MODEL

COURSE
1.13

ELEMENTARY
FIRST AID
2000 Edition

Course and Compendium

MODEL COURSE 1.13
ELEMENTARY FIRST AID

2000 Edition

Course and Compendium

 First published in 1989 as Medical Emergency - Basic Training
by the INTERNATIONAL MARITIME ORGANIZATION
4 Albert Embankment, London SE1 7SR
www.imo.org

Revised edition 2000

Printed in the United Kingdom by CPI Books Limited, Reading RG1 8EX

ISBN: 978-92-801-6117-5

IMO PUBLICATION
Sales number: TA113E

ACKNOWLEDGEMENTS
IMO wishes to express its sincere appreciation to the International Labour Organization
and the World Health Organization for their valuable assistance and co-operation
in the production of this course. In particular, IMO wishes to thank
the World Health Organization for permission to utilize relevant parts
of the International Medical Guide for Ships as the course compendium.

Copyright© International Maritime Organization 2001

All rights reserved.

No part of this publication may be reproduced,
stored in a retrieval system, or transmitted in any form or by any means,
without prior permission in writing from the
International Maritime Organization.
 Contents

Page

Foreword V

Introduction 1

Part A:

Course Framework 4
Part B:

Course Outline and Timetable 6

Part C:

Detailed Teaching Syllabus 9

Part D:

Instructor Manual 15

Attachment: Guidance on the implementation of model courses

19

iii
Foreword

Since its inception the International Maritime Organization has recognized the importance of
human resources to the development of the maritime industry and has given the highest
priority to assisting developing countries in enhancing their maritime training capabilities
through the provision or improvement of maritime training facilities at national and regional
levels. IMO has also responded to the needs of developing countries for postgraduate
training for senior personnel in administration, ports, shipping companies and maritime
training institutes by establishing the World Maritime University in Malmo, Sweden, in 1983.

Following the earlier adoption of the International Convention on Standards of Training,

Certification and Watchkeeping for Seafarers, 1978, a number of IMO Member Governments
had suggested that IMO should develop model training courses to assist in the
implementation of the Convention and in achieving a more rapid transfer of information and
skills regarding new developments in maritime technology. IMO training advisers and
consultants also subsequently determined from their visits to training establishments in
developing countries that the provision of model courses could help instructors improve the
quality of their existing courses and enhance their effectiveness in meeting the requirements
of the Convention and implementing the associated Conference and IMO Assembly
resolutions.

In addition, it was appreciated that a comprehensive set of short model courses in various
fields of maritime training would supplement the instruction provided by maritime academies
and allow administrators and technical specialists already employed in maritime
administrations, ports and shipping companies to improve their knowledge and skills in
certain specialized fields. IMO has therefore developed the current series of model courses in
response to these generally identified needs and with the generous assistance of Norway.

These model courses may be used by any training institution and the Organization is
prepared to assist developing countries in implementing any course when the requisite
financing is available.

W. A. O'NEIL

Secretary-General

V
Introduction
■ Purpose of the model courses
/

The purpose of the IMO model courses is to assist maritime training institutes and their
teaching staff in organizing and introducing new training courses, or in enhancing, updating
or supplementing existing training material where the quality and effectiveness of the training
courses may thereby be improved.

It is not the intention of the model course programme to present instructors with a rigid
"teaching package" which they are expected to "follow blindly". Nor is it the intention to
substitute audiovisual or "programmed" material for the instructor's presence. As in all
training endeavours, the knowledge, skills and dedication of the instructor are the key
components in the transfer of knowledge and skills to those being trained through IMO model
course material.

Because educational systems and the cultural backgrounds of trainees in maritime subjects
vary considerably from country to country, the model course material has been designed to
identify the basic entry requirements and trainee target group for each course in universally
applicable terms, and the skill necessary to meet the technical intent of IMO conventions and
related recommendations.

■ Use of the model course

To use the model course the instructor should review the course plan and detailed syllabus,
taking into account the information provided under the entry standards specified in the course
framework. The actual level of knowledge and skills and prior technical education of the
trainees should be kept in mind during this review, and any areas within the detailed syllabus
which may cause difficulties because of differences between the actual trainee entry level
and that assumed by the course designer should be identified. To compensate for such
differences, the instructor is expected to delete from the course, or reduce the emphasis on,
items dealing with knowledge or skills already attained by the trainees. He should also
identify any academic knowledge, skills or technical training which they may not have
acquired.

By analyzing the detailed syllabus and the academic knowledge required to allow training in
the technical area to proceed, the instructor can design an appropriate pre-entry course or,
alternatively, insert the elements of academic knowledge required to support the technical
training elements concerned at appropriate points within the technical course.

Adjustment of the course objectives, scope and content may also be necessary if in your
maritime industry the trainees completing the course are to undertake duties which differ
from the course objectives specified in the model course.

Within the course plan the course designers have indicated their assessment of the time
which should be allotted to each learning area. However, it must be appreciated that these
allocations are arbitrary and assume that the trainees have fully met all the entry
requirements of the course. The instructor should therefore review these assessments and
may need to reallocate the time required to achieve each specific learning objective.
- r

ELEMENTARY FIRST AID

■ Lesson plans

Having adjusted the course content to suit the trainee intake and any revision of the course .
objectives, the instructor should draw. up lesson plans based on the detailed syllabus. The
detailed syllabus contains specific references to the textbooks or teaching material proposed
to be used in the course. An example of a lesson plan is shown in the instructor manual on
page 18. Where no adjustment has been found necessary in the learning objectives of the
detailed syllabus, the lesson plans may simply consist of the detailed syllabus with keywords
or other reminders added to assist the instructor in making his presentation of the material.

■ Presentation

The presentation of concepts and methodologies must be repeated in various ways until the
instructor is satisfied, by testing and evaluating the trainee's performance and achievements,
that the trainee has attained each specific learning objective or training outcome. The
syllabus is laid out in learning objective format and each objective specifies a required
performance or, what the trainee must be able to do as the learning or training outcome.
Taken as a whole, these objectives aim to meet the knowledge, understanding and
proficiency specified in the appropriate tables of the STCW Code.

■ Implementation

For the course to run smoothly and to be effective, considerable attention must be paid to
the availability and use of:

• properly qualified instructors

• support staff
• rooms and other spaces
• equipment
• textbooks, technical papers
• other reference material.

Thorough preparation is the key to successful implementation of the course. IMO has
produced "Guidance on the implementation of model courses", which deals with this aspect
in greater detail and is included as an attachment to this course.

■ Training and the STCW 1995 Convention

The standards of competence that have to be met by seafarers are defined in Part A of the
STCW Code in the Standards of Training, Certification and Watchkeeping for Seafarers
Convention, as amended in 1995. This IMO model course has been revised and updated to
cover the competences in STCW 1995. It sets out the education and training to achieve
those standards set out in Chapter VI Table A-Vl/1-3.
11

Part A provides the framework for the course with its aims and objectives and notes on the
suggested teaching facilities and equipment. A list of useful teaching aids, IMO references
and textbooks is also included.

2
 INTRODUCTION

Part B provides an outline of lectures, demonstrations and exercises for the course. A
suggested timetable is included but from the teaching and learning point of view, it is more
important that the trainee achieves the minimum standard of competence defined in the
STCW
Code than that a strict timetable is followed. Depending on their experience and ability, some
students will naturally take longer to become proficient in some topics than in others. Also
included in this section are guidance notes and additional explanations.

A separate IMO model course addresses Assessment of Competence. This course explains
the use of various methods for demonstrating competence and criteria for evaluating
competence as tabulated in the STCW Code.

Part C gives the Detailed Teaching Syllabus. This is based on the theoretical and practical
knowledge specified in the STCW Code. It is written as a series of learning objectives, in other
words what the trainee is expected to be able to do as a result of the teaching and training.
Each of the objectives is expanded to define a required performance of knowledge,
understanding and proficiency. IMO references, textbook references and suggested teaching
aids are included to assist the teacher in designing lessons.

The new training requirements for these competences are addressed in the appropriate parts
of the detailed teaching syllabus.

The Convention defines the minimum standards to be maintained in Part A of the STCW
Code. Mandatory provisions concerning Training and Assessment are given in Section A-1/6
of the STCW Code. These provisions cover: qualification of instructors; supervisors as
assessors; in-service training; assessment of competence; and training and assessment
within an institution. The corresponding Part B of the STCW Code contains non-mandatory
guidance on training and assessment.

As previously mentioned, a separate model course addresses Assessment of Competence

and use of the criteria for evaluating competence tabulated in the STCW Code.

■ Responsibilities of Administrations

Administrations should ensure that training courses delivered by colleges and academies are
such as to ensure those completing training do meet the standards of competence required
by STCW Regulation Vl/1.

■ Validation

The information contained in this document has been validated by the Sub-Committee on
Standards of Training and Watchkeeping for use by technical advisors, consultants and
experts for the training and certification of seafarers so that the minimum standards
implemented may be as uniform as possible. Validation in the context of this document means
that the Sub-Committee has found no grounds to object to its content. The Sub-Committee
has not granted its approval to the documents, as it considers that this work must not be
regarded as an official interpretation of the Convention.

In reaching a decision in this regard, the Sub-Committee was guided by the advice of a
Validation Group comprised of representatives designated by ILO and IMO.

3
ELEMENTARY FIRST AID

Part A: Course Framework

Aims
This model course aims to provide the training for candidates to provide elementary first aid
on board ship, in accordance with Section A-Vl/1 of the STCW Code.

Objective
This syllabus covers the requirements of the 1995 STCW Convention Chapter VI, Section A
Vl/1, Table A-Vl/1-3. On meeting the minimum standard of competence in elementary first
aid, a trainee will be competent to take immediate action upon encountering an accident or
medical emergency until the arrival of a person with medical first aid skills or the person in
charge of medical care on board.

Entry standards
The course is open to all seafarers who are to serve on board sea-going merchant ships.
There are no particular educational requirements.

Course certificate
On successful completion of the course and demonstration of competence, a document may
be issued certifying that the holder has met the standard of competence specified in Table
A Vl/1-3 of STCW 1995.

A certificate may be issued only by centers approved by the Administration.

Course intake limitations

The maximum number of trainees attending each session will depend on the availability of
instructors, equipment and facilities available for conducting the training. It should not
exceed six trainees per instructor.

Staff requirements
The course should preferably be under the control of a qualified first aider assisted by other
appropriately trained staff.

Training facilities and equipment

Ordinary classroom facilities and an overhead projector are required for the lectures. When
making use of audiovisual material such as videos or slides, make sure the appropriate
equipment is available.

Smaller rooms for practical instruction, demonstration and application should be available.

The following equipment should be available:

ship's medical chest with contents (no drugs)

various splints, braces, etc.
dressings, bandages
life-size dummy for practical resuscitation training
stretcher

4
 PART A: COURSE FRAMEWORK

Teaching aids {A)

A1 Instructor Manual (Part D of the course)
/

A2 Videos

First Aid Series:

V1 A Matter of Life and Death (Code No. 564)
V2 Dealing with Shock (Code No. 565)
V3 Bone and Muscle Injuries (Code No. 566)
V4 Dealing with the Unexpected (Code No. 567)
VS Well Travelled? - Staying Healthy on Working Trips (Code No. 599)
l V6 Entering into Enclosed Spaces (Edition 2) (Code No. 534)

Available from: Video Tel Marine International Ltd

84 Newman Street
London W1P 3LD, UK
Tel: +44 (0)20 7299 1800
Fax: +44 (0)20 7299 1818
E-mail: mail@videotelmail.com
URL: www.videotel.co.uk
All reference material necessary for the course has been incorporated in the Course
Compendium (T1)

IMO and other references {R)

R1 The International Convention on Standards of Training, Certification and
Watchkeeping for Seafarers, 1995 (STCW 1995), 1998 edition (IMO Sales No. 938E)
R2 Medical section (pages 111 to 148) of International Code of Signals, 1987 edition (IMO
Sales No. 994E)
R3 Assembly Resolution A.438(XI) - Training and qualification of persons in charge of
medical care aboard ship ·
R4 IMO/ILO Document for Guidance, 1985 (IMO Sales No. 935E)
RS ILO/IMO/WHO International Medical Guide for Ships (IMGS), 2nd ed., (Geneva, World
Health Organization, 1988) (ISBN 92 4 154231 4)
R6 Medical First Aid Guide for use in Accidents Involving Dangerous Goods (MFAG)
(IMO Sales No. 251E)

Details of distributors of IMO publications that maintain a permanent stock of all IMO
publications may be found on the IMO website at http://www.imo.org

Textbooks {T)
T1 A Course Compendium is provided for use as a textbook. This contains selected
extracts from ILO/IMO/WHO International Medical Guide for Ships (Ref RS)

5
ELEMENTARY FIRST AID

Part B: Course Outline and Timetable

Lectures / .
As far as possible, lectures should be presented within a familiar context and should make
use of practical examples. They should be well illustrated with diagrams, photographs and
charts where appropriate, and be related to life at sea.

An effective manner of presentation is to develop a technique of giving information and then

reinforcing it. For example, first tell the trainees briefly what you are going to present to
them; then cover the topic in detail; and, finally, summarize what you have told them. The
use of an overhead projector and the distribution of copies of the transparencies as trainees'
handouts contribute to the learning process.

Course Outline
The tables that follow list the competencies and areas of knowledge, understanding and
proficiency, together with the estimated total hours required for lectures and practical
exercises. Teaching staff should note that timings are suggestions only and should be
adapted to suit individual groups of trainees depending on their experience, ability,
equipment and staff available for training.
 PART 8: COURSE OUTLINE

Course Outline

Competence: Take immediate action upon encountering an accident or other

medical emergency

Course Outline Approximate time

(hours)
Knowledge, understanding and proficiency Lectures, demonstrations
and practical work

1 General Principles 1.0

2 Body Structure and Functions 2.0
3 Positioning of Casualty 1.5
4 The Unconscious Casualty 1.0
5 Resuscitation 2.0
6 Bleeding 1.5
7 Management of Shock 1.0
8 Burns and Scalds, and Accidents caused by Electricity 1.0
9 Rescue and Transport of Casualty 1.5
10 Other Topics 2.5
TOTAL 15.0
11 Review and Assessment

Note: Teaching staff should note that outlines are suggestions only as regards sequence and length of time
allocated to each objective. These factors may be adapted by lecturers to suit individual groups of trainees
depending on their experience, ability, equipment and staff available for training.

