Medical Emergencies Offshore

Prerequisites

You must hold a valid first aid certificate before taking the Yachtmaster Offshore exam: the RYA First Aid Certificate, an HSE-approved first aid at work certificate, or STCW Elementary First Aid (or higher). If you intend to use the certificate commercially you will also need an ML5 or ENG1 medical fitness certificate and STCW Elementary First Aid (renewed every five years, with Proficiency in Medical First Aid or Medical Care advisable for remote voyages). This lesson assumes you already know basic life support (CPR), the recovery position and basic dressing techniques. It concentrates on what changes when help is hours or days away: assessment, stabilisation, using remote medical advice, and evacuation.

Learning Objectives

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

• Carry out a primary survey (DRABC) and a structured secondary survey on a moving yacht.
• Control severe bleeding, recognise and treat shock, and manage suspected spinal injury.
• Recognise and give first-response treatment for a heart attack and a stroke.
• Manage hypothermia, seasickness and dehydration, burns, fractures and crush injuries offshore.
• Gather patient data and obtain Telemedical Advice Services (TMAS) through the coastguard.
• Prepare the yacht and crew for a helicopter evacuation (medevac) and know the alternatives.
• Plan, stock and maintain a medical kit suited to the voyage, and keep medical records.
• Recognise and manage the other common offshore emergencies: diabetes, asthma, abdominal pain, drowning and near drowning, heat illness, carbon monoxide poisoning and eye injuries.

RYA syllabus mapping. This lesson covers the Yachtmaster Offshore course objectives for medical emergencies at sea: stabilise casualties for onboard treatment or evacuation using remote medical advice; manage hypothermia, seasickness, trauma, cardiac events and stroke offshore; contact Telemedical Advice Services and prepare for helicopter evacuation; and administer medical kit contents appropriately, including pharmaceutical management. It builds on the first aid certificate required for the exam (RYA First Aid, STCW Elementary First Aid or equivalent).

Exam note. The examiner expects calm, ordered, safe responses and will ask what you would do in a scenario (a crewman with a head injury, a scalded hand, chest pain). Starting with danger, response, airway, breathing and circulation, and describing when you would call the coastguard, matters more than clinical detail. You are not expected to be a doctor.

The Offshore Context

Ashore, a casualty with a serious injury reaches hospital within an hour. Eighty miles offshore, the same casualty may wait four to twelve hours for a helicopter, or days if beyond helicopter range. The yacht is moving, cramped, wet and possibly cold; the "first aider" may also be needed on deck. So the principles shift:

• Stabilisation over definitive treatment. Your aim is to keep the casualty alive and stop them deteriorating, not to cure them.
• Prevention is the best treatment. Most offshore injuries come from falls below, boom strikes, winches and burns in the galley. Crew briefings, handholds, galley straps and a reefed main before nightfall prevent more harm than the medical kit can treat.
• Get advice early. Radio medical advice is free and available 24 hours a day. A doctor can help you decide whether to divert, call for evacuation or continue.
• Write everything down. Times, observations, drugs and doses. Records guide the doctor on the radio and the hospital later.
• The skipper is responsible for the whole crew, including the first aider's safety, the navigation of the vessel while a casualty is treated, and the decision to divert.

Primary Survey: DRABC

Every casualty assessment starts the same way. Work through each step and deal with any problem before moving on.

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1. Danger. Is it safe to approach? On a yacht: is the boom secured, is the boat under control, is someone helming, is there gas or fire? Clip on. Do not create a second casualty.
2. Response. Use AVPU: Alert; responds to Voice; responds to Pain; Unresponsive. Record the level and the time.
3. Airway. Open the airway. If a spinal injury is possible (fall, blow to the head), use a jaw thrust rather than head tilt, keeping the head in line.
4. Breathing. Look, listen and feel for no more than 10 seconds. If not breathing normally, start CPR (30 compressions to 2 breaths) and send someone to make a Mayday call and fetch the AED if carried.
5. Circulation. Look for and control severe bleeding. Check pulse rate and quality.

