Sea Survival and Basic First Aid for Crew

Prerequisites

This lesson is for new crew and requires no previous qualification. It is helpful, but not essential, if you have already worked through the lessons on personal safety, safety equipment and man overboard. It draws on the content of the RYA Sea Survival Handbook (G43) and the RYA First Aid Manual (G4), which are on the reading list for the Competent Crew course.

You should:

• Be physically able to take part in the practical safety drills on board, including wearing a lifejacket and harness.
• Know where the lifejackets, the first aid kit, the liferaft and the flares are stowed on the boat you sail on.
• Be willing to tell the skipper about any medical condition, allergy or regular medication before you sail. Skippers keep this information confidential, and it could save your life.

An important note: this lesson is a guide, not a substitute for a practical course. The RYA recommends that all crew attend a recognised first aid course (the RYA Basic First Aid or First Aid at Sea course, or an equivalent) and a practical sea survival course, ideally with a pool session for liferaft practice.

Learning Objectives

By the end of this lesson you will be able to:

• Explain the hazards of cold water immersion: cold shock, swim failure and hypothermia, and the survival timeline.
• Describe how to prevent hypothermia on board and how to treat it.
• Use the HELP and huddle positions in the water to conserve heat.
• Explain how to inflate, use and care for a lifejacket, and list its features.
• Describe when to abandon ship, what to take, and how to board and live in a liferaft.
• Describe how to attract rescue: flares, VHF, EPIRB and PLB.
• Recognise, prevent and treat seasickness, dehydration, sunburn and heat exhaustion.
• Carry out a primary survey (DRABC), manage bleeding, treat burns and scalds, and perform basic CPR and the recovery position.
• Know the contents of a yacht first aid kit and when and how to call for medical advice.

Why this matters

The sea is a hostile environment. The water around the British Isles never gets warmer than about 17 to 18 degrees Celsius at its warmest in late summer and falls to 6 to 8 degrees in winter. Most deaths in the water are caused not by drowning in the way people imagine, but by the first minutes of cold shock, followed by loss of strength. Most sailors who come to harm do so after a series of small errors, such as an unclipped harness, a lifejacket left in the locker, or an injury ignored. Understanding what happens to your body, and what you can do about it, is the best protection.

The principle in both survival and first aid is the same: prevention first, then early action, and keep calm. A prepared crew who know what to do will work as a team, whereas an unprepared crew will lose precious minutes.

Cold water: what happens to the body

The temperature of the water is much colder than the air: water conducts heat away from your body about 25 times faster than air at the same temperature. Because of this, the effects come in stages. The first three of these are collectively called the cold water immersion problem.

The diagram below shows the timeline.

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Stage 1: Cold shock (first 0 to 3 minutes)

When you enter water below about 15 degrees Celsius, the skin sensors trigger a series of involuntary reactions:

• A sudden gasp reflex: you gasp uncontrollably. If your head is underwater at that moment you will breathe in water.
• Hyperventilation: very rapid, uncontrolled breathing, which can last for a few minutes. This causes panic and makes it hard to shout or hold your breath.
• A sharp rise in heart rate and blood pressure. For a person with heart disease, this can be fatal.

Cold shock is the biggest killer. Many deaths occur within the first few minutes. It is not the cold temperature as such but the breathing response that causes drowning, even in strong swimmers who are wearing a lifejacket.

What to do: Keep your airway clear. Your lifejacket will keep your face out of the water. Float on your back, do not swim, and concentrate on controlling your breathing. The gasp and hyperventilation pass in about a minute or two. Do not try to swim until your breathing is under control. Keep still, and wait until you are calm before you act.

Stage 2: Swim failure (3 to 30 minutes)

As the cold penetrates the arms and legs, the muscles and nerves lose strength and coordination. Within about 10 to 30 minutes in cold water, you cannot swim, hold on to a line or grasp a rescuer's hand, even if you are physically fit. The fingers become numb and useless. This is called swim failure or cold incapacitation, and it occurs long before you are actually hypothermic.

This is why it is so important that a casualty in the water is recovered quickly, and why you must never delay a rescue to wait for the lifeboat: if you can reach and recover the casualty, do so at once. It is also why crew should wear a lifejacket with a crotch strap and keep a whistle or light on it, so that the casualty can attract attention before strength fails.

Stage 3: Hypothermia (30 minutes onwards)

Hypothermia means that the deep (core) body temperature has fallen below 35 degrees Celsius (normal is 37). In cold UK water, survival without protective clothing is typically about one hour or less, although this varies greatly with water temperature, build, fitness, clothing and sea state. Even after being pulled out, the core temperature may continue to fall: this is afterdrop.

Survival factors

Preventing cold and hypothermia on board

Hypothermia is not only an issue for those in the water. A crew member who is cold, wet, tired and underfed on deck at night can suffer the same condition slowly. The most common cause is wet clothing, particularly cotton, which loses its insulating ability and draws heat from the body. Wet cotton on a cold night can be dangerous even if you have not fallen in the water.

