CATASTROPHE comes quickly at sea. On any dark stormy night a doctor's bed- side telephone may ring and the urgent voice of a coastguard may ask for immediate medical assistance to a ship several miles from shore. If he agrees, and the honorary secretary of the station has authorized a launch, a life-boat will be standing by to take him out. What should he take with him and what will he find when he gets there ? Placing a doctor on board a ship in a heavy sea subjects a life-boat crew to considerable danger ; and the doctor must try to make this a risk worth taking.

Doyen once remarked that the success- ful surgeon arose from a mountain of corpses. One might claim, less drama- tically, that a successfully packed emergency bag can arise from some mountainous seas. Certainly, once the life-boat is launched, there is no going back.

Strong Bag Needed One needs a strong bag, the older the better. This applies also to clothes : on a stormy night we shall be lucky not to have both well soaked with sea-water and battered against the ship's side before we return. When packing this bag it is wise to assume that no indi- vidual item, except plenty of unsterile water and the patient, will be found at the end of the journey. I have expected to use a well-equipped ship's hospital only to find it flooded and sliced in half, after collision with the sharp prow of another vessel. I have asked for surgical spirit on an American ship only to find that every drop of alcohol on board, including the contents of mag- netic compasses and ten jars containing pathological specimens, had been drained away by a dipsomaniac on board.

It is as well to be self-contained for dressings, suture material, and minor instruments. I found that four 3 in.

plaster bandages, two 3 in. rolls of " Elastoplast ", and a small supply of cellulose tissue sufficed for any fracture likely to be reduced on board. Mor- phine will probably have been given to any severely injured man but you mu-t take your own anaesthetic. Thio- pentone and chloroform are the most convenient for single-handed emergency * This article is a digest of an article which appeared in the Lancet on the 20th of June, 1959, and is published by kind permission of the editor.

use. Although the mate will always offer to sit on the head of any obstreper- ous patient, the negligible risk of a small quantity of anaesthetic is much to be preferred.

It is advisable to pack things in some definite order in waterproof tins or boxes, which in turn can be labelled and wrapped in cellophane. Without this, plaster bandages and dressings will only survive one journey. Salt-water never seems to dry out, but the interior of the bag can be kept quite wholesome by putting a few paraformaldehyde tablets in the pockets or in loose gauze swabs.

Little Difference in War Looking at my records I was sur- prised to find that the 100 cases seen at sea since 1946 differed little from the 700 I treated during the war. In table one I have set out the emergencies which have caused 325 vessels in the English Channel, the North Sea, or the Downs, off Deal, to send messages asking for urgent medical help.

TABLE I—EMERGENCIES AT SEA WHICH HAVE PROMPTED 325 RE- QUESTS FOR URGENT MEDICAL HELP Injuries .. .. .. 84 Suspected appendicitis .. 41 Venereal diseases .... 35 Septic conditions .... 27 Pneumonia or bronchitis.. 17 Tonsillitis or sinusitis . . 17 Infectious diseases .. 16 Dental cases .. . . 12 Acute neuroses . . . . 11 Heart-disease .... 10 Renal colic .... 9 Foreign body in eye .. 8 Enteritis 8 Intestinal obstruction . . 6 Landed dead .... 6 Non-traumatic haemorrhage 4 Acute rheumatism .. 4 Gastric or duodenal ulcer 4 Immersion .... 4 Inoculations .... 2 In peace or war, injuries head the list: of 84 cases 47 were soft-tissue injuries, 24 fractures, 7 dislocations, and 6 severe burns. Provision for these will take up half the contents of a sizeable bag.

Life-boats of the larger types are equipped with Neil-Robertson stretchers.

This stretcher wraps round the patient and even enables him to be passed vertically through a manhole. Prob- ably the safest way of transferring a stretcher case to a small boat is to lower it down the ship's side with four separate ropes and a man holding each under the direction of a boatswain. As soon as the receiving party in the boat have a firm hold of the patient the ropes are dropped completely slack.

Perpetual Nightmare Suspected appendicitis is a perpetual nightmare at sea and causes some 12% of all urgent calls. Diagnosis at sea is more accurate than on shore, and I found over half the cases to be genuine.

These are best landed as soon as possible : almost all of them required urgent operation.

Gastric and duodenal ulcers seem to be rare at sea and fortunately in twenty years I have encountered no perforation.

The commonest causes of non-traumatic haemorrhage have been epistaxis and bleeding piles. By the time one reaches the ship the trouble will usually have ceased and little more than examination and reassurance will be needed ; but I believe that a few sod. calc. lactate tablets and liquid-paraffin emulsion respectively are more than placebos.

Nine cases of renal colic were seen, and all had been diagnosed efficiently in advance. We landed 8 for further examination and treatment. A rubber catheter for acute retention should always be ready in the emergency bag.

Frantic Radio Signals Septic conditions are plentiful ; and most abscesses are pointing by the time they become occasions for urgent calls.

Ischiorectal abscesses are surprisingly common, and I could always open these easily with great relief to the patient.

Some judgment is called for, however, in opening abscesses on board and I should now think twice before dealing with a quinsy. Unless the haemorrhage is very slight, there will be frantic radio signals for further advice, or a firm request that the patient be landed for hospital treatment.

Fifth and sixth on the frequency list come the respiratory infections. Upper- respiratory infections, especially tonsil- litis and sinusitis, have been four times commoner in American ships than in those of other nationalities.