7
_
1

ELEMENTARY FIRST AID

Course Timetable

Period/Day 1st Day 2nd Day 3rd Day

1st Period 1 General Principles 5 Resuscitation 9 Rescue and

(1.5 hours) (continued) Transport of
2 Body Structure and Casualty (continued)
Functions
10 Other Topics

2nd Period 2 Body Structure and 6 Bleeding 10 Other Topics

(1.5 hours) Functions (continued)
(continued)

:
LUNCH BREAK
3rd Positioning of 7 Management 11 Review and
I
3
Period Casualty of Shock Assessment
(1.5
hours) 8 Burns and Scalds

4th 4 The 8 Burns and Scalds

Period Unconscious (continued)
(1.5 Casualty
hours)
5 Resuscitation 9 Rescue and
Transport of
Casualty

Teaching staff should note that the hours for lectures and exercises are suggestions only as regards
sequence and length of time allocated to each objective. These factors may be adapted by lecturers to
suit individual groups of trainees depending on their experience, ability, equipment and staff available for
teaching.
 PART C: DETAILED TEACHING SYLLABUS

Part C: Detailed Teaching Syllabus

Introduction /
The detailed teaching syllabus has been written in learning objective format in which the
objective describes what the trainee must do to demonstrate that knowledge has been
transferred.

All objectives are understood to be prefixed by the words, "The expected learning outcome is
that the trainee....................."

In order to assist the instructor, references are shown against the learning objectives to
indicate IMO references and publications, textbooks, additional technical material and
teaching aids, which the instructor may wish to use when preparing course material. The
material listed in the course framework has been used to structure the detailed teaching
syllabus; in particular,

Teaching aids (indicated by A),

IMO references (indicated by R), and
Textbooks (indicated by T)

will provide valuable information to instructors. The abbreviations used are:

App. Appendix
; Ch. chapter
pa. paragraph
p., pp. page, pages
Reg. Regulation
Sect. Section.

The following are examples of the use of references:

"R4- Sect.17, App.2" refers to Appendix 2 of Section 17 of IMO/ILO Document for Guidance,
1985.

■ Note
Throughout the course, safe working practices are to be clearly defined and emphasized with
reference to current international requirements and regulations.

It is expected that the national institution implementing the course will insert references to
national requirements and regulations as necessary.

9
ELEMENTARY FIRST AID

Proficiency in Elementary First Aid IMO Textbooks Detailed

Reference Teaching
Syllabus
Reference

Competence: Take immediate action upon R1 -

Sect.
encountering an accident or other medical A-Vl/1
emergency Table
A-Vl/1-3
Knowledge, understanding and proficiency
1, 10.2-
Assessment of needs of casualties and threats to
10.4
own safety
Appreciation of body structure and functions 2
Understanding of immediate measures to be taken in
cases of emergency, including the ability to:
.1 position casualty 3,4
.2 apply resuscitation techniques 5
.3 control bleeding 6
.4 apply appropriate measures of basic shock 7
management
.5 apply appropriate measures in event of burns 8
and scalds, including accidents caused by
electric current
.6 rescue and transport of casualty 9
.7 7 improvise bandages and 10.1
use materials in emergency kit

Objectives are:

1 the manner and timing of raising the alarm is

appropriate to the circumstances of the accident
or medical emergency

2 the identification of probable cause, nature and

extent of injuries is prompt and complete and the
priority and sequence of actions is proportional to
any potential threat to life

3 risk of further harm to self and casualty is

minimized at all times
 PART C:DETAILED TECHING SYLLABUS

Knowledge, understanding and proficiency IMO Textbooks, Teaching

Reference Bibliography Aid
/ R4- T1 -pp.1-3
General Principles (1 hour)
1 Sect.17,
App.1
Required performance:
.1 demonstrates how to raise the alarm

.2 states that in emergency first consideration is for own V6

safety

.3 describes the sequence of immediate measures to be

taken in cases of emergency
.4 states the content of an emergency checklist as:
- assessment of the accident situation
- assessment of own hazards to self
V
- unconsciousness
- respiratory arrest
- cardiac arrest
severe bleeding
- rescue of casualty and notification of emergency

R4- T1 -pp.53-
2 Body Structure and Functions (2 hours)
Sect.17, 60
App.1
Required performance:
.1 describes body structure in terms of:
- skeleton
- joints, muscles and tendons
- major organs (brain, heart, lungs, etc.)
circulatory systems

.2 states in simple words the functions of the parts forming

the body structure

3 Positioning of Casualty (1.5 hours) R4- T1 - p.6 V1

Sect.17,
App.1
Required performance:
.1 describes appropriate procedures for positioning a
casualty in an emergency, in particular:
- the recovery positions
- the resuscitation positions

.2 demonstrates the correct procedure for positioning

casualties

4 The Unconscious Casualty (1 R4- T1 - pp.3-

Sect.17, 6
hour) Required performance: App.1

recognizes the signs and hazards of unconsciousness

.1 applies appropriate measures, including:

- keeping air passages clear
- positioning of an unconscious casualty
- action in the case of respiratory or cardiac arrest
- no food, liquid or other substancmouth

11
ELEMENTARY FIRST AID /

Knowledge, understanding and proficiency IMO Textbooks, Teaching

Reference Bibliography Aid
/
5 Resuscitation (2 hours) R4- T1 -pp.6- V1
Sect.17, 1.4
App.1
Required performance:
.1 recognizes the necessity of immediate resuscitation in
appropriate emergency situations

.2 applies resuscitation procedures alone and with the

assistance of a further person for a minimum period of
ten minutes, including:
- control of respiration
- function of reclined position of head
- mouth-to-mouth respiration
- mouth-to-nose respiration
- cardiac arrest

.3 in cases of cardiac arrest states the methods and limiting

factors of:
- cardiac massage
- cardiopulmonary resuscitation (CPR)

6 Bleeding (1.5 hours) R4- T1 pp.14 - V2

Sect.17 17, 40 -42
App.1
Required performance:
.1 recognizes the hazards of bleeding

.2 applies appropriate basic measures to limit bleeding, in

particular dealing with:
- internal/external bleeding
- shock (also refers to section 7)
- application of external pad and pressure to site
- positioning of patient
- application and dangers of a tourniquet

7 Management of Shock (1 hour) R4- T1 -pp.17- V2

Sect.17, 18
App.1
Required performance:-
.1 States the main factors causing shock

recognises the signs of shock as:

- colour of face
- rate and character of pulse

.2 applies the appropriate measures of basic shock

management

.3 states the essential measures of shock management as:

- stopping of bleeding
- protection from cooling
- early intake of ample fluids if the patient is conscious
- positioning of the patient
- no smoking
- no alcohol
- no active rewarming

12

:..
 PART C: DETAILED TEACHING SYLLABUS

Knowledge, understanding and proficiency IMO Textbooks, Teach

Reference Burns and Scalds, and Accidents Caused by/ R4- Bibliography Aid

T1 - V4

Electricity (1

Required performance:
.1 recognizes the signs of burns and scalds and of
accidents caused by electric current

.2 applies the appropriate measures for burns and scalds:

- cooling of the area as quickly as possible

.3 applies the appropriate measures for chemical burns:

- removal of clothes
- rinsing with ample water

.4 applies the appropriate measures for chemical burns of

eyes:
- rinsing of eyes with ample water

.5 applies the appropriate measures for accidents caused

by electric current:
- noting hazards to rescuers
- isolation of the casualty
- protection from collapse
- control of vital functions

9 Rescue and Transport of Casualty (1.5

R4- T1 - pp.44 - V4
hours) Sect.17, 48
App.1
Required performance:
.1 applies appropriate transportation alone and with the
assistance of a further person, taking into account the
confined spaces and varying heights on board ship

.2 identifies and uses:

- temporary and ad hoc aids for transport
- stretcher transport
- transport on a chair
- transport with a triangular cloth
- transport as illustrated in IMGS R5

.3 recognizes the hazards of transporting a patient with

injury of pelvis and/or spine and demonstrates the
correct procedures for the transport of such casualties

13
.1 bandaging: V3
- improvises bandages by means available T1 - pp.
- uses bandaging materials in the emergency kit 23
- demonstrates the correct use of bandages -28, 39,
44
.2 enclosed spaces: T1 - p.43 V6
- recognizes the dangers when making entry
- states that the internal atmosphere may contain
dangerous gases or lack sufficient oxygen
- takes all necessary and appropriate precautions

.3 infectious diseases:
- recognizes the dangers from blood and other V5
excretion from persons suffering from infectious
diseases, particularly hepatitis, and from HIV-
positive persons
- takes all necessary precautions for self
protection when dealing with such cases
- describes the correct procedures for disposing of
blood and other excretions in such cases

.4 personal health and hygiene:

- applies simple rules for maintaining health and
personal cleanliness

14
 PART D: INSTRUCTOR MANUAL

Part D: Instructor Manual

/

Introduction
The instructor manual provides guidance on the material that is to be presented during
the
'
course. The course structure follows the requirements of the STCW 1995 Convention and
the
recommendations in section 17 of the IMO/ILO Document for Guidance, 1985. The detailed
teaching syllabus is based on Appendix 1 of that section.

' The course should be under the control of a qualified medical practitioner or
professional
trainer meeting Red Cross, Red Crescent or equivalent standard. The precise structure
and content of the lectures and practical work and the way in which the course work is
arranged and developed is left to the discretion of that person.
'
The Document for Guidance advises that the IMGS or the appropriate national medical
guide
may be used to implement the course.

A Course Compendium (T1) has been compiled, making use of extracts from IMGS, and
this should be used to implement and support the course work, introducing specific national
requirements as appropriate.

The detailed teaching syllabus is arranged in ten main sections which reflect the
requirements
in IMO/ILO Document for Guidance, 1985. Where supporting material is available in the
Course Compendium (T1) an appropriate reference to it is indicated in the detailed
teaching syllabus.

The times allocated for each section are suggested values, and the instructor should adjust
them as necessary. In particular, it may be found necessary to increase the times allocated
for practical applications to ensure that the trainees can demonstrate their competence to
carry out the procedures and measures effectively.

15
ELEMENTARY FIRST AID

Guidance Notes
Section A-Vl/1, paragraph 2, requires seafarers employed or engaged in any capacity on board a
ship on the business of that ship as part of the hip's complement with designated safety oI
pollution prevention duties in the operation of the ship, to complete approved basic training
before being assigned to any shipboard duties. The basic training includes elementary firs,
aid.

The minimum standard of competence set out in Table A-Vl/1-3 of the STCW 1995 Code h
based on recommendations originally contained in Section 17, Appendix 1 of the IMO/ILC
Document for Guidance. All seafarers should receive this elementary first aid training as pre.
sea training, i.e., before service aboard any ship. It provides the seafarer with some
preparedness for the potentially hazardous environment on board ship.

The training enables effective immediate action to be taken at the scene of an accident 01 other
medical emergency pending the arrival of a person with medical first aid skills, or until the person
in charge of medical care aboard ship arrives.

The aim should be to familiarize the trainees with the accidents, injuries, and illnesses commonly
found aboard ship and the actions and procedures that can be immediately applies in any given
situation. In particular the training should ensure that all seafarers are able, if accident situations, to
assess both the needs of any casualties and the hazards to themselves The training also includes
basic instruction in healthy living and personal hygiene.

Although the lectures based on the detailed teaching syllabus are important in informing and
explaining and making sure that emphasis is placed on critical aspects, the practical session
are of equal importance in establishing that understanding and knowledge have been properly
transferred and, therefore, wherever it is practicable to do so, the trainees should demonstrate
the actual procedures involved.

To support the objectives of the syllabus, a compendium has been compiled; a copy of this
should be provided to each trainee taking the course.

The compendium for this course consists of the following extracts from the IMO/WHO/ILC
International Medical Guide for Ships (IMGS):

Chapter 1: First Aid, and

Annex I: Anatomy and Physiology.

Although only certain parts of the chapter and the annex relate directly to the syllabus!
objectives, it was considered preferable to provide the whole of Chapter 1 and Annex 1, rather
than unconnected parts of them.

16
 PART D: INSTRUCTOR MANUAL

Table 1: Extracts from /MGS used in the Compendium

/
The following table shows the relevant pages and figures from IMGS used to support each
section of the syllabus.

Section of Syllabus Extract used from IMGS*

1. General Principles Chapter 1, pages 1-3

2. Body Structure and Functions Annex 1, pages 341-348, Figs. 147-151

3. Positioning of Casualty
Chapter 1, page 6, Fig. 3

4. The Unconscious Casualty Chapter 1, pages 3-6, Figs. 1 & 2, Table 1

5. Resuscitation Chapter 1, pages 6-14, Figs. 4-11

6. Bleeding Chapter 1, pages 14-17, 40-42, Figs.

12-15,41-43

7. Management of Shock Chapter 1, pages 17-18

8. Burns and Scalds, and Accidents Chapter 1, pages 18-19
Caused by Electricity

9. Rescue and Transport of Casualty Chapter 1, pages 44-48, Figs. 47-61

1O. Other Topics Chapter 1, Figs. 19, 20, 23-25, 40, 46
(bandages and dressings); page 43
. (enclosed spaces)

* The page numbers quoted are those in IMGS.

17
SAMPLE LESSON PLAN

COURSE:
TRAINING AREA: 1.13 ELEMENTARY FIRST AID Duration: 30 Minutes: Lecture
5 Resuscitation 60 Minutes: Demonstration/Practical
Main element Specific learning objective Teaching Textbook IMO ref. AN aid Instructor Lecture Time
method guidance notes (mins.)
notes
Recognition of need for and Lecture, T1 - R1, R3 V1 A 40
procedures for resuscitation Demonstration/ pp.3-14 pp.19-20
practical

In an emergency recognises if Examines casualty, checks for difficulty in p.28 30

casualty needs resuscitation breathing

"
Applies resuscitation Place casualty on back on hard surface, Practical pp.&-9, 13 50
procedures lift neck, push forehead back, clear
mouth, check carotid pulse in neck, check
CP again after one minute and then every
five minutes.
Give four quick breaths, then at rate of 12
per minute; check for rise and fall of
chest; if there is no pulse, begin heart
compression - no delay; check pupils of
eyes for confirmation of blood circulating
in the brain.
 Attachment

GUIDANCE ON THE IMPLEMENTATION

OF MODEL COURSES
_ r ""''
1

GUIDANCE ON THE IMPLEMENTATION OF MODEL COURSES

Contents

Part 1 Preparation

Part 2 Notes on Teaching Technique

Part 3 Curriculum Development

Annex Preparation checklist

A1 Example of a Model Course syllabus in a subject area

Annex Example of a lesson plan for annex A2

A2

Annex A3
 GUIDANCE ON THE IMPLEMENTATION OF MODEL COURSES

Part 1 - Preparation
1 Introduction
1.1 The success of any enterprise depends heavily on sound and effective preparations.