Some protocols use ABCDE (Airway, Breathing, Circulation, Disability, Exposure) for the next phase: D checks neurological status (AVPU, pupils, limb movement), and E means exposing the body to look for injuries while protecting from the cold. On a yacht, expose a small area at a time and cover again.

Secondary survey

Once the casualty is stable, carry out a head-to-toe check (head, neck, chest, abdomen, pelvis, limbs, back by log-roll if needed), and gather history with SAMPLE:

Record vital signs every 15 minutes, or more often if unstable: pulse rate, breathing rate, AVPU, skin colour and temperature, and if you have the equipment, blood pressure, oxygen saturation and temperature. Normal adult values: pulse 60 to 100, breathing 12 to 20 per minute, oxygen saturation 95 per cent or above. The trend matters more than any single value.

Severe Bleeding

A severed artery can kill in minutes. Act fast and in order.

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1. Direct pressure with a sterile pad or the cleanest material available, held firmly for at least 10 minutes without lifting to look. Lay the casualty down.
2. Bandage firmly over the pad. If blood soaks through, add a second pad on top; do not remove the first.
3. Haemostatic dressing (packed into a deep wound) and tourniquet for catastrophic limb bleeding that direct pressure cannot control. Apply the tourniquet 5 to 8 cm above the wound, never over a joint, tighten until bleeding stops, and write the time on the casualty's forehead or the tourniquet. Once applied it should be left for medical professionals to remove.
4. Monitor for shock, keep warm, and contact TMAS.

Never remove an embedded object (a splinter of wood, a fish hook deep in tissue, a piece of metal): it may be plugging the wound. Pad around it and bandage over the padding.

Shock

Shock means the circulation is failing to supply the vital organs with enough oxygen. Causes include blood loss (external or internal, for example from a fractured femur or a ruptured spleen), severe burns, dehydration from prolonged vomiting, heart attack and anaphylaxis.

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Treatment: treat the cause (stop bleeding), lay the casualty flat, raise the legs if no leg or pelvic injury, insulate from the cold deck with sleeping mats and blankets, loosen tight clothing, reassure, and do not give food or drink (moisten lips only; an operation may be needed later). Monitor vital signs every 5 to 10 minutes and get TMAS advice early: shock can be fatal and is a common reason for medevac. If the casualty becomes unresponsive but is breathing, place in the recovery position (unless spinal injury is suspected).

Spinal Injury

Suspect spinal injury after a fall from the mast or down the companionway, a blow to the head from the boom, or any casualty who is unconscious from trauma.

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• Do not move the casualty unless they are in immediate danger (fire, flooding, sinking) or you must do so to open the airway.
• One person holds the head in line, hands over the ears, for as long as needed.
• An improvised collar can be made from a rolled towel or a SAM splint, but manual stabilisation remains essential.
• If the casualty must be turned (to vomit, to check the back, to slide a mattress underneath), use a log-roll with at least three people, the person at the head giving the commands.
• On a yacht in a seaway, wedge the casualty in a leeward bunk or on the cabin sole with sails bags, cushions and lee cloths to stop rolling.
• Contact TMAS and expect to arrange evacuation. Helicopter winching with a stretcher is the normal method.

Heart Attack (Myocardial Infarction)

A heart attack occurs when a blood clot blocks a coronary artery. Older crew, smokers and those with a history of heart disease are most at risk, but stress, cold and exertion on a yacht can trigger it.

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Recognition: crushing, gripping central chest pain lasting more than a few minutes, often spreading to the left arm, jaw, neck or back; sweating, pale grey skin; nausea; breathlessness; a sense of impending doom. In older people, women and diabetics the signs may be milder: breathlessness and indigestion-like pain.

Treatment:

1. Sit the casualty in the half-sitting "W" position (back supported, knees bent), which eases the work of the heart.
2. Give one 300 mg aspirin to chew slowly, unless allergic or advised otherwise.
3. If the casualty has their own GTN spray, help them use it.
4. Give oxygen if carried and trained.
5. Call for help immediately: a suspected heart attack is grounds for a DSC distress or urgency alert and medevac. TMAS will advise.
6. Have the AED ready and brief two crew on CPR. If the casualty collapses and stops breathing normally, start CPR and use the AED.
7. Keep them calm and still; do not let them walk around.

