling deck. Log roll him as a team onto it, leader at the head giving the commands, keeping head, neck and trunk in one line. Add head blocks or rolled blankets taped either side of the head, a rigid cervical collar if the medical chest has one, and straps across the chest, hips and legs without restricting breathing. Pad pressure points and keep him warm.
Observations every 15 minutes: AVPU, pupils, respiratory rate and effort, pulse, blood pressure if possible, and power and sensation in all four limbs, asking specifically about the tingling in his hands and whether it is spreading. Watch for breathing deterioration, which points to a higher cord injury, and for bradycardia with falling blood pressure, which suggests spinal shock. Keep him nil by mouth.
To the master: a conscious patient with bilateral neurological signs after a fall has a time-critical spinal injury. Twenty-six hours to port is unacceptable when a helicopter is 90 minutes away. Request radio medical advice, prepare the winching area, brief the crew on the transfer and keep the cervical spine controlled throughout.