1.2 Although the IMO model course "package" has been made as comprehensive as possible, it is nonetheless vital
that sufficient time and resources are devoted to preparation. Preparation not only involves matters concerning
administration or organization, but also includes the preparation of any course notes, drawings, sketches, overhead
transparencies, etc., which may be necessary.

2 General considerations
2.1 The course "package" should be studied carefully; in particular, the course syllabus and associated material must
be attentively and thoroughly studied. This is vital if a clear understanding is to be obtained of what is required, in
terms of resources necessary to successfully implement the course.

2.2 A "checklist", such as that set out in annex A1, should be used throughout all stages of preparation to ensure that
all necessary actions and activities are being carried out in good time and in an effective manner. The checklist
allows the status of the preparation procedures to be monitored and helps in identifying the remedial actions
necessary to meet deadlines. It will be necessary to hold meetings of all those concerned in presenting the course
from time to time in order to assess the status of the preparation and "trouble-shoot" any difficulties.

2.3 The course syllabus should be discussed with the teaching staff who are to present the course, and their views
received on the particular parts they are to present. A study of the syllabus will determine whether the incoming
trainees need preparatory work to meet the entry standard. The detailed teaching syllabus is constructed in
"training outcome" format. Each specific outcome states precisely what the trainee must do to show that the
outcome has been achieved. An example of a model course syllabus is given in annex A2. Part 3 deals with
curriculum development and explains how a syllabus is constructed and used.

2.4 The teaching staff who are to present the course should construct notes or lesson plans to achieve these
outcomes. A sample lesson plan for one of the areas of the sample syllabus is provided in annex A3.

2.5 It is important that the staff who present the course convey, to the person in charge of the course, their
assessment of the course as it progresses.

3 Specific considerations
3.1 Scope of course
In reviewing the scope of the course, the instructor should determine whether it needs any adjustment in order to
meet additional local or national requirements (see Part 3).

3.2 Course objective

3.2.1 The course objective, as stated in the course material, should be very carefully considered so that its
meaning is fully understood. Does the course objective require expansion to encompass any additional task that
national or local requirements will impose upon those who successfully complete?
the ?curse? Conversely, are there elements included which are not validated by national industry requirements?

3.2.2 It is important that any subsequent assessment made of the course should include a review of the course
objectives.

21
GUIDANCE ON THE IMPLEMENTATION OF MODEL COURSES

3.3 Entry standards

3.3.1 1 If the entry standard will not be met by your intended trainee intake, those entering the u should first
be required to complete an upgrading course to raise them to the stated entry le Alternatively, those
parts of the course affected could be augmented by inserting course mate which will cover the knowledge
required.

3.3.2 If the entry standard will be exceeded by your planned trainee intake, you may wish a bridge or omit
those parts of the course the teaching of which would be unnecessary, or which co be dealt with as revision.

3.3.3 Study the course material with the above questions in mind and with a view to assess whether or
not it will be necessary for the trainees to carry out preparatory work prior to joining course. Preparatory
material for the trainees can range from refresher notes, selected topics for textbooks and reading of
selected technical papers, through to formal courses of instruction. It may necessary to use a combination of
preparatory work and the model course material in modified to It must be emphasized that where the model
course material involves an international requirement such as a regulation of the International Convention
on Standards of Training, Certification c Watchkeeping (STCW) 1978, as amended, the standard must not be
relaxed; in many· instances, intention of the Convention is to require review, revision or increased
depth of knowledge candidates undergoing training for higher certificates.

3.4 Course certificate, diploma or document

Where a certificate, diploma or document is to be issued to trainees who successfully complete course, ensure
that this is available and properly worded and that the industry and all authori concerned are fully aware of its
purpose and intent.

3.5 Course intake limitations

3.5.1 The course designers have recommended limitations regarding the numbers of trainees may participate in
the course. As far as possible, these limitations should not be exceeded; otherw the quality of the course will be
diluted.

3.5.2 It may be necessary to make arrangements for accommodating the trainees and provi facilities for food and
transportation. These aspects must be considered at an early stage of preparations.

3.6 Staff requirements

3.6.1 It is important that an experienced person, preferably someone with experience in course curriculum
development, is given the responsibility of implementing the course.

3.6.2 Such a person is often termed a "course co-ordinator" or "course director". Other staff, s as lecturers,
instructors, laboratory technicians, workshop instructors, etc., will be neede implement the course
effectively. Staff involved in presenting the course will need to be pro briefed about the course work they will
be dealing with, and a system must be set up for checking material they may be required to prepare. To do this,
it will be essential to make a thorough stud the syllabus and apportion the parts of the course work
according to the abilities of the staff c upon to present the work.

3.6.3 The person responsible for implementing the course should consider monitoring the quali teaching in such
areas as variety and form of approach, relationship with trainees, and communic and interactive skills; where
necessary, this person should also provide appropriate counselling support.

3.7 Teaching facilities and equipment

Rooms and other services
3.7.1 It is important to make reservations as soon as is practicable for the use of lecture roo laboratories,
workshops and other spaces.

22
 GUIDANCE ON THE IMPLEMENTATION OF MODEL COURSES

Equipment
3.7.2 Arrangements must be made at an early stage for the use of equipment needed in the spaces
mentioned in 3.7.1 to support and carry through the work of the course. For example:
.1 blackboards and writing materials
.2 apparatus in laboratories for any associated demonstrations and experiments'
.3 machinery and related equipment in workshops

.4 equipment and materials in other spaces (e.g., for demonstrating fire fighting, personal
survival, etc.).

: 3.8 Teaching aids

Any training aids specified as being essential to the course should be constructed, or checked for
availability and working order.
:
3.9 Audio-visual aids
Audio-visual aids (AVA) may be recommended in order to reinforce the learning process in some
parts of the course. Such recommendations will be identified in Part A of the model course. The
following points should be borne in mind:
.1 Overhead projectors
Check through any illustrations provided in the course for producing overhead · projector (OHP)
:
transparencies, and arrange them in order of presentation. To produce transparencies, a supply of
transparency sheets are required; the illustrations can be transferred to these via photocopying.
Alternatively, transparencies can be produced by writing or drawing on the sheet. Coloured pens are
useful for emphasizing salient points1 Ensure that spare projector lamps (bulbs) are available.

.2 Slide projectors
If you order slides indicated in the course framework, check through them and arrange them in order
of presentation. Slides are usually produced from photographic negatives. If further slides are
considered necessary and cannot be produced locally, OHP transparencies should be resorted to.

.3 Cine projector
If films are to be used, check their compatibility with the projector (i.e., 16 mm, 35 mm, sound, etc.).
The films must be test-run to ensure there are no breakages.

.4 Video equipment
It is essential to check the type of video tape to be used. The two types commonly used are VHS and
Betamax. Although special machines exist which can play either format, the majority of machines play
only one or the other type. Note that VHS and Betamax are not compatible, the correct machine type
is required to match the tape. Check also that the TV raster format used in the tapes (i.e., number of
lines, frames/second, scanning order, etc.) is appropriate to the TV equipment available. (Specialist
> advice may have to be sought on this aspect.) All video tapes should be test-run prior to their use on
the course.
1

.5 Computer equipment
If computer-based aids are used, check their compatibility with the projector and the available
software.

.6 General note
The electricity supply must be checked for voltage and whether it is AC or DC, and every precaution
must be taken to ensure that the equipment operates properly and safely. It is important to use a
proper screen which is correctly positioned; it may be necessary to exclude daylight in some cases. A
check must be made to ensure that appropriate screens or blinds are available. All material to be
presented should be test-run to eliminate any possible troubles, arranged in the correct sequence in
which it is to be shown, and properly identified and cross-referenced in the course timetable and
lesson plans.

23
GUIDANCE ON THE IMPLEMENTATION OF MODEL COURSES

3.10 IMO references

The content of the course, and therefore its standard, reflects the requirements of all the relevant
IM(
international conventions and the provisions of other instruments as indicated in the model
course The relevant publications can be obtained fro11y the Publication Service of IMO, and
should be
available, at least to those involved in presenting the course, if the indicated extracts are not
included
in a compendium supplied with the course. .

3.11 Textbooks
The detailed syllabus may refer to a particular textbook or textbooks. It is essential that these
boo
are available to each student taking the course. If supplies of textbooks are limited, a copy should
be loaned to each student, who will return it at the end of the course. Again, some courses are
provided with a compendium which includes all or part of the training material required to support
the course.

3.12 Bibliography
Any useful supplementary source material is identified by the course designers and listed in the
mod course. This list should be supplied to the participants so that they are aware where addition :
information can be obtained, and at least two copies of each book or publication should be
available for reference in the training institute library.

3.13 Timetable
If a timetable is provided in a model course, it is for guidance only. It may only take one or
presentations of the course to achieve an optimal timetable. However, even then it must be borne
™·
mind that any timetable is subject to variation, depending on the general needs of the trainees in
and one class and the availability of instructors and equipment.

24
 GUIDANCE ON THE IMPLEMENTATION OF MODEL COURSES

Part 2 - Notes on Teaching Technique

Preparation /
1 Identify the section of the syllabus which is to be dealt with.
1.1
Read and study thoroughly all the syllabus elements.
1.2
Obtain the necessary textbooks or reference papers which
. 1.3
1.3
cover the training area to be presented

.
1.4 Identify the equipment which will be needed, together with support staff necessary for its operation.
.

1.5 It is essential to use a "lesson plan", which can provide a simplified format for co-ordinating lecture
notes and supporting activities. The lesson plan breaks the material down into identifiable steps,
making use of brief statements, possibly with keywords added, and indicating suitable allocations of
time for each step. The use of audio-visual material should be indexed at the correct point in the
lecture with an appropriate allowance of time. The audio-visual material should be test-run prior to its
being used in the lecture. An example of a lesson plan is shown in annex A3.

The syllabus is structured in training outcome format, and it is thereby relatively straightforward to
each trainee's grasp of the subject matter presented during the lecture. Such assessment may
take the form of further discussion, oral questions, written tests or selection-type tests, such as
multichoice questions, based on the objectives used in the syllabus. Selection-type tests and
short-answer tests can provide an objective assessment independent of any bias on the part of the
assessor. For certification purposes, assessors should be appropriately qualified for the particular
type of training or assessment.

REMEMBER - POOR PREPARATION IS A SURE WAY TO LOSE THE INTEREST OF A GROUP

1.7 Check the rooms to be used before the lecture is delivered. Make sure that all the equipment and
apparatus are ready for use and that any support staff are also prepared and ready. In particular,
check that all blackboards are clean and that a supply of writing and cleaning materials is readily
available.

2 Delivery
2.1 Always face the people you are talking to; never talk with your back to the group.

2.2 Talk clearly and sufficiently loudly to reach everyone.

2.3 Maintain eye contact with the whole group as a way of securing their interest and maintaining it (i.e.,
do not look continuously at one particular person, nor at a point in space).

2.4 People are all different, and they behave and react in different ways. An important function of a
lecturer is to maintain interest and interaction between members of a group.

2.5 Some points or statements are more important than others and should therefore be emphasized. To
ensure that such points or statements are remembered, they must be restated a number of times,
preferably in different words.

2.6 If a blackboard is to be used, any writing on it must be clear and large enough for everyone to see.
Use color to emphasize important points, particularly in sketches.
2.7 It is only possible to maintain a high level of interest for a relatively short period of time; therefore,
break the lecture up into different periods of activity to keep interest at its highest level. Speaking,
Writing, sketching, use of audio-visual material, questions, and discussions can all be used to
accomplish this. When a group is writing or sketching, walk amongst the group, looking at their work,
and provide comment or advice to individual members of the group when necessary.
25
I

GUIDANCE ON THE IMPLEMENTATION OF MODEL COURSES

2.8 When holding a discussion, do not allow individual members of the group to monopolize
the activity but ensure that all members have a chance to express opinions or ideas.
/
2.9 If addressing questions to a group, do not ask them collectively; otherwise. the same
person m; reply each time. Instead, address the questions to individuals in turn, so that
everyone is invited participate.
1

2.1O It is important to be guided by the syllabus content and not to be tempted to introduce
material which may be too advanced or may contribute little to the course objective. There is
often compatriotic between instructors to achieve a level which is too advanced. Also,
instructors often strongly rest attempts to reduce the level to that required by a syllabus.

2.11 Finally, effective preparation makes a major contribution to the success of a lecture. Things
often c wrong; preparedness and good planning will contribute to putting things right.
Poor teaching canon be improved by good accommodation or advanced equipment, but
good teaching can overcome are disadvantages that poor accommodation and lack of
equipment can present.

26
 GUIDANCE ON THE IMPLEMENTATION OF MODEL COURSES

Part 3 - Curriculum Development

1
Curriculum
The dictionary defines curriculum as a "regular course of study", while syllabus ·is defined as "a
concise statement of the subjects forming a course of study". Thus, in general terms, a curriculum is
simply a course, while a syllabus can be thought of as a list (traditionally, a "list of things to be
taught").

2 Course content
The subjects which are needed to form a training course, and the precise skills and depth of
knowledge required in the various subjects, can only be determined through an in-depth assessment
of the job functions which the course participants are to be trained to perform (job analysis). This
analysis determines the training needs, thence the purpose of the course (course objective). After
ascertaining this, it is possible to define the scope of the course.

(NOTE: Determination of whether or not the course objective has been achieved may quite possibly
entail assessment, over a period of time, of the "on-the-job performance" of those completing the
course. However, the detailed learning objectives are quite specific and immediately assessable.)

3 Job analysis
A job analysis can only be properly carried out by a group whose members are representative of the
organizations and bodies involved in the area of work to be covered by the course. The validation of
results, via review with persons currently employed in the job concerned, is essential if undertraining
and overtraining are to be avoided.

4 Course plan
Following definition of the course objective and scope, a course plan or outline can be drawn up. The
potential students for the course (the trainee target group) must then be identified, the entry standard
to the course decided and the prerequisites defined.

5 Syllabus
The final step in the process is the preparation of the detailed syllabus with associated time scales;
the identification of those parts of textbooks and technical papers which cover the training areas to a
sufficient degree to meet, but not exceed, each learning objective; and the drawing up of a
bibliography of additional material for supplementary reading.

6 Syllabus content
The material contained in a syllabus is not static; technology is continuously undergoing change and
there must therefore be a means for reviewing course material in order to eliminate what is redundant
and introduce new material reflecting current practice. As defined above, a syllabus can be thought of
as a list and, traditionally, there have always been an "examination syllabus" and a "teaching
syllabus"; these indicate, respectively, the subject matter contained in an examination paper, and the
subject matter a teacher is to use in preparing lessons or lectures.