Prevention:

• Dress in layers. A base layer of synthetic or wool wicks moisture away; fleece or wool mid layers trap air; a windproof and waterproof outer layer keeps rain and spray out. Avoid cotton jeans and sweatshirts.
• Protect the extremities. Wear a warm hat (a large amount of heat is lost through the head), gloves, and warm socks and boots. A neck gaiter helps.
• Eat and drink regularly. Warm drinks and high-energy food such as chocolate, flapjacks and sandwiches keep the body fuelled. Avoid alcohol.
• Rest properly. Fatigue reduces resistance to cold. Get below and sleep during the off-watch.
• Keep dry. Change into dry clothes as soon as possible after getting wet. Carry spare dry clothes in a waterproof bag.
• Shelter. Use the cockpit spray hood and sprayhood or dodger to reduce wind chill, and rig lee cloths and tarpaulin if necessary.

The diagram below shows why wet cotton is a danger.

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Recognising hypothermia

The signs come on gradually and the casualty is often unaware. Crew members should watch each other, because a hypothermic person is often the last to realise.

• Mild (core temperature about 32 to 35 degrees Celsius): shivering, cold pale skin, numb hands, slurred speech, confusion, clumsiness, irritability, "the umbles" (stumbles, mumbles, fumbles, grumbles).
• Moderate (about 28 to 32 degrees): intense shivering that may become irregular, drowsiness, slow speech, poor judgement, and failure to respond to questions.
• Severe (below about 28 degrees): shivering stops (a very dangerous sign), the casualty becomes unconscious, with a slow weak pulse and slow shallow breathing, and may appear dead.

The signs of hypothermia in a casualty include a lack of interest in his own survival, apathy, stopping shivering, and refusal to help.

Treating hypothermia

The aim is to stop further heat loss and rewarm slowly. The diagram below shows the stages and the actions.

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1. Get the casualty out of the wind and water. Take them below or into a sheltered spot. Handle them gently and keep them horizontal, particularly if they were immersed. Moving a severely cold casualty roughly, or lifting them upright, can cause a fatal heart rhythm.
2. Remove wet clothing (cut it off if necessary, to avoid rough movement) and replace with dry clothing, or wrap the casualty in a dry sleeping bag, blankets or a survival bag. Insulate from the cold deck below the casualty, and cover the head.
3. Rewarm slowly, passively. Use dry insulation and, if available, warm (not hot) hot-water bottles against the trunk (the chest, armpits and groin), well wrapped to avoid burns. The warm body of another crew member in the sleeping bag can help.
4. Give warm, sweet drinks and food only if the casualty is fully conscious and able to swallow. No alcohol.
5. Do not rub the limbs, do not use direct heat, and do not give a hot bath. Rubbing or heating the limbs drives cold blood to the core and can cause the rapid fall in core temperature known as afterdrop, which can trigger cardiac arrest.
6. Monitor. Check the airway, breathing and pulse. Be ready to start CPR if breathing stops. A severely hypothermic casualty may appear dead; check for breathing and pulse for a full minute before you decide. Continue CPR until medical help takes over: a casualty is not considered dead until warm and dead.
7. Call for help early. For anything more than mild hypothermia, call the Coastguard on VHF channel 16 and ask for medical advice from a doctor through the Telemedical Maritime Assistance Service (TMAS). All casualties who have been immersed should be assessed by a doctor, even if they seem to have recovered, because of the risk of secondary drowning (water in the lungs causing problems hours later).

In the water: protecting yourself

The lifejacket

A lifejacket is the single most important safety item. It is designed to turn an unconscious person face-up and keep the airway clear. The usual standard for yacht use is a 150 newton (N) inflatable lifejacket meeting ISO 12402. This provides enough buoyancy for adults wearing heavy clothing and foul weather gear. Lower buoyancy aids (50 N) are not lifejackets and do not turn an unconscious wearer face-up.

A good yacht lifejacket should have:

• A crotch strap or thigh straps, which keep the lifejacket from riding up over your head.
• A built-in harness with a lifeline attachment point, and a jackstay clip.
• A spray hood, which keeps spray from the airway and reduces the chance of inhaling water. A hood is especially valuable in cold water or rough seas.
• A light, which comes on automatically in water, and a whistle.
• Reflective tape.
• A personal locator beacon (PLB) in a pocket or as part of the lifejacket, if possible, or a AIS man overboard beacon.

Maintenance. Inflate by mouth every season to check for leaks. Check the gas cylinder is screwed up tight and not discharged, the indicator is green, and the automatic mechanism (a bobbin or a hydrostatic device) is in date. Replace the cylinder and bobbin as the manufacturer says (typically service annually or every two years). Rinse with fresh water. Do not dry on a radiator.

Fitting. A lifejacket should be adjusted so that it is snug, with the crotch strap in place. Check that you can pull the jacket upwards over your ears; if you can lift it more than a few centimetres from the shoulders, it needs tightening.

Wear it. The RYA advice is to wear a lifejacket at all times on deck at night, when alone on deck, in rough weather, when the skipper tells you to, and in a dinghy at all times. If in doubt, put it on.