Angina, a temporary narrowing that eases with rest and GTN within a few minutes, should still be discussed with TMAS.

Stroke

A stroke is a blockage or bleed in the brain. Rapid treatment in hospital greatly improves outcome, so recognition and early evacuation matter.

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Use FAST: Face (ask them to smile: does one side droop?), Arms (can they raise both arms and hold them?), Speech (is it slurred, or can they not understand?), Time (note the time symptoms began and call for help). Other signs: sudden severe headache, confusion, loss of balance, vision problems.

Keep the casualty at rest with head and shoulders slightly raised, give nothing by mouth (swallowing may be affected), and watch the airway: if they become unresponsive, place in the recovery position with the affected side down. Contact TMAS immediately; the time of onset is the single most important piece of information you can give.

Other Offshore Conditions

Hypothermia

Cold water causes heat loss many times faster than air at the same temperature. In 10 degree water, cold shock can kill in the first minutes, swimming failure follows within 10 to 30 minutes, and hypothermia after that.

Treatment:

• Recover the casualty horizontally if possible, to avoid a fall in blood pressure (circum-rescue collapse).
• Handle gently; rough handling of a severely cold casualty can trigger ventricular fibrillation.
• Shelter out of the wind, remove wet clothing carefully (cut it off), and insulate in dry clothing, sleeping bag and a survival bag, with insulation underneath.
• Mild cases who are alert and shivering can be given warm, sweet drinks (no alcohol) and rewarm actively.
• Moderate and severe cases: no drinks, no rubbing of limbs, no hot bath. Apply warmth only to the trunk (armpits, chest, groin) and let the body rewarm slowly to avoid "afterdrop", when cold blood from the limbs returns to the core.
• Check breathing for a full minute in severe cases; if absent, start CPR and get urgent help. "Nobody is dead until they are warm and dead."

Seasickness and dehydration

Seasickness is often dismissed, but days of vomiting cause dehydration, low blood sugar, exhaustion and loss of judgement, and seasick crew are prone to falling overboard. Start medication before sailing (hyoscine patches or tablets, cinnarizine; check for drowsiness and contraindications), keep sufferers on deck, in the fresh air, looking at the horizon, ideally steering, warm and clipped on. Give small, frequent sips of water or oral rehydration salts and plain food such as crackers. Monitor urine output and colour: dark, infrequent urine means dehydration. Prolonged vomiting (more than 24 to 48 hours) needs TMAS advice; ondansetron or prescribed injections may be recommended.

Burns and scalds

Galley scalds are common. Cool with clean cool water for at least 20 minutes (sea water if fresh water is short), remove jewellery and loose clothing that is not stuck, then cover loosely with cling film or a burn gel dressing. Do not burst blisters or apply creams. Burns larger than the casualty's palm on the trunk, or any burn to the face, hands, feet, genitals or airway, need TMAS advice. Watch for shock: large burns lose fluid fast.

Fractures and dislocations

Immobilise the injury in the position found, using a SAM splint, padding and bandages, then check circulation beyond the injury (colour, warmth, capillary refill) every 15 minutes. A fractured femur can lose a litre or more of blood internally, so watch for shock. Strap an injured arm to the body; strap an injured leg to the good leg. Do not attempt to reduce a dislocation unless advised by TMAS.

Crush injuries

A hand crushed in a winch or a leg pinned by a fallen spar may release toxins from damaged muscle when freed. For a brief entrapment, release immediately; for a prolonged entrapment (over 15 minutes), seek TMAS advice before releasing if at all possible.

Head injuries

Any head injury with loss of consciousness, confusion, vomiting, unequal pupils, fluid from the ears or nose, or worsening AVPU needs TMAS advice and probably evacuation. Monitor AVPU every 15 minutes. Do not give sedating drugs.

Anaphylaxis

A severe allergic reaction (to a sting, food or drug) causes swelling of the face and throat, wheeze, a widespread rash and collapse. Use the casualty's adrenaline auto-injector into the outer thigh immediately, call for help (DSC alert and Mayday if breathing is compromised), sit them up if breathing is difficult or lay them flat with legs raised if faint, and give a second dose after 5 minutes if there is no improvement. Every case needs evacuation, because symptoms can return hours later.