27
 GUIDANCE ON THE IMPLEMENTATION OF MODEL COURSES

7 Training outcomes
7.1 The prime communication difficulty presented by any syllabus is how to convey the "depth" knowledge required. A syllabus is usually constructed as
a series of "training outcomes" to h resolve this difficulty. / · _

7.2 Thus, curriculum development makes use of training outcomes to ensure that a common minim level and breadth of attainment is achieved by all
the trainees following the same course, irrespective of the training institution (i.e., teaching/lecturing staff).

7.3 Training outcomes are trainee-oriented, in that they describe an end result which is to be achieved the trainee as a result of a learning process.

7.4 In many cases, the learning process is linked to a skill or work activity and, to demonstrate prope the attainment of the objective, the trainee
response may have to be based on practical application use, or on work experience.

7.5 The training outcome, although aimed principally at the trainee to ensure achievement of a specie learning step, also provides a framework for the
teacher or lecturer upon which lessons or lecture can be constructed.

7.6 A training outcome is specific and describes precisely what a trainee must do to demonstrate knowledge, understanding or skill as an end
product of a learning process.

7.7 The learning process is the "knowledge acquisition" or "skill development" that takes place during course. The outcome of the process is an acquired
"knowledge", "understanding", "skill"; but the terms alone are not sufficiently precise for describing a training outcome.

7.8 Verbs, such as "calculates", "defines", "explains", "lists", "solves" and "states", must be used wh constructing a specific training outcome, so as to
define precisely what the trainee will be enabled do.

7.9 In the IMO model course project, the aim is to provide a series of model courses to assist instruct in developing countries to enhance or update
the maritime training they provide, and to allow common minimum standard to be achieved throughout the world. The use of training outcomes I
tangible way of achieving this desired aim.

7.10 As an example, a syllabus in training-outcome format for the subject of ship construction appear annex A2. This is a standard way of structuring
this kind of syllabus. Although, in this case, outcome for each area has been identified - and could be used in an assessment procedure - t
stage is often dropped to obtain a more compact syllabus structure.

8 Assessment
Training outcomes describe an outcome which is to be achieved by the trainee. Of equal import is the fact that such an achievement can be
measured OBJECTIVELY through an evaluation wh will not be influenced by the personal opinions and judgements of the examiner. Objective
testing evaluation provides a sound base on which to make reliable judgements concerning the levels understanding and knowledge achieved,
thus allowing an effective evaluation to be made of progress of trainees in a course.

28
 Annex A1 - Preparation checklist

Ref. Component Identified Reserved Electricity Purchases Tested Accepted Started Finished Status OK
supply

1 Course plan

2 Timetable

3 Syllabus

4 Scope
G
C
5 Objective 0

6 Entry standard

7 Preparatory
course

8 Course '\
certificate
9 Participant
numbers

. 10 Staffing

Coordinator
Lecturers
Instructors
Technicians
Other
---

Annex A1 - Preparation checklist (continued)

Ref. Component Identified Reserved Electricity Purchases

supply Tested Accepted Started Finished Status OK

11 Facilities
(a) Rooms
Lab
Workshop
Other
Class
(b) Equipment
Lab
Workshop

Other

12 AVA Equipment
and materials

OHP

Slide

Cine

Video

13 IMO reference

14 Textbooks

15 Bibliography
 GUIDANCE ON THE IMPLEMENTATION OF MODEL COURSES

Annex A2 - Example of a Model Course syllabus in a subject area

Subject area: Ship construction

Prerequisite:
Have a broad understanding of shipyard practice
General aims:
Have knowledge of materials used in shipbuilding, specification of
shipbuilding steel and process of approval
Textbooks:
No specific textbook has been used to construct the syllabus, but the
instructor would be assisted in preparation of lecture notes by referring to
suitable books on ship construction, such as Ship Construction by Eyres
(T12) and Merchant Ship Construction by Taylor (T58)

31
GUIDANCE ON THE IMPLEMENTATION OF MODEL COURSES

COURSE OUTLINE

Total hours
for each
Total hours for
Knowledge, understanding and proficiency subject area
each topic
of Required
performance

Competence:
3.1 CONTROL TRIM, STABILITY and STRESS
3.1.1 FUNDAMENTAL PRINCIPLESOF SHIP
CONSTRUCTION, TRIM AND STABILITY

.1 Shipbuilding materials 3
.2 Welding 3
.3 Bulkheads 4
.4 Watertight and weathertight doors 3
.5 Corrosion and its prevention 4
.6 Surveys and dry-docking 2
.7 Stability 83 102

32
 GUIDANCE ON THE IMPLEMENTATION OF MODEL COURSES

Part C3: Detailed Teaching Syllabus

/

Introduction
The detailed teaching syllabus is presented as a series of learning objectives. The
objective, therefore, describes what the trainee must do to demonstrate that the
specified knowledge or skill has been transferred.

Thus, each training outcome is supported by a number of related performance

elements in which the trainee is required to be proficient. The teaching syllabus
shows the Required performance expected of the trainee in the tables that follow.

In order to assist the instructor, references are shown to indicate IMO references
and publications, textbooks and teaching aids that instructors may wish to use in
preparing and presenting their lessons.

The material listed in the course framework has been used to structure the detailed
teaching syllabus; in particular,
Teaching aids (indicated by A)
IMO references (indicated by R) and
Textbooks (indicated by T)
will provide valuable information to instructors.

Explanation of information contained in the syllabus tables

The information on each table is systematically organized in the following way.
The line at the head of the table describes the FUNCTION with which the training is
concerned. A function means a group of tasks, duties and responsibilities as
specified in the STCW Code. It describes related activities which make up a
professional discipline or traditional departmental responsibility on board.

The header of the first column denotes the COMPETENCE concerned. Each
function comprises a number of competences. For example, the Function 3,
Controlling the Operation of the Ship and Care for Persons on board at the
Management Level, comprises a number of COMPETENCES. Each competence is
uniquely and consistently numbered in this model course.

In this function the competence is Control trim, stability and stress. It is

numbered 3.1, that is the first competence in Function 3. The term "competence"
should be understood as the application of knowledge, understanding, proficiency,
kills, experience for an individual to perform a task, duty or responsibility on board
in a safe, efficient and timely manner.

Shown next is the required TRAINING OUTCOME. The training outcomes are the
areas of knowledge, understanding and proficiency in which the trainee must be
able !o demonstrate knowledge and understanding. Each COMPETENCE
comprises a number of training outcomes. For example, the above competence
comprises three training outcomes. The first is concerned with the fundamental
principles of FUNDAMENTAL PRINCIPLES OF SHIP CONSTRUCTION, TRIM
A D STABILITY. Each training outcome is uniquely and consistently numbered in
this model course. That concerned with fundamental principles of Ship

33
 GUIDANCE ON THE IMPLEMENTATION OF MODEL COURSES

Construction, Trim And Stability is uniquely numbered 3.1.1. For clarity, training
outcomes are printed in black type on grey, for example TRAINING OUTCQME.

Finally, each training outcome embodies a variable number of Required performances -

as evidence of competence. The instruction, training and learning should lead to the
trainee meeting the specified Required performance. For the training outcome
concerned with fundamental principles of ship construction, trim and stability there are
three areas of performance. These are:
3.1.1.1 Shipbuilding materials
3.1.1.2 Welding
3.1.1.3 Bulkheads

Following each numbered area of Required performance there is a list of activities that
the trainee should complete, and which collectively specify the standard of competence
that the trainee must meet. These are for the guidance of teachers and instructors in
designing lessons, lectures, tests and exercises for use in the teaching process. For
example, under the topic 3.1.1.1, to meet the Required performance, the trainee should
be able to:
-state that steels are alloys of iron, with properties dependent upon the type and
amounts of alloying materials used
-state that the specifications of shipbuilding steels are laid down by classification
societies
-state that shipbuilding steel is tested and graded by classification society surveyors
who stamp it with approval marks
and so on.

IMO references (Rx) are listed in the column to the right-hand side. Teaching aids (Ax),
videos (Vx) and textbooks (Tx) relevant to the training outcome and required
performances are placed immediately following the TRAINING OUTCOME title.

It is not intended that lessons are organized to follow the sequence of Required
performances listed in the Tables. The Syllabus Tables are organized to match with the
competence in the STCW Code Table A-11/2. Lessons and teaching should follow
college practices. It is not necessary, for example, for ship building materials to be
studied before stability. What is necessary is that all of the material is covered, and that
teaching is effective to allow trainees to meet the standard of the Required performance.

34

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 GUIDANCE ON THE IMPLEMENTATION OF MODEL COURSES

FUNCTION 3: CONTROLLING THE OPERATION OF THE SHIP AND CARE FOR

PERSONS ON BOARD AT THE MANAGEMENT LEVEL

COMPETENCE 3.1 Control trim, stability and stress IMO reference

3.1.1 FUNDAMENTAL PRINCIPLES OF SHIP

CONSTRUCTION, TRIM AND STABILITY

Textbooks:T11, T12, T35, T58, T69

Teaching aids: A1, A4, V5, V6, V7
Required performance:

1.1 Shipbuilding materials (3 hours) R1

- states that steels are alloys of iron, with properties dependent upon
the type and amounts of alloying materials used
- states that the specifications of shipbuilding steels are laid down by
classification societies
- states that shipbuilding steel is tested and graded by
classification society surveyors, who stamp it with approval
marks
- explains that mild steel, graded A to E, is used for most parts of the
ship
- states why higher tensile steel may be used in areas of high stress,
such as the sheer strake
- explains that the use of higher tensile steel in place of mild steel
results in a saving of weight for the same strength
- explains what is meant by:
• tensile strength
• ductility
• hardness
•toughness
- defines strain as extension divided by original length
- 'sketches a stress-strain curve for mild steel
- explains:
• yield point
• ultimate tensile stress
• modulus of elasticity
- explains that toughness is related to the tendency to brittle fracture
- explains that stress fracture may be initiated by a small crack or notch
in a plate
- states that cold conditions increase the chances of brittle fracture
- states why mild steel is unsuitable for the very low temperatures
involved in the containment of liquefied gases
- lists examples where castings or forgings are used in ship
construction
- explains the advantages of the use of aluminium alloys in the
construction of superstructures
- states that aluminium alloys are tested and graded by classification
society surveyors
- explains how strength is preserved in aluminium superstructures in the
event of fire
- describes the special precautions against corrosion that are needed
where aluminium allow is connected to steelwork

35
 (

Annex A3 - Example of a lesson plan or annex A2

Subject area: 3.1 Control trim, stability and stress Lesson number: 1 Duration: 3 hours

Training Area: 3.1.1 Fundamental principles of ship construction, trim and stability

Main element Teaching Textbook IMO A/V aid Instructor Lecture Time
Specific training outcome in teaching sequence, with method reference guidelines notes (minutes)
memory keys

1.1 Shipbuilding materials (3 hours)

States that steels are alloys of iron, with properties dependent Lecture T12, T58 STCW 11/2, VS to V7 A1 Compiled 10
upon the type and amounts of alloying materials used A-11/2 by the
lecturer

States that the specifications of shipbuilding steels are laid Lecture T12, T58 STCW 11/2, VS to V7 A1 Compiled 20
down by classification societies A-11/2 by the
0
lecturer J)

f,- Explains that mild steel, graded A to E, is used for most parts Lecture T12, T58 STCW 11/2, VS to V7 A1 Compiled 15
of the ship A-11/2 by the
lecturer

States why higher tensile steel may be used in areas of high Lecture T12, T58 STCW 11/2, VS to V7 A1 Compiled 10
stress, such as the sheer strake A-11/2 by the
lecturer

Explains that use of higher tensile steel in place of mild steel Lecture T12, T58 STCW 11/2, VS to V7 A1 Compiled 15
results in a saving of weight for the same strength A-11/2 by the
 ACKNOWLEDGEMENTS

IMO expresses its sincere appreciation to

the International Labour Organization and
to the World Health Organization
for their assistance and co-operation
in the production of this compendium

Copyright© WHO 1988, IMO 2001

 Contents

Page

Extracts from International Medical Guide for Ships

Chapter 1: First Aid 1
Annex 1: Anatomy and Physiology 53

iii
 Chapter 1 First aid is the emergency treatment given to the
ill or injured before professional medical services
First aid can be obtained. It is given to prevent death or
further injury, to counteract shock, and to relieve
pain. Certain conditions, such as severe bleeding
or asphyxiation, require immediate treatment if
the patient is to survive. In such cases, even a few
seconds' delay might mean the difference
between life and death. However, the treatment of
most injuries or other medical emergencies may
be safely postponed for the few
_minutes required to locate a crew-member
skilled in first aid, or to locate suitable medical
supplies and equipment.
All crewmembers should be prepared to ad
Contents minister first aid. They should have sufficient
Priorities knowledge of first aid to be able to apply true
General principles of first aid aboard1ship emergency measures and decide when treatment
Unconscious casualties Basic Ife support: can be safely delayed until more skilled personnel
2
artificial respiration and heart compression arrive. Those not properly trained must rec
Severe bleeding Shock 3 cognize· their limitations. Procedures and tech
Clothing on fire
inquest beyond the rescuer's ability should not be
Heat burns and scalds Electrical burns and
attempted. More harm than good might result.
electrocution Chemical splashes Fractures
6 Dislocations
Head injuries Blast injuries Internal14
bleeding Choking Suffocation Strangulation Standard dressing
Transporting a casualty First aid satchels
17 Priorities
or boxes 18
Oxygen administration (oxygen therapy) On finding a casualty:
19
■ look to your own safety: do not become the
19 next casualty.
19 ■ if necessary, remove the casualty from danger
19 or remove danger from the casualty (but see
37 observation below on a casualty in an enclosed
space). If there is only one unconscious or
39 bleeding casualty (irrespective of the total
39 number of casualties), give immediate treat-
40 ment to that casualty only, and then send for
42 help.
43
43 If there is more than one unconscious or bleeding
44 casualty:
44 ■ send for help; .
■ then start giving appropriate treatment to the
48 worst casualty in the following order of prior
ity: severe bleeding; stopped breathing/heart;
51 unconsciousness.
If the casualty is in an enclosed space, do not
enter the enclosed space unless you are a trained

1
ELEMENTARY FIRST AID: COMPENDIUM

member of a rescue team acting under instruc- The patient should be kept in the position that
tions. Send for help and inform the master. best provides relief from his injuries. Usually
It must be assumed that the atmosphere in the this is a lying-down position, which increases
space is hostile. The rescue team MUST NOT circulation of the blood to the head.
enter unless wearing breathing apparatus which The patient should be observed for type of
must also be fitted to the casualty as soon as breathing and possible bleeding. If he is not
possible. The casualty must be removed breathing, mouth-to-mouth or mouth-to-nose
quickly to the nearest safe adjacent area outside artificial respiration must be given (see pages 8-
the enclosed space unless his injuries and the 9).
likely time of evacuation make some treatment . I

essential before he can be moved. Severe bleeding must be controlled.