HELP and huddle

If you are in cold water and awaiting rescue, you must conserve heat. Two positions are taught:

• HELP (Heat Escape Lessening Position). Float with the lifejacket on, bring your knees up to your chest, and hold your arms tightly across your chest and against your sides. This protects the areas that lose heat fastest: the groin, the armpits and the sides of the chest. You cut heat loss by up to about a third. Keep your head out of the water.
• Huddle. Two or more people in the water bring their bodies together, side by side, with arms around each other's backs, chest to chest. This reduces heat loss and helps morale, and makes the group easier to see for rescuers. Children and the weakest are put in the centre.

Do not swim unless you are close to a safe refuge, such as a liferaft or the boat, and you are confident you can get there. Hold on to anything that floats. A lifejacket with a spray hood greatly helps.

Attracting attention in the water

• Use the whistle: three blasts repeated.
• Use the lifejacket light at night.
• A personal locator beacon or AIS MOB device alerts rescuers and gives them your position.
• Wave a bright item above your head if a helicopter or vessel passes.
• Keep close to the boat if it is still afloat. The boat is a much bigger target than a person.

Recovering a casualty

Man overboard recovery is dealt with in a separate lesson, but two first aid points apply when the casualty is back on board:

• Lift the casualty horizontally if you possibly can. A person who has been in cold water for more than a few minutes has a lower blood pressure while immersed because the water pressure supports the circulation. If you lift them vertically, blood can pool in the legs and the heart may fail (called circum-rescue collapse). Use a lifting strop, a halyard with a sling, or a parbuckle, and keep the casualty as flat as possible.
• Treat for hypothermia, and watch breathing. Suspect secondary drowning.

Abandoning ship and the liferaft

When to abandon

The skipper's decision to abandon ship should be the very last resort. The Competent Crew course gives a clear message: "Step UP into the liferaft, never DOWN." Most vessels that are on fire or flooding stay afloat longer than people expect, and the yacht itself is a much bigger, more visible and more stable platform than a liferaft. Abandon only when the boat is sinking beyond your ability to control the flooding, or when a fire cannot be contained.

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Preparation (while there is still time)

If the skipper decides that abandoning ship is likely, the crew should prepare while the boat is still afloat. Typical actions are:

1. Send a distress call: a Mayday on VHF channel 16 or by DSC, giving position, nature of distress and number of people on board. Press the DSC distress button if fitted. Activate the EPIRB (406 MHz) and keep it with you. If a PLB or AIS beacon is carried, switch it on.
2. Put on warm clothing and a lifejacket, including waterproofs. Put on a hat. Seasick tablets can be taken. Do not take off your harness. Eat and drink something if there is time.
3. Assemble the grab bag (abandon-ship bag). A typical grab bag contains a handheld VHF radio, a handheld GPS, a PLB, flares, a torch, water, first aid items and seasickness tablets, a knife, a space blanket, ship's papers and a mobile phone in a waterproof pouch. Also take fresh water and extra food if possible.
4. Prepare the liferaft. Release the lashings, take it to the side of the boat on the leeward side (if possible), and check the painter is secured to a strong point on the yacht (not a guardrail).
5. Keep the liferaft in its container and use it as a last step. Do not throw it out too early: it can drift away before you can board, or tear on the deck.

Launching and inflating

1. Check the painter is made fast to the boat.
2. Throw the container into the water. The cradle or the hydrostatic release unit (HRU), if fitted, automatically releases a raft that is submerged to 2 to 4 metres, and allows it to float free if the boat sinks.
3. Pull the painter firmly. The first 5 to 10 metres of painter are a lanyard that activates the gas cylinder. Once the raft has inflated (usually 30 to 60 seconds), pull it to the boat.
4. If the raft inflates upside down, stand on the cylinder and pull on the righting strap while leaning back to flip it. Never inflate it on deck, since it could trap someone.

Boarding

Board the raft dry. This is of great importance because every wet person in the raft is at risk of hypothermia and will make the raft cold and wet. Step directly from the yacht's deck into the raft if you can, and do not enter the water.

• If the sea is rough, step into the raft from the lee side when it rises to the level of the deck.
• If you have to enter the water, swim directly to the raft and use the boarding ramp or the ladder. Pull the casualty in by the lifejacket shoulder straps. Help each other.
• Cut the painter only when everyone is aboard and the yacht is sinking or in danger. Use the knife in the raft. A cut painter means you may lose access to the yacht's supplies.
• Take the grab bag aboard first, and pass the EPIRB.