Ordinary infectious disease on a ship is a great nuisance to everyone ; luckily I have never had reason to suspect plague, smallpox, or cholera.

Unless there are grave reasons for landing infectious patients it is better to leave them in their bunks, with the appropriate treatment. After all, so far as the ship is concerned, the damage has already been done.

Foreign Bodies in Eyes Perhaps because they are such a source of pain and anxiety at sea, foreign bodies in eyes seemed more common than appears in table I. A spud and a little 5 % cocaine should be in the bag ; and a pocket-torch and a magnifying-glass help. A small Higgin- son's syringe was often useful for blocked ears.

Dental abscesses and severe tooth- ache are common, and a pair of straight incisor forceps more than earn their place in the bag. Fortunately a little chloroform is a good substitute for a whiff of gas, and it never gave me any cause for anxiety.

Cases of acute mental illness varied from nervous breakdown to homicidal mania. As most laymen have implicit faith in the power of a doctor to handle a dangerous lunatic, it is as well to ask a few questions before being introduced into the patient's cabin. Having had one narrow escape, I now look carefully to see whether any fire-axes or dangerous implements are missing from their prominent places in the corridors. It is usually necessary to land these patients after making the necessary shore arrangements by radio-telephone.

Coronary Thrombosis I have found that " heart-disease " always means coronary thrombosis, and that the patient is usually the ship's captain himself. Fortunately all senior deck-officers hold a master's certificate ; and more often than not, after re- assurance, the mate (who prefers to be called the first officer) will decide to take the ship and its skipper to the home port. With rest and sedatives all our heart cases arrived safely.

Rheumatism as an emergency is likely to be some form of lumbago. It is a common ailment in any merchant vessel. Manipulation of a few recent cases of sacroiliac strain and occasional injection of 2 % procaine into localised fibrositis were my only ventures into the more dramatic types of treatment.

Immersion demands first-aid rather than medicine, though nikethamide and a flask of brandy or whisky are useful additions to the medical bag.

Some Surprises Apart from the urgent cases, advice was often sought for other patients on board ship (table two). This list con- tains some surprises, among them the TABLE 2—NON-EMERGENCY AIL- MENTS FOR WHICH 845 PATIENTS RECEIVED MEDICAL ATTENTION ON BOARD 351 SHIPS 1 25 6 14 12 12 25 1 7 34 2 3 12 27 3 17 4 13 6 4 10 16 33 182 92 24 6 9 7 11 2 32 35 35 30 34 59 Asthma Appendicitis Found dead Bronchitis Burns Cholangitis Dental cases Diabetes Dislocations Enteritis Epilepsy Epistaxis Foreign body in eye Fractures Gastric ulcer Gastritis Haemorrhoids Heart-disease Hernia Hydrocele Immersion Infectious diseases Influenza Injuries Inoculations Neurosis Obstruction Pneumonia Pulmonary tuberculosis Renal colic Retention of urine Rheumatism Septic conditions ..

Sinusitis Skin disease Tonsillitis Venereal diseases ..

rarity of asthma and diabetes. Al- though adrenaline and insulin were almost the first drugs to be put in my seagoing bag, 1 never used either in twenty years. On the other hand, if one's favourite first-aid remedy for the remaining conditions is added to the contents of the bag, some very grateful patients will be left behind in almost every ship. One hopes, too, that the prompt production of an appropriate remedy may, in a small way, enhance the prestige of British medicine amongst the seafarers of many nations : in the freemasonry of the sea there is much wider publicity than ashore.

I often expected language difficulties but found few. American was the easiest language in which to get mis- understood. The word " aperient " will receive a blank stare from the purser ; but " did he take physic ? " obtains a prompt reply. And until " temperature " is changed to " fever " and " sick " to " vomit " there will be confusion of thought. But the standard of medical knowledge and emergency treatment is high. After an intensive course ashore, lasting a few months, the better pursers receive the interesting diploma of " pharmacist's mate".

After a further course they are permitted to give antibiotics.

Lastly, some non-medical recommend- ations to my successors in this work.

Pays to Follow Advice It pays to follow all advice, however simple, offered by these boatmen. They know the anchorage and its dangers better than you do. Such hazards as there are occur in transferring the patients or yourself on or off a larger vessel. Even a small ship at anchor stays relatively still : small boats and life-boats do not. Apart from the obvious advice not to release a firm handhold until you have found an- other, the keynote of safety is to let the ship's rope-ladder take you off the boat and vice versa. If you feel a lift under your foot you may safely transfer to either. To step off where you think the boat's gunwale is going to be is to invite disaster ; and nobody who has dropped ten feet and sat on the boat's anchor will wish to repeat the experience. Also, once on the ship's rope-ladder, climb fast to make sure that if sixteen tons of life-boat smash the rungs of the ladder, these rungs are the ones you have just left. I was also advised to make sure, when returning to a life-boat, that the fattest man in the crew was directly underneath, but this scarcely adds to one's popularity the next time. But for my own part I am glad to say that so far I have been able to avoid implementing the special threat held over the heads of successive coxswains. We have not yet had a confinement on board their vessel.

1 should like to pay a small tribute to the crew of the Walmer life-boat for their many years of devoted service and the good care they have given to all my patients and myself. This has often been at the cost of long hours without food and successive nights without sleep. At times they have accepted considerable risk to ensure our safety, and on one occasion no fewer than five members of the life-boat crew required treatment for injuries..