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Diabetes

A diabetic crew member on insulin can become hypoglycaemic (low blood sugar) after a missed meal, seasickness or hard exercise, and the signs are confusion, sweating, shaking, aggression, pale skin and drowsiness. Give 15 to 20 g of fast sugar (glucose tablets, a sugary drink, jelly babies) if they can swallow, then a longer-acting snack (biscuits, a sandwich) once they recover. If they are drowsy and cannot swallow safely, do not put anything in the mouth: place them in the recovery position and call for help. Anyone with diabetes should tell the skipper before the voyage, carry spare insulin kept cool, and carry a glucose meter. Prolonged vomiting makes control difficult, so seasickness in a diabetic is a reason to call TMAS early.

Asthma

Help the casualty sit upright, leaning forward, and use their own reliever inhaler (usually blue) with a spacer if they have one: one puff at a time, up to ten puffs, taking 30 to 60 seconds between puffs. If there is no improvement after a few minutes, or they cannot speak in full sentences, or become exhausted or blue, it is a serious attack and needs urgent help. Cold air, exertion, smoke and anxiety can all trigger attacks, and sea fog and diesel fumes in the cabin are common causes on yachts.

Abdominal pain, appendicitis and infection

Severe or worsening abdominal pain, especially with fever, vomiting, a rigid abdomen or pain moving to the right lower side, may mean appendicitis or another surgical emergency. Keep the casualty at rest, nil by mouth, record temperature and pulse, and obtain TMAS advice early. Do not give laxatives or strong painkillers without advice. Wounds should be cleaned, closed with adhesive strips if clean and shallow, and watched for infection: spreading redness, swelling, heat, pus or fever calls for antibiotics under TMAS guidance. Salt-water boils and sores are common offshore.

Drowning and near drowning

After any submersion that required rescue, even if the casualty seems to recover, expect water in the lungs, vomiting and later breathing problems. Open the airway, check breathing and, if absent, give five rescue breaths first, then CPR at 30 compressions to 2 breaths, because drowning is a respiratory problem. Treat for hypothermia and get medical advice for every near-drowning casualty, because secondary problems can appear hours later.

Heat illness and sun

Heat exhaustion (heavy sweating, pale clammy skin, headache, cramps, nausea) responds to shade, cooling, rest and fluids. Heatstroke (hot dry skin, confusion, collapse) is life threatening and needs rapid cooling with wet sheets, fanning, and urgent help. Prevent both with hats, shade, sun cream and drinking water, particularly on ocean passages, where sunburn, dehydration and heat can quickly follow a calm, hot spell.

Carbon monoxide

Petrol generators, gas heaters and engines can produce carbon monoxide, which is odourless and colourless. Headache, dizziness, nausea, confusion and drowsiness in several crew at once, especially after a stove or heater has been running in a closed cabin, should make you suspect it. Get everybody into fresh air at once, turn off the source, give oxygen if carried and get medical advice. Fit a marine carbon monoxide alarm.

Eye injuries

For a chemical splash, irrigate with clean water for at least 10 to 20 minutes, holding the eyelid open. For a foreign body that is stuck or a penetrating injury, do not rub or remove it. Cover both eyes loosely with a pad (the eyes move together, so covering one only does not rest the injured one) and obtain TMAS advice. Sunglasses, goggles and care with splicing, knife work and flares prevent most eye injuries.

Telemedical Advice Services (TMAS)

In UK waters you obtain radio medical advice by calling HM Coastguard. The coastguard connects you to a doctor (in the UK, via the TMAS service) and stays on the line, so that if evacuation is needed the SAR resources are already alerted. Other countries have their own TMAS (for example CIRM in Italy, and the CCMM in Toulouse for French waters); they are listed in ALRS Volume 1 and the almanac.

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How to call

• Life-threatening: DSC distress alert and Mayday on Ch 16.
• Urgent but not immediately life-threatening: DSC urgency alert and "PAN-PAN MEDICO" on Ch 16 (or a phone call to the coastguard). The coastguard will move you to a working channel.
• Beyond VHF range: satellite phone (programme the MRCC number before departure), Inmarsat C, or MF/HF radio.