Surviving in the raft

• Stay near the wreck if it is safe to do so; a boat or a debris field is easier to find than a small raft. Streaming the sea anchor (drogue) keeps the raft from drifting too fast and stabilises it.
• Close the canopy to keep out wind and rain. Ventilate occasionally.
• Bail out water and mop up with a sponge. Keep the floor dry. Inflate the floor if applicable.
• Treat the wounded and give them the best places. Check the repair kit and plug punctures with the plugs provided.
• Keep warm. Huddle together. Use survival blankets and spare clothing. Everyone should stay as dry as possible.
• Appoint a leader. The skipper or a senior person should direct the crew, set a watch rota (lookout, bailing, pumps, signalling), and keep morale high.
• Keep a lookout and be ready to attract attention with flares as ships or aircraft approach. Do not use all flares at once: use them when there is a real prospect of being seen.
• Do not drink seawater or urine. Rationing: nothing for the first 24 hours (unless injured or seasick), then half a litre a day, if you have a limited supply. Food should not be eaten if water is short, because digestion uses water.
• Seasickness. It is made worse in a raft. Take your antiemetic and keep a bucket handy.

Signalling for help

Flares are dangerous: they burn at over 1,000 degrees Celsius. Handle with care, point them away from the raft and your body, hold them downwind, and use gloves. Do not use flares if a helicopter is directly overhead without instructions. Out-of-date flares must be disposed of through the Coastguard, a Marine retailer or the local authority; do not throw them in the sea or the bin.

Rescue by lifeboat or helicopter

If a helicopter is winching you up, stay calm. Do not attach the winch wire to the raft or yacht, and let the winch hook touch the water first so that static electricity is discharged. Follow the winchman's instructions. Wear a lifejacket and do not lift your arms above your head in the strop. Stay in the raft until told to leave it. If a lifeboat approaches, they will usually come alongside the liferaft or the yacht.

Seasickness and other conditions of crew at sea

Seasickness (motion sickness)

Seasickness is caused by conflicting signals to the brain from the eyes and the balance organs in the inner ear. It affects most people at some time. It is miserable and can be dangerous, because vomiting and a loss of appetite lead to dehydration, fatigue, loss of judgement and hypothermia. A seasick crew member is also much more likely to be careless about safety.

The diagram below sets out management.

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Prevention:

• Get a good night's sleep before sailing, avoid heavy meals, alcohol and greasy food the night before and on the morning of the passage.
• Take anti-seasickness medication (hyoscine, cinnarizine, or similar) before departure, one to two hours before sailing, and according to the instructions. Once you are vomiting, tablets cannot be absorbed. Medication can cause drowsiness, so tell the skipper. Seek advice from a doctor or pharmacist if you have a medical condition or take other medication. Wristbands and ginger are popular, but evidence for their effects is limited.
• Stay on deck as much as you can, in the fresh air. Stay near the middle of the boat, where there is least movement, and avoid going below to read, cook, or work with your head down.
• Look at the horizon and keep busy: take the helm if you can, which often helps.
• Eat small amounts of plain food regularly, such as dry biscuits or crackers, and drink water in small sips.
• Wrap up warm, because being cold makes sickness worse.

Treatment of a casualty:

• Keep the casualty on deck if possible, harnessed and clipped on, with a bucket. Never allow a seasick person to hang over the side without a harness.
• Give small, frequent sips of water or oral rehydration solution (ORS) to replace lost fluids and salts.
• Encourage them to eat dry food when they can.
• Rest them in the cockpit or a bunk in the middle of the boat, lying down with eyes closed if they cannot function.
• If vomiting is severe or persistent for more than 24 hours, they cannot keep fluids down, or they become confused, drowsy or have a very dry mouth, contact the Coastguard for medical advice from TMAS. Severe dehydration may need injected medication or drip treatment.

Seasick crew members have usually recovered after 24 to 48 hours as the body adapts. Be sympathetic: do not make fun of someone who is ill.

Dehydration

Symptoms: thirst, dry mouth, dark urine, headache, tiredness and dizziness. Seasick crews and those in hot conditions are at special risk. Drink regularly, about 2 to 3 litres a day, more in hot weather. Avoid excess alcohol and caffeine.

Sunburn, heat exhaustion and sunstroke

Sun and reflected light off the water can cause severe sunburn and eye damage very quickly, even on cloudy days.

• Wear sunglasses with UV protection, a wide-brimmed hat and loose clothing. Use a high-factor, water-resistant sunscreen (SPF 30 or above) and re-apply every two hours. Cover exposed necks, ears and the backs of the knees.
• Heat exhaustion: heavy sweating, pale and clammy skin, weakness, headache, nausea, a fast pulse. Move the casualty to shade, lay them down, raise their legs, loosen clothing, give sips of water and cool them with wet cloths.
• Heat stroke (life-threatening): hot dry flushed skin, confusion, a very high temperature, loss of consciousness. Cool the casualty urgently with wet cloths and fanning, call for medical help immediately and monitor.
• Sunburn: move into shade, cool the skin with cool water, apply after-sun lotion and give fluids.

First aid: the primary survey (DRABC)

First aid on a yacht differs from first aid ashore: help may be hours away, there may be few people on board, and the vessel itself is moving and the casualty may be in a confined space. The principles are the same. Preserve life, prevent the condition worsening, and promote recovery.

The first step is always to carry out a primary survey, which is a quick check for life-threatening problems, using the mnemonic DRABC.

