Page 126 - JSOM Fall 2020

patients, given his primary injuries. Four of 21 patients had airway management were maintained on portable ventilators
traumatic musculoskeletal and soft-tissue injuries. These inju- with continuous sedation using intermittent boluses of ket-
ries were to the back and legs (n = 1), thoracic spine (n = 1), amine, fentanyl, and midazolam. Continuous infusion therapy
cervical/thoracic/lumbar spine and right hip (n = 1), and finally, was not used. Care of the burn patients consisted of intrave-
a left foot crush injury (n = 1). All injuries were sustained from nous infusion of lactated Ringer solution using the rule of 10s
accidents or failed or falling equipment on board the ship. (i.e., initial fluid rate = 10mL/h × %TBSA), dry sterile dressings,
debridement, and a combination of ketamine, fentanyl, and/
Of the six patients with GI illness, three had GI bleeds, two or midazolam for analgesia and sedation. Two patients with
had surgical abdomens (i.e., appendicitis and small-bowel per- GI bleeding underwent blood component transfusions, one re-
foration), and one had recurrent Salmonella enteritis. The pa- ceived 3 units of packed red blood cells (pRBCs) and the other
tient with necrotizing soft-tissue infection was diagnosed with received 2 units of pRBCs and 1 unit of fresh frozen plasma.
Fournier gangrene of the scrotum and upper thigh with sepsis.
Teleconsultation was used or attempted in the care of nine of
Patient Mortality 22 patients. One attempt failed due to technical issues. In one
Two patients who were alive at the time of initial PJ contact mission, a rescue FS parachuted in, provided on-scene medi-
died during subsequent care. The first was a 60-year-old man cal direction, and ultimately used teleconsultation to contact
who sustained 80%TBSA burns during an engine room fire a neurosurgeon for TBI management recommendations. Two
and explosion that capsized the ship and left him and his crew- other missions included FSs in a loitering HC-130 to provide
mates in the ocean for approximately 12 hours before being direct medical command and control for the PJs.
retrieved by another ship. The second was a 57-year-old man
with GI bleeding in hemorrhagic shock who died 14 hours The rescuers sustained no injuries on these missions; however,
after initial PJ assessment despite receiving supportive care there were reports of sea sickness (n = 2 missions) and food
including blood transfusions. In both instances, the patients poisoning (n =1). Of note, during a mission on a 35-foot sail-
were unstable on initial assessment. On one mission, four boat, three of four PJs were incapacitated by sea sickness and
sailors were burned, two of whom died while the PJs were required treatment with cinnarizine provided by the captain
en route. These two deceased patients were not included in of the vessel. 8
this analysis. In all cases in which patients died, the deceased
were placed in body bags and moved to onboard refrigerated Lessons Learned
storage. After the missions, in the AARs, PJs made note of lessons
learned, including optimization of teleconsultation, procure-
Medical Interventions ment of blood products, the need to counter motion sickness,
The details regarding patient-care interventions including med- more burn management training and improved advanced air-
ications administered and advanced procedures performed way training, and PFC training, including optimizing analge-
are listed in Table 2. The six patients who received advanced sia management.

TABLE 2 Medical Treatments and Procedures Reported in Each Category of Patient Injury in This Case Series
Patient Injury Airway Treatment Medications Other
Burn (10) Ventilator (5) IV fluids (10) Ketamine (7) Telecon (4)
Cricothyroidotomy Burn dressings (9) Fentanyl (9) CPR (1)
(4) Debridement (6) Midazolam (9)
Oxygen (3) Foley catheter (6) Ranitidine (2)
Intubation (1) Escharotomy (2) Topical silver (2)
Ertapenem (2)
Ondansetron (2)
Musculoskeletal (4) IV fluid (3) Ketamine (2) Telecon (1)
Splinting (1) Fentanyl (3)
Laceration irrigation and Midazolam (2)
repair (1) Atropine (1)
Ampicillin (1)
TBI (1) Oxygen IV fluid Midazolam Telecon
Levetiracetam
Captopril
GI (6) Intubation (1) IV fluid (4) Ketamine (2) Telecon (3)
Ventilator (1) Foley catheter (2) Vecuronium (1) CPR (1)
Intraosseous access (2) Fentanyl (1) EKG (1)
Blood transfusion (2) Midazolam (1)
Diazepam (1)
IV antibiotics (4)
Ondansetron (1)
Methylprednisolone (1)
Diphenhydramine (1)
Necrotizing soft-tissue infection (1) Oxygen IV fluid Midazolam Telecon
Ondansetron
IV antibiotics
NOTE: Numbers in parentheses refer to the no. of patients.
Abbreviations: CPR, cardiopulmonary resuscitation; ECG, electrocardiogram; GI, gastrointestinal; IV, intravenous; TBI, traumatic brain injury;
Telecon, teleconsultation.

124 | JSOM Volume 20, Edition 3 / Fall 2020