During this time, the patient, if conscious,
should be reassured and told that all possible
General principles of first aid help is being given. The rescuer should ask about
aboard ship the location of any painful areas.
First aid must be administered immediately to: The patient should be kept in a lying-down pos-
ition and moved only when absolutely necessary.
■ restore breathing and heartbeat.
The general appearance of the patient should be
■ control bleeding.
observed, including any signs and symptoms that
■ remove poisons.
may indicate a specific injury or illness.
■ prevent further injury to the patient (for in
stance, his removal from a room containing The patient should not be moved if injuries of
carbon monoxide or smoke). the neck or spine are suspected. Fractures
should be splinted before moving a patient (see
A rapid, emergency evaluation of the patient
pages 19-22). No attempt should be made to set
should be made immediately at the scene of the
a fracture.
injury to determine the type and extent of the
trauma. Because every second may count, only Wounds and most burns should be covered to
the essential pieces of the patient's clothing prevent infection. The treatment of specific in
should· be removed. juries will be discussed more fully in the rest of
this chapter, and in the next chapter.
In the case of an injured limb, get the sound limb
out of the clothing first, and then peel the clothes Once life-saving measures have been started or
off the injured limb. If necessary, cut clothes to deemed not necessary, the patient should be
expose the injured part. examined more thoroughly for other injuries.
Keep workers from crowding round. The patient should be covered to prevent loss of
body heat.
The patient's pulse should be taken. If it cannot
be felt at the wrist, it should be felt at the carotid If necessary, protect him also from heat,
artery at the side of the neck (see Fig. 2). If there remembering that in the tropics, the open steel
is no pulse, heart compression and artificial res- deck on
piration must be started (see Basic life support, · which he may be lying will usually be very hot.
page 6). The patient should be treated for shock
The patient should not be given alcohol in any
if the pulse is weak and rapid, or the skin pale,
form.
cold, and possibly moist, with an increased rate
of shallow, irregular breathing. Remember that
shock can be a great danger to life, and its Never underestimate and do not treat as minor
prevention is one of the main objectives of first m3unes:
aid (see Shock, page 17). ■ unconsciousness (page 3).
■ suspected internal bleeding (page 40).

2
 CHAPTER 1: FIRST AID

stab or puncture wounds (page 68); . .

• wounds near Jomts (see Fractures, page 19).
• possible fractures (page 19).
• eye injuries (page 76).
Note. Never consider anyone to be dead, until
you and others agree that:
•no pulse can be felt, and no sounds are heard
when the examiner's ear is put to the chest.
•breathing has stopped.
•the eyes are glazed and sunken.
•there is progressive cooling of the body (this
may not' apply if the surrounding air
temperature is close to normal body
temperature).

Unconscious casualties Breathing

(See also: Basic life support: artificial respiration With an unconscious patient, first listen for
and heart compression, page 6; General nursing breathing. To relieve obstructed breathing, tilt
care, Unconscious patients, page 104.). the head firmly backwards as far as it will go (see
The causes of unconsciousness are many and are Fig. I).
often difficult to determine (see Table I). Treat- Listen and feel for any movement of air, because
WHO 8615fi3?

ment varies with the cause, but in first aid it is Fig. 2. Carotid pulse.
usually not possible to make a diagnosis of the the chest and abdomen may move in the
cause, let alone undertake treatment. presence of an obstructed airway, without
The immediate threat to life may be: moving air. The rescuer's face should be placed
within 2-3 cm of the patient's nose and mouth
• breathing obstructed by the tongue falling so that any exhaled air may be felt against his
back and blocking the throat. cheek. Also, the rise and fall of the chest can be
• stopped heart: observed and the exhaled breath heard (see
Fig. I).
Remove patient's dentures, if any.

Heart
Next, listen for heart sounds. Feel pulse at wrist
(see page 94) and neck (carotid pulse, see Fig. 2).
1
Quickly check the carotid (neck) pulse by
placing the tips of the two fingers of one hand
into
► the groove between the windpipe and the large
muscle at the side of the neck.
The carotid pulse is normally a strong one if it
cannot be felt or is feeble, there is insufficient
circulation.

Check the pupils of the eyes to see if they are

dilated or constricted. When the heart stops

3
 WHO 861562?

Fig.ELEMENTARY
1. Unconscious patient.
FIRSTFirst
AID:listen for breathing.
COMPENDIUM

Table 1. Diagnostic signs in unconsciousness

-..
1 2 3 4 5 6 7
Fainting Concussion Brain com- Epilepsy Stroke Alcohol Opium and
pression morphine
I
(p. 199) (p. 74) (p. 74) (p. 195) (p. 231) (p. 164) (p. 191)

Onset usually, sudden usually, sudden sudden as gradual gradual

sudden gradual a rule I
Mental complete unconscious- unconscious- complete complete or stupor, later unconscious-
condition unconscio ness but ness unconsciousn partial un- unconsciousn ness
usness sometimes deepening ess conscious- ess deepening
confusion ness
only l

Pulse feeble and feeble and gradually fast slow and full full and fast, feeble and
fast irregular slower later fast . slow
and feeble
Respiration quick and slow and noisy, later deep, slow,
shallow and stow and stow, may be
shallow noisy deep and and noisy
irregular noisy deep
stow

Skin pate, cold, hot and livid, later flushed, later

pate and hot and pale,
and flushed pale cold and
cold flushed cold, and
clammy clammy
clammy
Pupils equal and unequal equal and dilated, later
dilated equal dilated unequal equal, very
may con-
tract; eyes contracted
bloodshot
Paralysis none present none none
none (of leg present in none
or arm) leg, arm, or
face, or all
three, on
one side
Convulsions none present in present none
none some cases present in none
I

some cases
Breath - - - . smells of
- - . alcohol with opium,
musty smell
Special points often giddi- often signs of tongue often absence of
ness and often signs of head injury. bitten; urine over middle the smell of look for
swaying head injury, remember or faeces age: eyes alcohol ex- source of
before vomiting on delayed may be may look to eludes it as Supply
collapse recovery onset of voided; one side; cause, but
symptoms sometimes sometimes its presence
injury in fal- loss of does not
ling speech prove that
alcohol is
the cause

CHAPTER 1: ·FIRST AID

Table 1. Diagnostic signs in unconsciousness

- 8 9
Uremic
10
Sunstroke
11
Electric
12
Cyanide
13
Diabetic
14
Shock
barbiturate
(sedative coma and heat- shock (prussic acid) coma
tablets) stroke
(p. 57) (p. 236) (p. 205) (p. 19) (p. 57) (p. 187) (p. 17)
-gradual gradual gradual or sudden very rapid gradual gradual Onset
sudden

stupor, later very drowsy, delirium or unconscious- confusion, drowsiness. listlessness, Mental
later un- unconsciou ness later un- later un- later un-
5
ELEMENTARY FORST AID: COMPENDIUM

I
Fig 3. The position for an unconscious patient: turn chin. Stretch another arm out, as shown. His
clothes
him face down, head to one side; no pillows should
should be loosened at the neck and waist, and any \
be used under the head. Pull up the leg and the arm artificial teeth removed. ·
on the side to which the head is facing, pull up the
,
beating, the pupils will begin to dilate within If the heart is beating and breathing restored
45-60 seconds. They will stay dilated and will and the casualty is still unconscious, place the
not react to light (see Physical examination casualty in the UNCONSCIOUS POSITIO
(eyes), p. 63). (see Fig. 3).
The examination for breathing and heart action Turn casualty face down, head to one side
should be done as quickly as possible. The other (Fig. 3). No pillows should be used under the
rescuer must immediately establish if the casualty heads. Now pull up the leg and the arm on that
side to which the head is facing. Then pull up to
■ is not breathing and the heart has stopped, or
chin. Stretch the other arm out as shown.
That
■ is not breathing but the heart has not subsequent treatment of an unconscious perms
stopped.
Not breathing, heart stopped is described in Chapter 5 (page 104).

A trained first: aider must begin heart com Follow other general principles of first aid (set
page 2).
pression at once. Unless circulation is restored,
the brain will be without oxygen and the person
will die within 6 minutes. Basic life support:
■ Lay casualty on a hard surface. artificial respiration and heart
■ Start heart compression at once (see page 9). compression
■ Give artificial respiration (see page 8), since Basic life support is an emergency life-saving
breathing stops when the heart stops. procedure that consists of recognizing and
The necessary aid can be given by one person correcting failure of the respiratory or
alternately compressing the heart and then fill ing cardiovascular systems.
the lungs with air, or-· better still - by twoOxygen, which is present in the atmosphere in 1
people working together (see page 11-12). concentration of about 21%, is essential for the
life of all cells. The brain, the principal organ
Not breathing, heart not stopped for conscious life, starts to die if deprived of
■ Open mouth and ensure the airway is clear oxygen for as little as four minutes. In the
1

(see Airway, page 7). delivery of oxygen from the atmosphere to the
■ Begin ARTIFICIAL RESPIRATION at once brain cells
(see page 8). · there are two necessary actions: breath ill
(taking in oxygen through the body's air pal

6
 CHAPTER 1 : FIRST AID

sages) and the circulation of oxygen-enriched It is thus clear why speed is essential in
blood. Any profound disturbance of the determining the need for basic life support and
airway, the breathing, or the circulation can instituting the necessary measures.
promptly produce brain death.
Once you have started basic life support, do
Basic life support comprises the "ABC" steps, not interrupt it for more than 5 seconds for any
which concern the airway, breathing, and reason, except when it is necessary to move the
circulation respectively. patient even in that case, interruptions should
not exceed 15 seconds each.
Its prompt application is indicated for:
Airway (Step A)
A. Airway obstruction
B. Breathing (respiratory) arrest ESTABLISHING AN OPEN AIRWAY IS
C. Circulatory or Cardiac (heart) arrest. THE MOST IMPORTANT STEP IN ARTI
FICIAL RESPIRATION. Spontaneous breath
Basic life support requires no instruments or ing may occur as a result of this simple
supplies, and the correct application of the measure. Place the patient in a face-up position
steps for dealing with the above three on a hard surface. Put one hand beneath the
problems can maintain life until the patient patient's neck and the other hand on his
recovers sufficiently to be transported to a forehead. Lift the neck with the one hand and
hospital, where he can be provided with apply pressure to the forehead with the other to
advanced life support. The latter consists of the tilt the head back ward (see Fig. 4). This
use of certain equipment, cardiac monitoring, extends the neck and moves the base of the
defibrillation, the maintenance of an tongue away from the back of the throat. The
intravenous lifeline, and the in head should he main
fusion of appropriate drugs. tainted in this position during the entire art(facial
respiration and heart compression procedure. If
Basic life support must be undertaken with the the airway is still obstructed, any foreign ma
maximum sense of urgency. trial in the mouth or throat should be removed
immediately with the fingers.
Ideally, only seconds should intervene between
recognizing the need and starting the treatment. Once the airway has been opened, the patient
Any inadequacy or absence of breathing or may or may not start to breathe again. To assess
circulation must be determined immediately. whether breathing has returned, the person
providing the basic life support must place his
If breathing alone is inadequate or absent, all ear about 2-3 cm above the nose and mouth of
that is necessary is either to open the AIRWAY the patient. If the rescuer can feel and hear the
or to apply ARTIFICIAL RESPIRATION. movement of air, and can see the patient's chest
and abdomen move, breathing has returned.
If circulation is also absent, artificial circulation Feeling and hearing are far more important than
must be instituted through HEART COM seeing.
PRESSION, in combination with artificial
With airway obstruction, it is possible that there
respiration.
will be no air movement even though the chest
If breathing stops before the heart stops, enough and abdomen rise and fall with the patient's
oxygen will be available in the lungs to maintain attempts to breathe. Also, observing chest and
life for several minutes. However, if heart arrest abdominal movement is difficult when the
occurs first, delivery of oxygen to the brain patient is fully clothed.
ceases immediately. Brain damage is possible if Breathing (Step 8)
the brain is deprived of oxygen for 4-6 minutes.
Beyond 6 minutes without oxygen, brain dam If the patient does not resume adequate,
age is very likely. spontaneous breathing promptly after his head
has

7
ELEMENTARY FIRST AID: COMPENDIUM

been tilted backward, artificial respiration Continue to exert pressure on the

should be given by the mouth-to-mouth or forehead, with the palm of the hand to
mouth-to-nose method or other techniques. maintain th1
Regardless of the method used, preservation of an backward tilt of the head.
open airway is essential. ■ Take a deep breath, then form a tight seal
Mouth-to-mouth respiration with your mouth over and around the
patient' mouth (see Fig. 5).
■ Keep the patient's head at a maximum back ■ Blow four quick, full breaths in first without
ward tilt with one hand under the neck (see allowing the lungs to deflate fully.
Fig. 4b). ■ Watch the patient's chest while inflating the
■ Place the heel of the other hand on the fore lungs. If adequate respiration is taking place
head, with the thumb and index finger toward the chest should rise and fall.
the nose. Pinch together the patient's nostrils ■ Remove your mouth and allow the patient
with the thumb and index finger to prevent air exhale passively. If you are in the right
from escaping. position, the patient's exhalation will be felt
o1 your cheek (see Fig. 6).
8
 CHAPTER 1: . FIRST AID

Fig. 5. Mouth-to-mouth respiration.

Attendant forms a tight seal around the patient's mouth with his own mouth and blows forcefully.