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1. D - Danger. Is it safe to approach? On a yacht the dangers may include a swinging boom, fire, fuel fumes, electricity, a lee shore or a rough sea. Make the situation safe before you approach and do not become a second casualty. Tell the helmsman, and if necessary, stop the boat or heave-to. Have someone take over the helm.
2. R - Response. Gently shake the shoulders and ask loudly "Can you hear me? Open your eyes!" If the casualty responds, treat for any injuries found, and keep checking. If not, shout for help and send someone to call the Coastguard on VHF.
3. A - Airway. Open the airway by gently tilting the head back and lifting the chin. Look in the mouth for obstructions such as vomit, food or loose teeth and remove them if you can see them. If a spinal injury is suspected (a fall from the mast or down the companionway, for example) take extra care with the neck and use the jaw thrust method if trained.
4. B - Breathing. Look, listen and feel for normal breathing for up to 10 seconds. Look for chest movement, listen at the mouth for breath sounds, feel for breath on your cheek. Occasional gasps are not normal breathing. If the casualty is not breathing normally, call for help and start CPR.
5. C - Circulation. Check for severe bleeding and control it. Look for signs of shock: pale, cold, clammy skin, fast weak pulse, and fast breathing.

After the survey, perform a secondary survey, a head-to-toe check for other injuries, and take a history if the casualty is conscious (what happened, where it hurts, allergies, medication, medical conditions). Record observations and the time, so that they can be handed on to the doctor or rescuers.

Getting help

Call for help early. Do not wait.

• Use VHF channel 16 and call Coastguard: "Pan-Pan, Pan-Pan, Pan-Pan" for a medical emergency needing advice or assistance, or "Mayday" if there is a threat to life requiring immediate help. The Coastguard will connect you with a doctor via TMAS, which provides free advice 24 hours a day. They can arrange a lifeboat or helicopter evacuation.
• Give your vessel name, position, nature of the problem, the casualty's age and sex, symptoms and any treatment already given.
• In many parts of the UK coast you can call 999 on a mobile phone and ask for the Coastguard.

Controlling bleeding

Bleeding can be serious on a boat, where the casualty may be thrown against fittings or injured by tools, winches and lines. Severe bleeding is a life-threatening emergency. Adults have about 5 to 6 litres of blood, and the loss of 1 to 1.5 litres is dangerous.

Principles of treatment:

1. Protect yourself. Wear gloves if available, or use a plastic bag over your hand.
2. Apply direct pressure. Press firmly on the wound with a clean pad or dressing, or with your fingers if nothing else is available. Hold the pressure for at least 10 minutes without lifting to look.
3. Raise and support the injured limb above the level of the heart, unless it is broken.
4. Bandage firmly. Apply a bandage over the pad to hold it in place. It should be firm but not so tight as to cut off the circulation. Check the fingers or toes beyond the bandage for warmth, colour and feeling. If blood soaks through, do not remove the pad; place another on top and bandage over both.
5. Treat for shock. Lay the casualty down, raise the legs if there are no leg injuries, keep them warm, and reassure them.
6. Call for medical advice for all significant bleeding.
7. Tourniquets are to be used only as a last resort for life-threatening limb bleeding that cannot be controlled by direct pressure. Apply it high on the limb, tighten until the bleeding stops, note the time, and do not loosen it. Specialised commercial tourniquets are preferred.

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Special cases:

• Nosebleed: sit the casualty upright, leaning forward, and pinch the soft part of the nose for 10 minutes.
• Head wounds bleed heavily. Apply pressure around the wound, not directly on a suspected skull fracture. Any head injury with loss of consciousness, vomiting, confusion or drowsiness needs urgent medical advice.
• Crush injuries from winches and blocks: immobilise and raise the limb, and monitor circulation.
• Fishhook and deep puncture wounds should be left for medical attention if the hook is deep. Do not pull out embedded objects.

Shock

Shock means that the circulatory system is failing to deliver enough oxygen to the body. It can follow severe bleeding, burns, severe pain and heart problems. The signs are pale, cold, clammy skin, a fast weak pulse, rapid shallow breathing, thirst, restlessness and later drowsiness. Treat by laying the casualty down, raising the legs if there is no fracture, keeping them warm, controlling the cause (e.g. bleeding) and reassuring them. Do not give food or drink, because they may need surgery. Call for help.

Burns and scalds

Burns on a boat are most often caused by galley scalds, gas fires, hot engine parts, flares and sunburn. The immediate treatment is the same for all heat burns, as shown below.

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1. Make the area safe. Remove the casualty from the heat source. If clothing is on fire, stop, drop and roll them or smother with a blanket. Turn off the gas.
2. Cool the burn with cool running water for at least 20 minutes. Seawater is acceptable if fresh water is limited; a bucket over the side will do. Cooling reduces pain and limits tissue damage.
3. Remove jewellery and watches and loose clothing from the area before swelling begins, unless stuck to the skin. Do not remove anything that is stuck to the burn.
4. Cover loosely with a clean, non-fluffy dressing, or cling film laid lengthways (not wrapped around a limb). This protects against infection.
5. Do not apply ice, butter, creams, toothpaste or lotions. Do not burst blisters.
6. Give pain relief, such as paracetamol, if the casualty is not allergic and the dose is recorded.
7. Treat for shock, give small sips of water if conscious.
8. Get medical advice for any burn larger than the casualty's hand, any burn on the face, hands, feet, genitals or over a joint, any deep burn (white, brown or charred skin, which may be painless), and any burn in a child or an elderly person. Contact TMAS.

