Rescue Boat Recovery of an Unconscious Casualty in Cold Water
At 03:20, in the approach to a port, a crew member falls from the forecastle head. The ship is making 6 knots, wind is 20 knots, sea 2 m, air 5 °C, water 9 °C, and it is dark. The bridge rings "man overboard", reduces speed and turns, and the ship's rescue boat - a rigid inflatable with a coxswain and two crew - is launched within six minutes. The searchlight finds him twenty minutes later, face down, no lifejacket, not moving, about 150 m off the ship's starboard bow. The rescue boat carries a boarding ladder, a rescue sling, a throw line, a thermal protective aid and a first aid kit. The ship's davit is rated for the boat and its normal complement; there is also a three-part tackle available at the davit.
1. Describe your approach and the recovery of the casualty into the boat, including the judgements you are making about the boat, the propeller and the crew.
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The casualty must be treated as a live hypothermic patient until proven otherwise, and the boat crew must not become the second and third casualties.
Approach. Come up from downwind and down-sea so the boat drifts toward the casualty rather than over him, with the ship used as a windbreak if it can be positioned. Slow to bare steerage and put the engine in neutral - propeller stopped - as soon as the casualty is within a boat's length; a moving propeller is the single biggest hazard at this moment and no one enters the water near it. Keep the casualty on the lee side of the boat.
Recovery. A conscious casualty can be talked through grabbing the sling and rolling into it. This man is not conscious and cannot help. The judgement is whether anyone goes in: only a trained, suited crew member with a lifeline, and only if he cannot be hooked from the boat. Otherwise use the boat hook and sling to get a purchase on him, pass the sling under the armpits and around the chest, secure the lifting point, and haul him in over the lowest freeboard - a rigid inflatable's tube, not the gunwale - with two people lifting. Do not use the ship's davit or a tackle to lift an unconscious body into a small boat unless the equipment and the crew are set up for it; a swinging casualty over a rolling boat is how people are dropped.
On the floorboards. Immediately: check for breathing, get him horizontal, remove wet clothing by cutting it off, wrap in the thermal protective aid with the head covered but the face clear, and get him out of the wind. Then recover the boat.
2. He is breathing but unresponsive, cold to the touch, and his pulse is very slow. What is the care plan during the run back to the ship?
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This is moderate-to-severe hypothermia, and the priority order is airway, breathing, insulation and gentle handling - in that sequence, and with the understanding that his heart is irritable and his core temperature, not his surface temperature, is what matters.
- Airway and breathing. Check and keep checking. He is breathing now; the risk is that he stops. Keep the head in a neutral position, do not force fluids into an unresponsive mouth, and be ready to ventilate if breathing stops.
- Horizontal, gentle, no rough handling. Keep him lying flat. Do not sit him up, do not let him walk, and do not rub or massage his limbs. Cold blood and cold extremities returning to the core, plus the mechanical stimulus of rough movement, can trigger ventricular fibrillation in a cold heart.
- Insulate. Remove the wet clothing without unnecessary movement, cover him in the thermal protective aid, add dry blankets or other survivors' spare clothing over the trunk, and insulate the head. Protect him from the boat's spray and wind - a casualty who stays wet in a 20-knot wind is losing heat faster than any wrap can put it back.
- No alcohol, no hot bath, no hot drinks while unresponsive. Warm, sweet fluid only for a casualty who is fully conscious and shivering.
- Watch for afterdrop and arrest. His condition may worsen even as you warm him. Keep him horizontal during transfer to the ship and into the ambulance, monitor breathing continuously, and be prepared to start CPR - a hypothermic casualty in cardiac arrest is not declared dead until he is warm and has been resuscitated in hospital.
3. During transfer alongside the ship the casualty stops breathing and has no palpable pulse. What do you do, and what do you say to the ship?
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Start resuscitation immediately, and do not let the transfer delay it.
In the boat: begin chest compressions and rescue breaths at the standard ratio, on the floorboards, with the casualty horizontal and the airway managed. Do not pause to move him somewhere more convenient. Hypothermic casualties can be resuscitated successfully after long periods of arrest, so the effort is not futile, and the rewarming that will happen ashore is what gives him a chance.
Minimise the interruption to compressions. Move him as a unit, keep him horizontal, and continue compressions through the transfer if the geometry allows - a rescuer in the boat's bow, or on the stretcher, can keep working while the boat comes alongside.
What to say to the ship: a clear, short situation report by radio before arrival - casualty recovered, in cardiac arrest, CPR in progress, hypothermic, water temperature 9 degrees, request medical advice and ambulance on arrival - followed by the exact position and side for the recovery. The ship needs that information early enough to call the ambulance, prepare the stretcher party and pass the water temperature and immersion time to the medical service, because those two facts change the hospital's management.
On board: continue CPR, keep him horizontal, insulate and protect him from the deck, and do not stop until a medical authority takes over. Do not allow anyone to convert the resuscitation attempt into a discussion of sea temperature and survival times - the task is to keep oxygenated blood moving until the hospital warms him.