Before you call, have ready

Write the advice down, repeat it back, and record every drug given (name, dose, time, route). Agree when you will call back with updated observations.

Evacuation

The skipper, the coastguard and the TMAS doctor together decide whether to continue, divert to the nearest port, rendezvous with a lifeboat or ship, or call a helicopter. Factors include the casualty's condition and trend, distance and time to port, weather and sea state, daylight, helicopter range, and the yacht's ability to provide a safe winching platform.

UK coastguard helicopters (Sikorsky S-92 and AW189) can operate roughly 200 miles or more offshore, but a hi-line transfer to a pitching yacht with a tall rig in a Force 6 is high risk for everyone. Often the best answer is to close the coast at best speed while the helicopter is tasked, shortening its flight, or to transfer the casualty to an RNLI all-weather lifeboat first.

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Preparing for a helicopter transfer

1. The coastguard will brief you on a working channel and the aircraft will call you on VHF (usually Ch 16 then a working channel such as Ch 67).
2. Clear the deck of loose gear: halyards, sheets, flags, cushions, biminis and the dinghy. The downdraught is violent and noise makes speech impossible, so brief the crew on hand signals before the aircraft arrives.
3. Lower the mainsail and secure it; stow headsails. The pilot will usually ask you to motor at a steady speed into the wind on a given heading, or occasionally with the wind 30 degrees on the port bow so the pilot (sitting on the right) can see you.
4. Everyone on deck wears a lifejacket and is clipped on; no loose hats.
5. The casualty should be ready with documents, the medical record and any medication, in a waterproof bag.
6. Often the helicopter lowers a hi-line: a weighted rope with a weak link. Let it touch the water or the boat first to discharge static electricity. One crew member takes in the hi-line and coils it into a bucket, keeping it clear of the rig, as the winchman or stretcher is lowered. Never tie the hi-line to the boat. If the aircraft has to break away, it must be free to go.
7. Only touch the winch wire and hook after it has earthed on the boat or water. Do not attach the wire to anything on the yacht.
8. Follow the winchman's instructions exactly.
9. In heavy seas or with a tall rig, the pilot may ask for the casualty to be transferred from the liferaft or dinghy towed astern, or even from the water.

Worked Example: Fall Below 80 Miles Offshore

On day two of a passage from Falmouth to La Coruña, the yacht lurches off a wave and a crew member falls from the chart table to the cabin sole. She is unconscious and her lower leg is obviously deformed. The sea is moderate, wind Force 5.

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1. Skipper's first decision: put the yacht on a comfortable heading, reef and assign a helmsman. Send one crew to help.
2. Primary survey: danger (secure loose items), response (unresponsive to voice, groans to pain: AVPU P), airway (jaw thrust, head held in line because of the fall), breathing normal at 18 per minute, circulation: pulse 96, a cut on the scalp bleeding moderately (direct pressure).
3. Stabilise: one crew holds the head; a pressure dressing goes on the scalp; the leg is splinted in the position found with SAM splints and padding; she is insulated with sleeping bags and wedged in place with sail bags.
4. Secondary survey and SAMPLE as she begins to rouse: confused, complains of headache and leg pain; no allergies, takes no medication.
5. Contact: out of VHF coast station range, the skipper calls Falmouth MRCC by satellite phone with a Pan-Pan medico report. The coastguard links to the TMAS doctor.
6. Decision: the doctor is concerned about the head injury with loss of consciousness and recommends evacuation. The MRCC tasks a helicopter, which needs the yacht to close the coast by about 20 miles. The skipper motors north at best speed.
7. Prepare: deck cleared, crew briefed on hi-line procedure, casualty packaged, medical log written up.
8. Monitor and document: AVPU, pulse, breathing and leg circulation every 15 minutes until handover.