Chemical burns: flood the area with large amounts of water for at least 20 minutes, removing contaminated clothing. Electrical burns are more serious than they appear: switch off the power before you touch the casualty, and take them to hospital.

Airway burns: inhaling smoke or hot gas can burn the airway. Watch for soot around the nose and mouth, a hoarse voice or difficulty breathing. This is an emergency.

Cardiopulmonary resuscitation (CPR)

If a casualty is unresponsive and not breathing normally, they are in cardiac arrest. Without CPR, the brain begins to suffer damage within three or four minutes. Early CPR and early defibrillation increase the chances of survival.

Procedure for an adult:

1. Confirm the casualty is unresponsive and not breathing normally (DRABC). Call for help; ask someone to call the Coastguard (Mayday) and to fetch the first aid kit and any defibrillator (AED).
2. Lay the casualty flat on their back on a firm surface. On a yacht this may be the cockpit sole or saloon floor; jam yourself and the casualty so you do not slide.
3. Kneel beside the casualty. Place the heel of one hand in the centre of the chest, on the lower half of the breastbone. Place the other hand on top and interlock your fingers. Keep your arms straight and your shoulders directly above your hands.
4. Compress the chest by about 5 to 6 centimetres at a rate of 100 to 120 compressions per minute (about two per second). Allow the chest to recoil fully after each compression. Count aloud.
5. After 30 compressions, give 2 rescue breaths if you are trained and willing. Open the airway (head tilt, chin lift), pinch the nose, make a seal over the mouth and blow steadily for about 1 second, watching the chest rise. Use a face shield from the first aid kit if available. If you are unable or unwilling to give breaths, continue with chest compressions only; this is much better than doing nothing.
6. Continue cycles of 30:2 without stopping, except to check for signs of life if the casualty starts to move, breathe, or open their eyes.
7. Change over with another rescuer every two minutes if possible, because CPR is tiring.
8. If an AED is available, switch it on and follow its voice prompts. Attach the pads to the bare, dry chest and follow the instructions.
9. Continue until the casualty recovers, qualified help takes over, an AED tells you to stop, or you are exhausted.

CPR for drowning victims: In a drowning casualty, the cause of cardiac arrest is lack of oxygen, so rescue breaths are particularly important. Give five initial rescue breaths before starting compressions if you are trained.

CPR for children and infants: The technique varies slightly: for children use one or two hands to compress by one third of the chest depth; for infants use two fingers. Give five initial rescue breaths and follow with 30:2. A first aid course will teach this properly.

Hypothermic casualties: Continue CPR for longer, and do not stop until the casualty is rewarmed and a doctor has confirmed death, because survival has been recorded after prolonged cold-water cardiac arrest.

On a moving boat: CPR is hard in a seaway. Brace yourself against the cabin side or a bunk, and where possible heave-to or stop the boat. Compressions must still be done on a firm surface, never in a soft bunk.

Recovery position

An unconscious casualty who is breathing normally should be placed in the recovery position to keep the airway clear and to prevent them from inhaling vomit.

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1. Kneel beside the casualty. Remove glasses and bulky items from pockets. Straighten the legs.
2. Place the arm nearest you at a right angle to the body, with the palm up. Bring the far arm across the chest and hold the back of the hand against the cheek nearest you.
3. With your other hand, grasp the far knee and pull it up with the foot flat on the floor.
4. Keeping their hand pressed against the cheek, pull on the knee to roll the casualty towards you onto their side.
5. Adjust the upper leg so that both hip and knee are bent at right angles. Tilt the head back to keep the airway open and adjust the hand under the cheek.
6. Monitor breathing continuously. Be ready to start CPR. Stay with the casualty and call for help. Record the time.

If you suspect a spinal injury, avoid moving the casualty unless the airway is threatened. A log-roll with several people is the safe technique.

Choking

For a conscious adult who is choking, encourage coughing. If they cannot cough, speak or breathe, give up to five sharp back blows between the shoulder blades, with the casualty leaning forward. If this fails, give up to five abdominal thrusts (Heimlich manoeuvre): stand behind them, put your arms around their waist, make a fist above the navel, and pull sharply inwards and upwards. Alternate five back blows and five thrusts. If the casualty becomes unconscious, call for help and begin CPR.