■ Take another deep breath, form a tight seal ■ Remove your mouth and allow the patient to
around the patient's mouth, and blow into the exhale passively.
mouth again. Repeat this procedure 10-12 ■ Repeat the cycle 10-12 times per minute.
times a minute (once every five seconds) for
adults and children over four years of age. Alternative method of artificial
■ If there is no air exchange and an airway respiration (Silvester method)
obstruction exists, reach into the patient's In some instances, mouth-to-mouth respiration
mouth and throat to remove any foreign mat cannot be used. For instance, certain toxic and
ter with your fingers, then resume artificial caustic materials constitute a hazard for the
respiration. A foreign body should be suspect rescuer, or facial injuries may prohibit the use
ed if you are unable to inflate the lungs despite of the mouth-to-mouth or mouth-to-nose
proper positioning and a tight air-seal round technique. An alternative method of artificial
the mouth or nose. respiration (shown in Fig. 8) should then be
Mouth-to-nose respiration applied. However, this method is much less
effective than

The mouth-to-nose technique should be used those previously described and it should be used
only when the mouth-to-mouth technique can not
when it is impossible to open the patient's be used.
mouth, when the mouth is severely injured, or
when a tight seal round the lips cannot be Artificial respiration should be continued as
obtained (see Fig. 7). long as there are signs of life; it may be necessary
to carry on for up to two hours, or longer.

• Keep the patient's head tilted back with one Heart compression (Step C)
hand. Use the other hand to lift up the
patient's lower jaw to seal the lips. In attempting to bring back to life a non-breath
• Take a deep breath, seal your lips round the ing person whose heart has stopped beating,
patient's nose, and blow in forcefully and heart compression (external cardiac
smoothly until the patient's chest rises. Re Compression) should be applied along with artificial
peat quickly four times. respiration.

9
ELEMENTARY FIRST AID: COMPENDIUM

Artificial respiration will bring oxygen-contain Kneel close to the side of the patient and place
ing air to the lungs of the victim. From there, the heel of one hand over the lower half of the
oxygen is transported with circulating blood to sternum. Avoid placing the hand over the tip
the brain and to other organs. Effective heart (xiphoid process) of the breastbone, which ex•
compression will - for some time -- artificially tends down over the upper abdomen .Pressure
restore the blood circulation, until the heart on the xiphoid process may tear the liver and
starts beating. lead to severe internal bleeding.
Feel the tip of the sternum and place the heel o!
Technique for heart the hand about 4 cm nearer the head of the
compression patient (see Fig. 9). Your fingers must never rest
on the patients’ ribs during compression, since
Compression of the sternum produces some arti- this .increases the possibility of rib fractures.
ficial ventilation, but not enough for adequate
oxygenation of the blood. For this reason, arti- ■ Place the heel of the other hand on top of the
ficial respiration is always required whenever first one.
heart compression is used. ■ Rock forward so that your shoulders are al·
most directly above the patient's chest.
Effective heart compression requires sufficient ■ Keep your arms straight and exert adequate
pressure to depress the patient's lower sternum pressure almost directly downwards to de·
about 4-5 cm (in an adult). For chest com press an adult's lower sternum 4-5 cm.
pression to be effective, the patient must he on a ■ Depress the sternum 60 times per minute for
firm surface. If he is in bed, a board or an adult (if someone else is available to give
improvised support should be placed under his artificial respiration). This is usually enough
back. How ever, chest compression must not be to maintain blood flow, and slow enough to
delayed for a search for a firmer support. allow the heart to fill with blood. The cot1l'

10

......
CHAPTE
R 1:
FIRST
AID

pression should be regular, smooth, and facial respiration (see Fig. 10). The most effective
uninterrupted, compression and relaxation artificial respiration and heart compression are
being
of equal duration. Under no circumstances achieved by giving one lung inflation quickly
should compression be interrupted for more? after each five heart compressions (5: 1 ratio).
than five seconds (see page 7). The compression rate should he 60 per minute for
two rescuers are operating. One rescuer performs
It is preferable to have two rescuers because heart compression, while the other remains at
artificial circulation must be combined with arti- the patient's head, keeps it tilted back, and
11
 ELEMENTARY FIRST AID: COMPENDIUM

continues rescue breathing (artificial

respiration). It is important to supply, the breaths
witho11t any pauses in heart compression,
because ever) interruption in this compression
results in a drop of blood flow and blood
pressure to zero.
A single rescuer must perform both artificial
respiration and artificial circulation using a 15 :1
ratio (see Fig. 11). Two very quick
lung inflations should be delivered after each 15
chest compressions, without waiting for full
exhale.
ton of the patient's breath. A rate equivalent to 80
chest compressions per minute must be main.
tainted by a single rescuer in order to achieve
50-60 actual compressions per minute, because
of the interruptions for the lung inflations.

Checking effectiveness of heart

compression: pupils and pulse
Fig. 9. Heart compression (pressure point). Check the reaction of the pupils. If the pupil’s
contract when exposed to light, this is a sign tha1

•l
•I

a. Airway WHO 861571?

Fig. 10. Two-rescuer heart compression and artificial respiration. WHO 861572?
Five chest compressions:
at a rate of 60 per minute
no pause for ventilation. Fig. 11. One-rescuer artificial respiration and
One respiration: heart compression.
after each 5 compressions Fifteen chest compressions:
interposed between compressions. - at a rate of 80 per minute.
Two quick lung inflations.

12

I
 CHAPTER 1: FIRST AID

the brain is receiving adequate oxygen and Other indicators of this effectiveness are:
blood. If the pupils remain widely dilated and do ■ expansion of the chest each time the operator
not react to light, serious brain damage is likely blows air into the lungs.
■ a pulse that can be felt each time the chest is
to occur soon or has occurred already. Dilated
but reactive pupils are a less serious sign. compressed.
■ return of color to the skin.
The carotid (neck) pulse (see Fig. 2, page 3) ■ a spontaneous gasp for breath.
should be felt after the first minute of heart ■ return of a spontaneous heartbeat.
compression and artificial respiration, and every
five minutes thereafter. The pulse will indicate
the effectiveness of the heart compression or the
return of a spontaneous effective heartbeat.

Summary of points to be remembered when applying artificial

respiration and heart compression
Do not delay Place victim on his back on a hard surface.

Step A. Airway - If patient is unconscious, open the airway; thereafter make sure
it stays open.

■ Lift up neck.
■ Push forehead back.
■ Clear out mouth with fingers.

Step B. Breathing - If patient is not breathing, begin artificial respiration.

Mouth-to-mouth or mouth-to-nose respiration.
■ Before beginning artificial respiration, check carotid pulse in neck. It
should be felt again after the first minute and checked every five minutes
, thereafter.
■ Give four quick breaths and continue at a rate of 12 inflations per minute.
■ Chest should rise and fall. If it does not, check to make sure the victim's
head is tilted as far back as possible.
■ If necessary, use fingers to clear the airway.

Step C. Circulation - If pulse is absent, begin heart compression. If possible, use

two rescuers. Do not delay. One rescuer can do the job.
■ Locate pressure point (lower half of sternum).
■ Depress sternum 4-5 cm, 60 to 80 times per minute.
■ If one rescuer - 15 compressions and two quick inflations.
■ If two rescuers - 5 compressions and one inflation.
Pupils of eyes should be checked during heart compression. Constriction
of a pupil on exposure to light shows that the brain is getting adequate
blood and oxygen.

13
 ELEMENTARY FIRST AID: COMPENDIUM

Terminating heart compression encouraged to lie quietly; and treated for shock
Deep unconsciousness, the absence of spon- (see page 17).
taneous respiration, and fixed, dilated pupils for Fluids should not be given by mouth when internal
15-30 minutes indicate cerebral death of the injury is suspected.
victim, and further efforts to restore circulation
and breathing are usually futile.
In the absence of a physician, artificial respira- Control
tion and heart compression should be continued
until: Bleeding may be controlled by direct pressure,
■ the heart of the victim starts beating again and elevation, and pressure at pressure points. A
breathing is restored. tourniquet should be applied only when every
or other method fails to control the excessive bleed.
■ the victim is transferred to the care of a doctor mg.
or of other health personnel responsible for
emergency care. Direct p.,reassure
or
■ the rescuer is unable to continue because of The simplest and preferred method of control
fatigue. ling severe bleeding is to place a dressing over
the wound and apply pressure directly to the
bleeding site with the palm of the hand (see
Severe bleeding Fig. 12). Ideally a sterile dressing should be
The human body contains approximately 5 liters applied; otherwise, the cleanest cloth available
of blood. A healthy adult can lose up to half a should be used. In the absence of a dressing or
litre of blood without harmful effects, but the cloth, the bare hand may be used until a dressing
loss of more than this can be threatening to life. is available. If the dressing becomes soaked with
blood, another dressing should be applied over
Haemorrhage from major blood vessels of the the first one with firmer hand pressure. The
arms, neck, and thighs may occur so rapidly and initial dressing should not be removed because
extensively that death occurs in a few minutes. this will disturb the clotting process.
Hemorrhages be controlled immediately to
prevent excessive loss of blood. A pressure bandage can be applied over the
dressing area to hold the dressing in place (see
meeting may occur externally following an in- Fig. 13). The bandage should be tied over the
I jury to the outside of the body, or internally dressing to provide additional pressure.
from an injury in which blood escapes into tissue
spaces or the body cavity.
The signs and symptoms of excessive loss of
blood are: weakness or fainting; dizziness; pale.
moist. and clammy skin; nausea; thirst; fast,
weak. and irregular pulse; shortness of breath;
dilated pupils; ringing in the ears; restlessness;
and apprehension. The patient may lose con-
sciousness and stop breathing. The number of
symptoms and their severity are generally related
to how fast the blood is lost and in what amount.
Once the bleeding has been controlled. the pa-
tient should be placed in a reclining position,
Fig. 12. Applying direct pressure to a wound.

14
 CHAPTER 1: FIRST AID

Do not cut off the circulation. A pulse should be technique reduces the circulation to the wound ed
felt on the side of the injured part away from the part below the pressure point, it should be

heart. If the bandage has been applied properly, applied only when absolutely necessary and only
it should be allowed to remain in place until the severe bleeding has lessened. There are
undisturbed for at least 24 hours. If the a large number of sites where the fingers may be
dressings are
not soaked with blood and the circulation applied to help control bleeding (see Fig. 14).
beyond the pressure dressing is adequate, they However, the brachia} artery in the upper arm
need not be changed for several days. and the femoral artery in the groin are those
where pressure can be most effective.
Elevation
When there is a severely bleeding wound of an The pressure points for the brachia} artery is
extremity or the head, direct pressure should be located midway between the elbow and the arm
applied on a dressing over the wound with the pit on the inner arm between the large muscles.
affected part elevated. This elevation lowers the To apply pressure, one hand should be round
blood pressure in the affected part and the flow the patient's arm with the thumb on the outside
of blood is lessened. of the arm and the fingers on the inside. Pressure
is applied by moving the flattened fingers and
the thumb towards one another. The pressure
Pressure points
point for the femoral artery is located on the front
When direct pressure and elevation cannot con- of the upper leg just below the middle of the
trol severe bleeding, pressure should be applied crease of the groin. Before pressure is applied,
to the artery that supplies the area. Because this the patient should be turned on his back.
Pressure

15
ELEMENTARY FIRST AID: COMPENDIUM

Anterior and posterior tibial a. Popliteal a.

Fig. 14. Pressure points (arteries).

16
 CHAPTER 1: FIRST AID

should be applied with the heel of the hand

while keeping the arm straight.

Tourniquet
A tourniquet should be applied to control bleed-
ing only when all other means have failed. Un
like direct hand pressure, a tourniquet shuts off
all normal blood circulation beyond the site of
application. Lack of oxygen and blood may lead
to the destruction of tissue, possibly requiring
amputation of a limb. Releasing the tourniquet
periodically will result in loss of blood and dan
ger of shock. If the tourniquet is too tight or too
narrow, it will damage the muscles, nerves, and
blood vessels; if too loose, it may increase blood
loss. Also, there have been cases where tourni-
quets have been applied and forgotten. If a
tourniquet is applied to save a life, immediate
RADIO MEDICAL ADVICE must be obtained.
A tourniquet must be improvised from a wide
band of cloth. An improvised tourniquet may be
made from folded triangular bandages, clothing,
or similar. material.
Fig. 15 shows how to apply a tourniquet, and
how to secure it with a piece of wood. Record
the time the tourniquet was applied. If you are
sending the casualty to hospital, attach a sheet
of paper to his clothing or an extremity,
indicating this time.
Note
■ Never cover the tourniquet with clothing or
bandages or hide it in any way.
• Never loosen the tourniquet unless a
physician advises it.

Shock
Shock following an injury is the result of a de
crease in the vital functions of the various organs
of the body. These functions are depressed be
cause of inadequate circulation of blood or an
oxygen deficiency.
Shock usually follows severe injuries such as
extensive burns, major crushing injuries (par-
ticularly of the chest and abdomen), fractures of
large bones, and other extensive or extremely

17
 ELEMENTARY FIRST AID: COMPENDIUM

painful injuries. Shock follows the loss of large and head. The legs should not be elevated if
quantities of blood; allergic reactions; poisoning there is injury to the head, pelvis, spine, or
from drugs, gases, and other chemicals; alcohol chest, or difficulty in breathing.
intoxication; and the rupture of a stomach ulcer.
It also may be associated with many severe ■ Keep the patient warm, but not hot. Too much
illnesses such as infections, strokes, and heart heat raises the surface temperature of the
attacks. body and diverts the blood supply away fro111
vital organs to the skin.
In some individuals the emotional response to
trivial injuries or even to the mere sight of blood ■ Relieve pain as quickly as possible. If pain is
is so great that they feel weak and nauseated and severe, IO mg of morphine sulfate may be
may faint. This reaction may be considered to be given by intramuscular injection. If the blood
an extremely mild form of shock which is not pressure is low, morphine sulfate should not
serious and will disappear quickly if the patient be given because it may cause an additional
lies down. drop in the pressure. Also, it should not be
given to injured patients unless pain is severe.
Severe shock seriously threatens the life of the The dosage should be repeated only after ob-
patient. taining RADIO MEDICAL ADVICE.
Signs and symptoms of shock are: ■ Administer fluids. Liquids should not be given
■ Paleness. The skin is pale, cold, and often by mouth if the patient is unconscious,
moist. Later it may develop a bluish, ashen drowsy, convulsing, or about to have surgery.
colour. If the patient has dark skin, the colour Also, fluids should not be given if there is a
of mucous membranes and nail beds should puncture or crush wound to the abdomen, or
be examined. a brain injury. If none of the above conditions
■ Rapid and shallow respirations. Alternatively is present, give the patient a solution of oral
breathing could be irregular and deep. rehydration salts (half a glass every 15 minutes).
■ Thirst. nausea, and vomiting. These frequently Alcohol should NEVER be given.
occur in a hemorrhaging patient in shock. The intravenous administration of fluids is
■ Weak and rapid pulse. Usually, the pulse rate is preferable in the treatment of shock if a person
over I 00. trained to administer them is available (see page
■ Restlessness. excitement, and anxiety. These 117). Dextran (60 g/litre, 6%) and sodium
occur early, later giving way to mental dull chloride (9 g/litre, 0.9%) solution (injection)
ness, and still later to unconsciousness. In this may be given intravenously.
late stage the pupils are dilated, giving the
patient a vacant, glassy stare. In a case of suspected shock, get RADIO
MEDICAL ADVICE.
Although these symptoms may not be evident,
all seriously injured persons should be treated
for shock to prevent its possible development. Clothing on fire
If someone's clothing is on fire, by far the best
Treatment way to put the fire out is to use a dry-powder fire
■ Eliminate the causes of shock. This includes extinguisher at once. If a dry powder extinguisher
controlling bleeding, restoring breathing, and is not available, then lay the person down and
relieving severe pain. smother the flames by wrapping till in any
available material, or throw bucketsful of water
■ Have the injured person lie down. The patient over him, or use a hose, if available. Make sure
should be placed in a horizontal position. The that all shouldering clothing is extinguished.
patient's legs may be elevated approximately
30 cm to assist the flow of blood to the heart