The Medical Kit

The kit must match the length and remoteness of the voyage, the crew's medical histories and the skills of the people aboard. Commercial vessels follow the MCA's Merchant Shipping and Fishing Vessels (Medical Stores) regulations (Category A for the most remote voyages, B for voyages up to 150 miles from a safe haven, C for coastal use; check the current MCA guidance for the exact definitions); a yacht going offshore should take Category B as its model and have a doctor review the drug list.

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Practical points:

• Pack in waterproof, labelled bags by purpose (bleeding, burns, fractures, drugs) so that a crew member can find the right item fast.
• Carry the drug list, dose guide and a comprehensive manual such as the Ship Captain's Medical Guide.
• Ask every crew member to declare medical conditions, medications and allergies before the voyage (in confidence to the skipper) and to bring enough of their own medication, plus spare.
• Check expiry dates before each season. Prescription and controlled drugs must be locked away and recorded in a register.
• An AED is increasingly common and is worth carrying on long passages. Keep it dry, check the battery and pad expiry dates, and know where it is stowed.

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Image: Infrogmation, CC BY-SA 4.0, via Wikimedia Commons

• Know the kit before you need it: hold a kit briefing at the start of each passage.

Medicines: Pharmaceutical Management

A skipper with a medical kit that includes drugs carries a serious responsibility. Follow these rules.

• Use only what the kit's guide and the TMAS doctor advise. Give the dose, route and interval they say, and write it in the medical log with the time, the dose and the effect.
• Check for allergies and interactions first. Ask about allergies, current medication and pregnancy. Do not give aspirin to someone allergic to it or with active bleeding or a stomach ulcer.
• Common examples. Paracetamol 500 mg to 1 g every 4 to 6 hours, maximum 4 g in 24 hours, for pain and fever. Ibuprofen with food, avoided in asthmatics sensitive to it, in dehydration, and in kidney or stomach disease. Antihistamine for mild allergic reactions. Oral rehydration salts for dehydration. Antiemetics for severe seasickness. Stronger painkillers and antibiotics only on medical advice.
• Controlled drugs. Strong painkillers such as morphine are controlled drugs; a yacht cannot normally carry them without prescription authority. A doctor will advise what the kit can carry.
• Storage and expiry. Keep drugs cool, dry and secure, checked every season. Dispose of out-of-date medicines through a pharmacy.
• Record everything. The medical log should record who, what, when, how much, route and result.

Death at Sea and Duties of the Skipper

If a casualty dies, report to the coastguard immediately, do not move the body unnecessarily, note the time and circumstances, and follow the coastguard's instructions on where to land. In UK waters the police and coroner will be involved, and the coastguard or the harbour authority will arrange the arrival. Preserve the log and the medical records: they will be needed. Protect the crew's welfare: shock and grief affect the whole boat, and skippers should ensure the crew have time to talk and rest.

Common Mistakes

• Rushing to treat the injury before checking for danger and airway. Always DRABC first.
• Moving a suspected spinal casualty unnecessarily.
• Rewarming a severely hypothermic casualty quickly, rubbing limbs or giving hot drinks to someone drowsy.
• Calling for advice too late. TMAS is free and the coastguard would rather hear early.
• Poor records: not noting the times of observations and drugs, which the doctor and hospital need.
• Tying the hi-line to the yacht or grabbing the winch wire before it has earthed.
• Dismissing seasickness. A dehydrated, exhausted crew member is a danger to themselves and the boat.
• A kit nobody can use: expired drugs, no inventory, items buried in a locker.
• Forgetting to sail the boat: the skipper must keep someone in charge on deck.
• Giving drugs without checking allergies or dose, or without recording the time and amount.
• Not asking about crew medical history before sailing, so that diabetes, asthma, allergies and heart conditions are discovered in an emergency.

Summary

• Offshore, help is hours away: aim to stabilise and prevent deterioration, and get medical advice early.
• Primary survey DRABC, then secondary survey with SAMPLE and regular recorded vital signs.
• Control severe bleeding with direct pressure, then bandage, haemostatic dressing and tourniquet for catastrophic limb bleeds.
• Recognise and treat shock early: lay flat, legs raised, keep warm, nothing by mouth.
• Do not move spinal casualties unless in danger; use a log-roll with three people.
• Heart attack: W position, chewed aspirin 300 mg, GTN if prescribed, call for help, AED ready. Stroke: use FAST and note the time.
• Obtain TMAS through the coastguard (Pan-Pan medico or Mayday), with the patient data prepared.
• For helicopter evacuation, clear the deck, brief the crew, never tie the hi-line on, and let the wire earth before touching it.
• Stock and maintain a medical kit appropriate to the voyage and keep a medical log.