Other injuries and illnesses that occur on yachts

• Fractures and sprains: support the injured part in the position found, pad and splint above and below the fracture with a rolled-up sailbag, a cushion or a bandage, and check circulation beyond. Pain relief and medical advice.
• Spinal injury: suspect after any fall from height. Keep the head, neck and spine in line, immobilise, and obtain urgent medical advice.
• Head injury: a casualty who loses consciousness, vomits, becomes drowsy or confused needs urgent advice.
• Fishhooks, splinters, rope burns and cuts: clean with fresh water, cover with a sterile dressing and monitor for infection.
• Sea water boils and sores: keep clean and dry.
• Carbon monoxide poisoning: from gas fires, engines, petrol generators and portable heaters in a closed cabin. Symptoms are headache, dizziness, drowsiness and nausea. Move the casualty into fresh air, call for help and give CPR if needed. Fit a carbon monoxide alarm.
• Allergic reactions and anaphylaxis: crew with severe allergies must tell the skipper and carry their own auto-injector (adrenaline).
• Marine animals: jellyfish stings are treated by rinsing with seawater (not fresh water) and removing tentacles with tweezers.

The yacht first aid kit

The skipper is responsible for supplying a suitable first aid kit, in a waterproof, clearly marked container, in a known location. Every crew member should know where it is. The contents should be tailored to the voyage and crew, with a basic kit for coastal sailing along these lines:

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The kit should be inspected regularly. Replace used and out-of-date items. A record of any medication given should always be made: drug, dose, time, patient and reason. Controlled and prescription drugs must be locked away.

Worked Example

Scenario. You are crew aboard a 10 metre sloop, 6 nautical miles off the coast, in a force 5 wind and a moderate sea. It is dusk. Skipper Sam is at the helm, and you and two other crew members are in the cockpit. A crew member, Chris, who was working at the mast, slips on the wet foredeck and falls backwards into the cockpit, striking his head on a winch. He is lying on the cockpit floor, motionless, with a bleeding wound on his scalp.

1. Danger. Sam warns you of the boom and the motion. Sam hands over the helm to another crew member, brings the boat head to wind and heaves-to to reduce the motion. You check that there is nothing sharp, loose or hazardous around the casualty. You are wearing gloves from the first aid kit.
2. Response. You speak loudly and tap Chris's shoulders. There is no response. You shout for help and ask the crew member who is now off watch to call the Coastguard on VHF channel 16, giving the vessel name, position, number on board and the injury.
3. Airway. Because he fell from a height and hit his head, you suspect a neck injury. You support his head and neck in line with the body. You look in his mouth. It is clear. You open his airway using a jaw thrust, then head tilt and chin lift as the airway is not clear.
4. Breathing. You look, listen and feel for 10 seconds. He is breathing normally, with a slow, snoring noise.
5. Circulation. The scalp wound is bleeding heavily. You press a sterile dressing firmly on the wound, avoiding any area that feels depressed (a possible skull fracture). You bandage over the pad. His pulse is steady but fast and his skin is pale.
6. Positioning. He is breathing and unconscious, so you need to protect his airway. Together with two others, you log-roll him on to his side into the recovery position, keeping the head, neck and body in line. You keep him warm with a sleeping bag and insulate him from the cold, wet cockpit sole.
7. Information. You note the time of the fall, how long he was unconscious, his pulse and breathing every few minutes, and any changes. At the Coastguard's request you pass on his age, history and observations, and they link you to a TMAS doctor. The doctor advises that a head injury with loss of consciousness requires evacuation. The Coastguard sends a lifeboat and helicopter.
8. While awaiting rescue. You continue to monitor his breathing, and you are prepared to start CPR if he stops breathing. You give him nothing to eat or drink. You prepare the deck for the helicopter: clear the loose gear, and follow the instructions from the aircraft.

The key lessons: protect yourself first, call for help early, protect the airway, control bleeding, prevent further heat loss, and monitor and record.

Common Mistakes

• Not wearing a lifejacket or harness because the weather seems calm. Most man overboard incidents happen in moderate conditions.
• Swimming after falling in. Float, control your breathing and wait.
• Gasping with your head under water because of cold shock. Keep your airway clear and stay calm.
• Wearing cotton clothes, which hold water and cool the body.
• Taking seasickness tablets too late (after you have started to vomit).
• Hanging over the side while seasick without a harness.
• Launching the liferaft too early, or stepping down into it from the boat when stepping up is possible.
• Boarding the raft wet and getting everybody cold. Step in dry if at all possible.
• Rubbing a cold casualty's limbs or giving them alcohol or a hot bath.
• Lifting a person out of the water vertically, risking collapse.
• Forgetting to protect yourself from a hazard, becoming a second casualty.
• Stopping CPR too early or not starting it for fear of doing it wrong.
• Putting ice, butter or cream on burns.
• Delaying the call for help. Advice from a doctor via the Coastguard is free and expert.
• Not recording treatment, medication, times and observations.