18
 CHAPTER 1: FIRST AID

Note. The powder from a fire extinguisher will Send for help.
not cause much, if any, eye damage. Most
When the casualty is breathing, cool any burnt
people shut their eyes tightly if sprayed with
areas with cold water and apply a clean, dry,
powder. Any powder in the eye should be
non-fluffy covering to these areas.
washed out immediately after the fire has been
extinguished and while burns are being cooled. The treatment for electrical burns is the same as
for thermal burns (see page 80). It includes relief
of pain, prevention and treatment of shock, and
Heat burns and scalds control of infection.
All heat burns should be cooled as quickly as Electrical burns may be followed by paralysis of
possible with running cold water (sea or fresh), the respiratory center, unconsciousness, and in
applied for at least ten minutes, or by immersion stunt death.
in basins of cold water. If it is not possible to
cool a burn on the spot, the casualty should be Chemical splashes
taken to a place where cooling can be carried Remove contaminated clothing. Drench casualty
out. Try to remove clothing gently but do not with water to wash the chemical from the
tear off any that adheres to the skin. Then cover eyes and skin. Give priority to washing the eyes
the burned areas with a dry, non-fluffy dressing which are particularly vulnerable to chemical?
, larger than the burns, and bandage in place. splashes. If only one eye is affected, incline the
For further advice on classification, treatment, head to the side of the affected eye to prevent the
and prognosis in burns, see Burns and scalds chemical from running across into the other eye.
(page 80). For further advice on treatment, see Skin con
, In cases of severe burns followed by shock (see tact and Eye contact (page 56) in Chapter
page 17), obtain RADIO MEDICAL ADVICE Toxic hazards of chemicals.
as soon as possible.
Fractures
A fracture is a broken bone. The bone may be
Electrical burns and broken into two or more pieces, or it may have a
electrocution linear crack. Fractures are described as closed if
: Make sure you do not become the next casualty the skin remains unbroken. If there is a wound
when approaching any person who is in contact at or near the break, it is said to be an open
with electricity. If possible, switch off the cur fracture (see Fig. 16).
rent. Otherwise insulate yourself before ap- Careless handling of a patient may change a
proaching and touching the casualty, by using simple fracture into a compound one, by forcing
rubber gloves, wearing rubber boots, or stand- jagged bone-ends through intact overlying skin.
ing on an insulating rubber mat. Compound fractures accompanied by serious
Electrical lines may be removed from the casu- bleeding are likely to give rise to shock (see page
alty with a wooden pole, a chair, an insulated 17), especially if a large bone is involved.
cord, or other non-metal object. The following are indications that a bone is very
Then check casualty immediately for breathing probably broken:
and heartbeat.
■ The fact that a heavy blow or other force has
been applied to the body or limbs.
If casualty is not breathing, give artificial
respiration (see page ■ The casualty himself, or other people, m
8).
have heard the bone break.
If heart has stopped, apply heart compression ■ Intense pain, especially on pressure or
(see page 9). Movement at the site.

19
ELEMENTARY FIRST AID: COMPENDIUM

Swelling almost always occurs immediately and

discoloration of the skin may follow. '

General treatment
RADIO MEDICAL ADVICE should be sought early
in the case of a compound fracture or a severe type of
fracture (skull, femur, pelvis spine) because it might
be necessary to evacuate the patient from the ship.
Unless there is an immediate danger of further injury,
the . patient should not be moved until bleeding is
controlled and all fractures are im. mobilized by
splinting.

Bleeding
Bleeding from open fractures should be stopped in
the normal way by pressing the area the blood comes
from and applying a dressing. Blood will not come
from the broken bone-end but from around the break.
Simple Compound Care must be exercised in lifting up the affected part
if it is broken, but it should always be elevated if
Fig. 16. Types of fracture.
bleeding is severe. People can die from loss of blood;
they will not die from a broken bone, although
moving it may be painful. Rest is very important to
• Distortion. Compare good with injured limb prevent further bleeding, to prevent further damage,
or side of the body to see if the affected and to relieve pain.
part is swollen, bent, twisted, or shortened.
• Irregularity. The irregular edges of a If bleeding is well controlled, the wound can be
broken bone can sometimes be seen in an treated. The area round it should be cleansed
open frac true. They may be seen or felt thoroughly with soap and water and then disinfected
under the skin in a closed fracture. with 1 % (l0g/litre) cetrimide solution. Surface
• Loss of use. The casualty may be washings should not be allowed to spill into the
unable or unwilling to use the injured part wound. The wound itself should not be washed. It
because of the pain. He may also experience should be covered with a sterile dress·
severe pain if an attempt, even a very ing. Particles of dirt and pieces of clothing,
gentle one, is made to help him move it. wood, etc. should be gently removed from the
wound with sterilized forceps. Blood clots should
Watch his face for signs of pain. not be disturbed, as this may cause fresh bleeding.
Occasionally, if the broken ends of a bone The wound should not be sutured. Dressings on it
are impacted together, the patient may be should be allowed to remain in place 4-5 days (if
able to use the affected part but usually there is no wound infection).
only with a fair amount of pain.
• Unnatural movement and grating of bone- Pain
ends. Neither of these symptoms should be
If the patient is in severe pain, 10 mg of mor· phone
sought deliberately. A limb may feel limp
sulfate may be given by intramuscular injection.
and wobbly, and grating may be felt when
Before repeating the dosage, RADIO MEDICAL
an attempt is made to apply support to the
ADVICE should be obtained.
limb. Either of these indicates that the bone
is certainly broken.
• Swelling. The site may be swollen and/or
bruised. This may be due to internal
bleeding.

20
 CHAPTER 1: FIRST AID

Car should be taken not to aggravate pain by Inflatable splints may be used when a patient is

moving or roughly managing the injured being transported about the ship or during re
part.
oval to hospital. They should not be left in place

Immobilization for more than a few hours. Other means of im

mobilizing the fracture should be used after that
Inflatable splints are a useful method for tem- period.
porarily immobilizing limb fractures but a e un
Immobilize a limb in the position in which it is
suitable for fractures that are more than a short
found if it is comfortable. If it does become
distance above the knee or elbow, as they cannot necessary to move an injured limb because of
'provide sufficient immobilization in these places.
The splint is applied to the limb and inflated by poor circulation or for any other reason, first
mouth (see Fig. 17). Other methods of inflation apply traction by pulling the limb gently and
can make the splint too tight and thus slow firmly away from the body before attempting to
down or stop the circulation. Inflatable splints move it.
can be applied over wound dressings. If a long bone in the arm or leg has been frac
Th splints are made of clear plastic through tured, it should be straightened carefully.
:htch any bleeding from the wound can easily Traction should be applied on the hand or the
foot
e seen. All sharp objects and sharp edges must and the limb moved back into position (see
be kept well clear of inflatable splints to avoid Fig. 1'8). Compound fractures of joints, such as the
Puncture. elbow or knee, should not be manipulated.
· They should be placed gently into a proper
position for splinting. The knee should be
provide adequate stability, the splint should splinted
long enough to extend beyond the joints
straight. The elbow should be splinted at a
end of the fractured bone. angle.

21
ELEMENTARY FIRST AID: COMPENDIUM

Fractures of specific body areas

/
j
Skull
A fracture of the skull may be caused by a fall
a direct blow, a crushing injury, or a penetrating
injury such as a bullet wound. The patient may
be conscious, unconscious, or dizzy, and have a
headache or nausea. Bleeding from the nose,
ears, or mouth may be present; and there may be
paralysis and signs of shock.
Treatment. The patient with a head injury
should receive immediate attention to prevent
additional damage to the brain. The patient
should be kept lying down. If the face.is flushed,
the head and shoulders should be elevated
slightly. If the face is pale, the head should be
kept level with the body or slightly lower. Bleed
ing can be controlled by direct pressure on the
temporal or carotid arteries. The patient should
Fig 18. Straightening a fractured limb. be moved carefully with the head supported on
each side with a sandbag.
Circulation of the blood
Check and re-check the circulation of blood in a Morphine sulfate should never be given.
fractured limb by pressing on a nail. When cir-
culation is normal, the nail becomes white when
pressed and pink when released. Continue until
you are satisfied that all is well. Danger signs are: Upper jaw
■ blueness or whiteness of fingers and toes.
■ coldness of the parts below the fracture. In all injuries of the face, ensuring an adequate
airway must be the first consideration (see Air
■ loss of feeling below the injury (test for this by
way, page 7).
.touching casualty lightly on fingers or toes
and asking him if he can feel anything). Treatment. If there are wounds, bleeding should
■ absence of pulse. be controlled. Loose teeth should not be re
moved without RADIO MEDICAL ADVICE,
If there is any doubt at all about the circulation,
unless it is feared that they will be swallowed or
loosen all tight and limb-encircling dressings at
block the airway.
once and straighten out the limb, remembering
to use traction when doing so. Check the circula-
tion again. If the limb does not become pink and Lower jaw
warm and you cannot detect a pulse, then medical
help is probably urgently necessary if amputation A fracture may cause a deformity of the jaw,
is to be avoided. Get RADIO MEDI CAL missing or uneven teeth, bleeding from the
ADVICE. gums, swelling, and difficulty in swallowing.
Remember that fractures may cause serious Treatment. The injured jaw may interfere with
blood loss internally. Check and take the appro- breathing. If this occurs, the jaw and tongue
priate action (see Internal bleeding, page 40, and should be pulled forward and maintained in that
Severe bleeding, page 14). position. A problem arises when both sides of the

22
 CHAPTER 1: FIRST AID

. ware broken. In this case the jaw and tongue

:
Jay moves backwards and obstruct the air pas
: es. Hook a finger - yours or the casualty's
_ over and behind the lower front teeth and pull
the jaw, and with it the tongue, forward. Th n,
·r possible, arrange for the casualty to sit up with
is head forward. Clenching the teeth may also
stop further slippage. If the casualty cannot be
put in a sitting position on account of other
injuries, he must be placed in the unconscious
position ano t h e r person must stay with him,
keeping the Jaw pulled forward, if necessary, and
watching carefully for any sign of obstructed
breathing. Normally, jaw fractures give little
trouble because the casualty sits with the teeth
clenched, often refusing to speak much on ac
count of pain. The spasm in the jaw muscles
which is caused by pain keeps the teeth clenched
and the jaw immobilized.
Application of cold compresses may reduce the
swelling and pain. The patient's jaw must be
immobilized not only by closing his mouth as
much as possible but also by applying a bandage
(see Fig. 19). If the patient is unconscious or
bleeding from the mouth, or if there is danger of
vomiting, an attendant must be present at all
times to loosen the bandage if necessary.
Treat for pain (see page 20).

tenderness at the fracture site, and obvious

Collar bone, shoulder blade,
deformity may be present. The patient may be
and shoulder unable to lift his arm or to bend his elbow.
Fractures in these areas are often the result Treatment. A full-arm, inflatable air splint
either of a fall on the outstretched hand or a should be applied to the fracture (see Fig. 17). If
fall
on the shoulder. Direct violence to the affected inflatable splints are not available, the arm
parts are a less common cause. Place loose should be placed in a sling, with the sling and
pad ding about the size of a fist into the armpit. arm secured to the body by a wide cravat
Then tie the arm to the body. A convenient bandage (see Fig. 20). A short, padded splint, ap
way of doing this is to use a triangular sling plied to the outer surface of the arm, may also be
(see Fig. 20). Keep the casualty sitting up as he used (see Fig. 21). The elbow should not be bent,
will be most comfortable in this position. if it does not bend easily. Long, padded splints
should be applied, one to the outer surface
Upper arm (humerus) another to the inner surface of the arm. If there
and the elbow is any possibility that the elbow participates in the
Complications may occur in fractures of the fracture, the joint should be immobilized with a
splint (see Fig. 22).
humerus because of the closeness of the nerves
and blood vessels to the bone. There is pain and Treat for pain (see page 20).

23
ELEMENTARY FIRST AID: COMPENDIUM

Fig. 20. Applying a sling and cravat bandage.

24
 CHAPTER 1: FIRST AID

•
•

a. Elbow bending easily b. Elbow not bending easily

Fig. 21. Splinting a fractured humerus.

Lower arm (radius and ulna) Fig. 23). If necessary, a splint may be
or forearm improvised using, e.g., a magazine.
There are two large bones in the forearm, and Treat for pain (see page 20).
either one or both of these may be broken.
When only one bone is broken, the other acts Wrist and hand
as a splint and there may be little or no
deformity. However, a marked deformity may A broken wrist is usually the result of a fall
be present in a fracture near the wrist. When with the hand outstretched. Usua11y there is a
both bones are broken, the arm usually appears lump like deformity on the back of the wrist,
deformed. along with pain, tenderness, and swelling.
Treatment. The fracture should be straightened A fracture of the wrist should not be manipulated
carefully by applying traction on the hand (see or straightened. In general, it should be
Fig. 18, page 22). managed like a fracture of the forearm.
A half-arm, inflatable air splint should be ap The hand may be fractured by a direct blow or
plied to the fracture (see Fig. 17). If inflatable may receive a crushing injury. There may be
splints are not available, two well-padded splints pain, swelling, loss of motion, open wounds, and
should be applied to the forearm, one at the top broken bones. The hand should be placed on a
and one at the bottom (see Fig. 23). The splints padded splint which extends from the middle of
should be long enough to extend from beyond the lower arm to beyond the tips of the fingers.
the elbow to the middle of the fingers. The hand A firm ball of gauze should be placed under the
should be raised about 10 cm higher than the fingers to hold the hand in a cupped position.
elbow, and the arm supported in a sling (see

25
ELEMENTARY FIRST AID: COMPENDIUM

a. Straight position b. Bent position

Fig. 22. Dislocated or fractured elbow.