Check Your Understanding

1. What does AVPU stand for and why do you record it with the time?

Answer: Alert, responds to Voice, responds to Pain, Unresponsive. Recording it with the time shows whether the casualty's level of consciousness is improving or deteriorating, which is vital information for TMAS.

1. A crew member has a deep cut to the forearm from a broken winch handle and blood is spurting. What do you do?

Answer: Apply firm direct pressure with a sterile pad and lay the casualty down. Hold pressure for at least 10 minutes and then bandage firmly, adding pads over the top if it soaks through. If bleeding cannot be controlled, pack a haemostatic dressing and apply a tourniquet 5 to 8 cm above the wound, noting the time. Treat for shock and call for medical advice.

1. List four signs of shock.

Answer: Any four of: pale, cold, clammy skin; rapid weak pulse; rapid shallow breathing; sweating; thirst; nausea; anxiety or confusion; capillary refill over 2 seconds; grey-blue lips.

1. How do you treat a suspected heart attack aboard?

Answer: Sit the casualty in the half-sitting W position, give 300 mg aspirin to chew (unless allergic), help with their own GTN spray, give oxygen if available, call for help (DSC alert and Mayday or Pan-Pan medico via the coastguard), keep them at rest, have the AED ready and be prepared for CPR.

1. What is "afterdrop" and how do you avoid it?

Answer: A further fall in core temperature, and risk of cardiac arrest, when cold blood from the limbs returns to the core during rapid rewarming. Avoid it by rewarming moderately and severely hypothermic casualties slowly, applying heat only to the trunk, not rubbing limbs or using hot baths, and handling gently.

1. How do you obtain radio medical advice in UK waters?

Answer: Call HM Coastguard: by DSC distress alert and Mayday if life-threatening, or by DSC urgency alert and Pan-Pan medico (or phone) if urgent. The coastguard connects you to a TMAS doctor. Beyond VHF range, use satellite phone, Inmarsat C or MF/HF.

1. What information should you prepare before a TMAS call?

Answer: Vessel name, position, course, speed and distance to port; casualty age, sex and weight; what happened and when; symptoms and findings; vital signs with times; medical history, medications and allergies; treatment given so far; and the contents of your medical kit.

1. During a helicopter evacuation, why must the hi-line never be tied to the yacht?

Answer: If the helicopter has to break away suddenly, a tied line could pull the yacht over, damage the aircraft's winch or snap the cable, endangering both crews. The hi-line is held and coiled by hand only.

1. What does FAST stand for in stroke recognition?

Answer: Face (drooping on one side), Arms (one arm weak or drifting down), Speech (slurred or confused), Time (note the time of onset and call for help immediately).

1. A crew member has been vomiting for 36 hours on passage and is producing little dark urine. What are the risks and what do you do?

Answer: Dehydration, electrolyte imbalance, exhaustion and impaired judgement, with increased risk of injury or falling overboard. Keep them warm, safe and clipped on, give small frequent sips of oral rehydration salts, record intake and urine output, and seek TMAS advice; prescription antiemetics or evacuation may be needed.

1. A crew member with insulin-dependent diabetes becomes sweaty, confused and shaky after a missed meal. What do you do?

Answer: Suspect hypoglycaemia. If they are able to swallow, give fast sugar (glucose tablets or a sugary drink), then a longer-acting snack when they recover, and recheck their blood sugar. If they become drowsy and cannot swallow, put them in the recovery position, do not put anything in the mouth, and call for help.

1. You rescue a person from the water who seems fully recovered after a period of submersion. Why do you still seek medical advice?

Answer: Water in the lungs can cause breathing problems that develop hours later, and hypothermia may also be present. Every near-drowning casualty should be assessed medically, so the skipper should contact TMAS or the coastguard.