Summary

• Cold water kills in stages: cold shock in the first minutes, swim failure within about half an hour, then hypothermia. The lifejacket and controlled breathing are the keys to surviving the first minute.
• Prevent hypothermia on board with layers (no cotton), a hat, regular food and drink, rest and dry clothes. Treat by shelter, removing wet clothing, insulating, rewarming slowly and passively, and calling for advice. Never rub limbs or apply direct heat.
• In the water use the HELP position alone or the huddle in a group. Do not swim unless safety is very close. Attract attention with a whistle, light, PLB and EPIRB.
• Wear a 150 N lifejacket with a crotch strap, spray hood, light and whistle, and check and service it. Lift a casualty out horizontally.
• Abandon ship only as a last resort and step up into the liferaft. Send Mayday, take the grab bag and EPIRB, board dry, cut the painter only when necessary, stream the drogue, close the canopy, ration water and use flares sparingly.
• Seasickness: take medication before it starts, stay on deck midships, sip fluids, and watch for dehydration.
• Primary survey is DRABC: Danger, Response, Airway, Breathing, Circulation. Call early for help on VHF channel 16, with TMAS medical advice.
• Bleeding: direct pressure, raise, bandage, treat shock. Burns: cool with water for 20 minutes, cover with cling film, no creams or ice.
• CPR for an adult: 30 compressions (5 to 6 cm, 100 to 120 per minute) then 2 breaths, without interruption until help arrives. Use the recovery position for an unconscious casualty who is breathing.

Check Your Understanding

1. What is cold shock, and how should you respond if you fall into cold water?

Answer: Cold shock is the involuntary gasp reflex and rapid, uncontrolled breathing that occurs in the first minute or two after entering cold water, along with a surge in heart rate and blood pressure. It is a major cause of drowning. Keep your airway clear (the lifejacket helps), float on your back, do not try to swim, and concentrate on controlling your breathing until it settles.

2. What is swim failure and when does it happen?

Answer: Swim failure is the loss of strength and coordination in the arms and legs due to cooling of the muscles and nerves. It occurs within about 3 to 30 minutes in cold water, long before true hypothermia, and makes it impossible to swim, hold a rope or climb a ladder. This is why the casualty must be rescued as quickly as possible.

3. Describe the HELP and huddle positions and when each is used.

Answer: HELP (Heat Escape Lessening Position) is used by a single person wearing a lifejacket: draw the knees up to the chest and press the arms across the chest and against the sides to protect the groin, armpits and chest, reducing heat loss. A huddle is used by two or more people: they link arms and hold their bodies together side by side, which reduces heat loss, helps morale and makes them easier to see.

4. Why is it safer to lift a casualty horizontally out of the water?

Answer: While immersed, the water pressure on the body helps maintain blood pressure. If the casualty is lifted vertically, blood can pool in the legs, the blood pressure falls suddenly, and this can cause collapse or cardiac arrest. A horizontal lift keeps the circulation stable.

5. List the main points in treating a hypothermic casualty.

Answer: Shelter from wind and water, handle gently, keep horizontal, remove wet clothing and replace or wrap in dry insulation including the head, rewarm slowly with warm hot-water bottles against the trunk only if well wrapped, give warm sweet drinks only if fully conscious, no alcohol, no rubbing of limbs, no direct heat or hot baths, monitor breathing and pulse, and get medical advice from TMAS via the Coastguard.

6. A liferaft is on deck and the skipper tells you that the boat is sinking. Describe what you should do before and while boarding.

Answer: A Mayday call has been sent, the EPIRB is activated, and you put on a lifejacket and warm clothes. Collect the grab bag. Check that the painter is secured to the yacht and throw the raft overboard, pull the painter to inflate it, and bring it alongside. Board by stepping up into the raft, keeping dry. Cut the painter only when everyone is aboard and the yacht is about to sink. Then stream the drogue and close the canopy.

7. When should seasickness tablets be taken and why?

Answer: Before setting off, usually one to two hours before sailing, because once you begin vomiting the tablet cannot be absorbed. Tablets can make you drowsy, so tell the skipper.

8. What does DRABC stand for?

Answer: Danger, Response, Airway, Breathing, Circulation. It is the order in which you carry out the primary survey for life-threatening problems.

9. How do you treat a burn on a yacht?

Answer: Remove the casualty from the source of heat and cool the burn with cool running water for at least 20 minutes, using seawater if necessary. Remove rings and loose clothing unless stuck, cover loosely with cling film or a clean non-fluffy dressing, and do not apply ice, butter or creams or burst blisters. Give pain relief, treat for shock, and seek medical advice for large, deep or facial burns.

10. Give the rate, depth and ratio for adult CPR.

Answer: Compress the centre of the chest by 5 to 6 centimetres at 100 to 120 compressions per minute, with 30 compressions followed by 2 rescue breaths. Continue until the casualty recovers, qualified help takes over, or you are too exhausted to continue.

11. How do you control severe bleeding from a limb?

Answer: Wear gloves if possible, press firmly directly on the wound with a clean pad for at least 10 minutes, raise the limb, bandage firmly over the pad without cutting off the circulation, add more pads if blood soaks through, and treat for shock. A tourniquet is a last resort for life-threatening bleeding that cannot be controlled otherwise.

12. An unconscious casualty is breathing normally. What do you do?

Answer: Place them in the recovery position to keep the airway clear, call for help and medical advice, keep them warm, and monitor breathing continuously. Be ready to start CPR if breathing stops. If a spinal injury is suspected, move them as little as possible and use a log-roll with several helpers if the airway must be protected.