Roller gauze or elastic bandage may be used to Finger

secure the hand to the splint (see Fig. 24). A m
and hand should be supported in a sling (see Fig. Only the fractured finger should be immobilized,
20). Often, further treatment is urgent, regardless and the mobility of the other fingers should be
of the severity of the injury, to preserve as much maintained. The finger should be straightened
of the function of the hand as possible. RADIO ?Y grasp ng the wrist with one hand and apply
mg traction to the fingertip with the other. The
MEDICAL ADVICE should be obtained. finger should be immobilized with a splint (see
Treat for pain (see page 20). Fig. ). The patient should be examined by a
phys1c1an as soon as possible.

26
 CHAPTER 1: FIRST AID

b. Magazine

C. Jacket Flap

D. Shirt tail

Fig. 23. Splinting a fractured forearm.

27
ELEMENTARY FIRST AID: COMPENDIUM

Falls from a height ar e t h e likeliest cause of

Firm ball of gauze
spinal injury at sea. Always suspect a fracture of
the spine if a person has fallen a distance of over
two meters. Ask if there is any pain in the back.
Most people with fractures of the spine have
pain, but a very few do not. So, check carefully
how the injury happened and, if in doubt, treat
. it as a fractured spine. First ask the casualty to
Padded splint Roller gauze or elastic bandage
move his toes to check whether or not he has
paralysis and check also that he can feel you
Fig 24 Splint for crushed or fractured hand. touching his toes.
A casualty who has a fractured spine must be
kept still and straight. He must never be bent or
jackknifed by being picked up under the knees
and armpits. He can, however, be safely rolled
Spine over (see Fig. 26) on to one side or the other,
because, if this is done gently, there is very little
A FRACTURED SPINE IS POTENTIALLY movement of the spine. The aim in first aid will
A VERY SERIOUS INJURY. IF YOU SUS be to place the casualty on a !lard flat surface
PECT A FRACTURED SPINE TELL THE where his spine will be fully supported and to
CASUALTY TO LIE STILL AND DO 'NOT keep him like that until X rays can be taken.
ALLOW ANYONE TO MOVE HIM UNTIL
HE IS SUPPORTED ON A HARD FLAT Tell the casualty to lie still immediately you
SU RFACE. Any careless movement of a suspect a fractured spine. If you drag him about
casualty with a fractured spine could damage or or move him unskillfully, you could cause
sever the spinal cord, resulting in permanent permanent paralysis.
paralysis and Joss of feeling in the legs and Tie the feet and ankles together with a figure-of
double incontinence for life. eight bandage and get the casualty lying still and

a.

Fig. 25. Dislocated or fractured finger.

28
 CHAPTER 1: · FIRST AID

Fig. 27. A patient with a fractured spine (or pelvis) immobilized on a wooden board.

Fig. 26. Rolling a patient on to his side.

ELEMENTARY FIRST AID: COMPENDIUM

Rolled blanket

Two pads to support and fill the hollows of the spine

Fig. 28. Lifting a patient with a spine fracture using a and stretching the blanket under him (attendants C, blanket rolled up at the edges on eithe
straight both by using traction (attendants A and 8)

straight. Use traction on the head and on the feet very carefully (see Fig. 26) on to a blanket
to straighten him out. Do not fold him. Take spread out flat. Then roll up both edges of the
your time. He can now lie safely in this position blanket very tightly and as close as possible to
for as long as is necessary. So do not be in a the casualty. Prepare a stretcher, stiffened with
hurry to move him. Prepare a stiff supporting wooden boards. Two pads must be provided to
stretcher. A Neil-Robertson or basket stretcher support and fill the hollows of the spine, which
will do. A canvas stretcher will not do unless it are in the small of the back and behind the
has stiff wooden boards laid transversely over neck. The back pad should be larger than the
the canvas to provide a rigid support for the neck pad (see Fig. 28).
back. There may be a need to stiffen some
models of the Neil-Robertson stretcher. Now prepare to lift the casualty. Have at least
two people grasping each side of the blanket,
If a Neil-Robertson stretcher is not available, a
and one person at the head and one at the feet to
wide wooden board may be used for immolation
apply traction. Those lifting the blanket should
of the patient, as shown in Fig. 27. This
be spaced so that more lifting power is available
improvised method of immobilization may also
at the body end which is heavy compared with
be used in a case of suspected pelvic fracture. the end bearing the legs. A further person is
Another method of lifting a patient with a spine required to push the prepared stretcher under
injury is shown in Fig. 28. First, roll the casualty the casualty when he is lifted.

30
 CHAPTER 1: FIRST AID

Begin by applying traction to the head and feet.

pull under the jaw, under the back of the head,
and around the ankles. When firm traction is
being applied, lifting can commence slowly.
Lift the casualty very slowly and carefully to a
height of about half a metre, i.e., just enough to
slip the stretcher under the casualty. Be careful,
take time, and keep the casualty straight.
Slide the stretcher between the legs of the person A. Field a newspaper so that the height is the distance from the chin
who is applying traction to the ankles. Then
move the stretcher in the direction of the head,
continuing until it is exactly underneath the
casualty. Adjust the position of the pads to fit
exactly under the curves in the small of the back
and neck.
Now lower the casualty very, very slowly on to
the stretcher. Maintain traction until he is rest
ing firmly on the stretcher.
8. Put the newspaper collar around the neck
The casualty is now ready for removal. ,If he with the center of the paper to the front of
the neck.
has to be placed on any other surface, that
surface must be hard and firm and removal
precautions must be as described above, with
plenty of people to help and with traction on
the head and feet during removal.
As there will be so many people helping and it
is important to manage the casualty with great
care, it may be useful to have someone read WHO 861590?
C. Fix the newspaper collar with an encircling tie.
out the
relevant instructions before each operation are
conducted. , Fig. 29. An improvised neck collar.

See Stroke and paralysis (page 231) for further

advice on how to treat a patient with an injury
to the spinal cord.

: Neck straight. A neck collar should then be applied

Injuries to the neck are often in the form of gently to stop movement of the neck while an
compression fractures of the vertebrae, due for assistant steadies the head. An improvised neck
example to the victim standing up suddenly and collar can be made quite easily from a news
bumping his head violently or to something fall paper. Fold the newspaper so that the width is
ing on his head. Falls from a height can also about IO cm at the front. Fold the top edge over
produce neck injuries. Treatment is similar to to produce a slightly narrower back. Then tie
that described above for fractures of the spine, this around the neck with the top edge under the
because the neck is the upper part of the spine. chin and the bottom edge over the top of the
collar bones. Tie a bandage, scarf, or necktie
The casualty should be laid flat, if not already in over the newspaper to hold it in place. This will
this position and should be kept still and keep the neck still (Fig. 29).

31
 ELEMENTARY FIRST AID: COMPENDIUM

Chest If nothing else is available, use the casualty's

own bloodstained clothing to plug the wound
Injuries to the ribs are often the result of falling temporarily.
against a sharp or angled edge. Serious injuries
The usual rules about stopping bleeding by
can result from heavy blows on the chest or from
pressing the point where the blood comes from
falls from a height.
also apply. In all cases of chest injury, a pulse
Sharp pain due to broken ribs may be felt, the chart should be started at an early stage in order
pain becoming stronger in time with the move to check on possible internal bleeding. The res
ments of breathing. The lung may be damaged; piratory rate should also be recorded.
this· may be shown by the casualty coughing up Conscious chest-injury casualties should be
bright red blood that is usually frothy. placed in a seated position because this makes
1
If there is an open wound (a sucking wound) of breathing easier. If the casualty cannot sit up, he
· the chest, this must be sealed immediately, should be placed in a half-sitting position, either
other wise air is drawn into the chest cavity and supported by a pillow at the back or leaning
the lungs cannot inflate as the vacuum inside the forward against a pillow over the knees (see
chest is destroyed. A large dressing should be Fig. 31). If possible, the casualty should also lean
applied over the sucking wound. and the dress ing on the injured side to cut down movement on that
and the whole area should be covered with wide side - this will ease pain and help to decrease
sticking plaster to provide an airtight seal (see any internal bleeding in the chest (Fig. 32).
Fig. 30). A useful dressing for a sucking wound Unconscious chest-injury casualties should be
can be made from petroleum jelly on gauze, placed in the unconscious position, lying on the
which is placed over the wound with a layer of injured side. This will cut down movement and
aluminium foil or polythene outside. The hole is so help to prevent bleeding inside the chest. A
then covered, and the dressing bound tightly with head-down tip should also be applied, if pos sible,
a wide sticking plaster. A wet dress ing may also to help to keep the air passage clear by drainage.
be used to provide an airtight seal. If there is frothy blood from the

32
 CHAPTER 1: FIRST AID

Fig. 32. A casualty with a chest injury should be placed leaning towards the

mouth or nose, use a sucker, if possible, or mop

out the blood to keep the air passages clear.

Pelvis
A fracture of the pelvis is usual1y due either to a
fa]) from a height or to direct violence in the
pelvic area. The casualty will complain of pain in
the hip, groin, and pelvic areas and perhaps also
of pain in the lower back and buttock areas.
The ring compression test is useful. Press gently
on the front of both hip bones in a downward
and inward direction so as to compress the pelvic
ring. This wil1 give rise to sharp pain if the
pelvis is broken. Some movement of the pelvic
bones may also be felt if there is a fracture.
If you think that the pelvis may be fractured, tell
the casualty not to pass urine. If he has to pass
urine, keep the specimen and examine it for the
. presence of blood (page I 07).

If the bladder or urethra (the channel from the

bladder to the tip of the penis) is damaged, urine
can leak into the tissues.
Pelvic fractures can cause severe and even life
threatening bleeding into the pelvic and lower
abdominal cavities. So, start a pulse chart
(Fig. 41, page 41) immediately and check for
. concealed internal bleeding (page 40).

33
ELEMENTARY FIRST AID: COMPENDIUM

Fig. 33. Three people lifting a casualty with a fracture of the pelvis.

34
 CHAPTER 1: FIRST AID

Casualties with a fractured pelvis should be A patient with a fractured pelvis may be in shock
lifted with great care (see Fig. 33). If the patient
(see page 17). If necessary. treat him for shock.
has a lot of pain, use the same technique as for but do not place him in a shock position.
a fractured spine (Fig. 28) before putting the
casualty on a stretcher or on a wooden board A long wooden board (see Fig. 27) or rigid
(Fig. 27). Keep the casualty lying in whatever stretcher will provide the necessary support
position is most comfortable to him - on the
back, on one side, or face downwards.
Remember to keep checking . for concealed
internal bleeding (page 40).
35
ELEMENTARY FIRST AID: COMPENDIUM

during transportation. The patient should not be Get RADIO MEDICAL ADVICE.
rolled, because this may cause additional inter nal
damage. A pad should be placed between the A fracture of the neck of the. thigh bone will
patient's thighs, and the knees and ankles ban- produce shortening of the injured leg and cause
daged together, as shown in Fig. 27. the casualty to lie with the whole lower limb
and foot flopped outwards.
Treat for pain (see page 20).
Fractures of the shaft of the thigh bone are usu
Hip to knee ally fairly easy to diagnose.
If you think that the thigh is broken, first pad
A broken thigh bone is a potentially serious between the thighs, knees, legs, and ankles with
injury and will cause significant blood loss. If it folded blankets or any other suitable soft ma-
is combined with other fractures and/or injuries, terial. Then bring the good leg to the broken leg.
then the loss may easily reach a level at which Do this slowly and carefully. Next, bring the feet
blood replacement will become necessary. together. If the attempt to do this causes pain,
There is severe pain in the groin area, and the apply traction gently and slowly and then bring
patient may not be able to lift the injured leg. the feet together. Now tie a figure-of-eight ban-
The leg may appear shortened and be rotated, dage around the feet and ankles to keep the feet
causing the toes to point abnormally outward. together. Next, prepare the splints to immobilize
the hip.
Shock will generally accompany this type of
fracture. A well-padded board splint should be placed
from the armpit to beyond the foot. Another
well-padded splint should be placed on the
inner side of the leg from the groin to beyond
the foot. The splints .should be secured in place
with an adequate number of ties, and both legs
tied together to provide additional support
(see Fig. 34). The patient should be transported
on a stretcher or a long board to a bed in his
quarters or sick bay.
Treat for pain (see page 20).

Knee
A fracture of the knee is generally the result of
a fall or a direct blow. Besides the usual signs of
a fracture, a groove in the kneecap may be felt.
There will be inability to kick the leg forward,
and the leg will drag if an attempt is made to
WHO 861596?
walk.
Fig. 35. Splinting a fractured kneecap. Treatment. The leg should be straightened care
fully (see Fig. 18). A full-leg, inflatable air splint
should be applied. If other types of splints are
used, a well-padded board splint should be ap
plied, with padding under the knee and below
the ankle. The splint should be secured in place
with ties (see Fig. 35).
Treat for pain (see page 20).

36
 CHAPTER 1: FIRST AID

Lower leg (tibia and fibula) fractures, and from the armpit to the ankles for
fractures of the lower leg are common and oc above-the-knee fractures. Pad between the thighs,
cur as a result of various accidents. There is a . knees, legs, and ankles. Then bring both feet
marked deformity of the leg when both bones together as gently as you can, using traction if
are broken. When only one bone is broken, the necessary (page 21).
other acts as a splint and little deformity may be Now tie a figure-of-eight bandage round the feet
present. When the tibia (the bone in the front of and ankles to keep the feet together.
the leg) is broken, a compound fracture is likely
to/occur. Swelling may be present, and the pain The padded splints should now be applied to the
is usually severe enough to require administra- outside of both legs. Tie with enough encircling
tion of morphine sulfate. bandages to keep the splints and the legs secured
Treatment. The leg should be straightened care firmly together. Avoid making any ties over the
site of any break. Then check circulation and
fully, using slight traction (see Fig. 18). A full feeling in the toes as described on page 22. The
leg, inflatable air splint may be applied, if avail casualty should be moved while remaining
able (see Fig. 17). The air splint will assis.t in straight and flat on a stretcher (Fig. 37).
controlling the bleeding if there is a compound
fracture. If other types of splints are used, a Treat for pain (page 20).
padded splint should be applied to each side of
the leg, and another should be placed under Ankle and foot
the
leg. The splints should extend from the middle of
the thigh to beyond the heel (see Fig. 36). A fracture of the ankle or foot is usually caused
Treat for pain (see page 20). by a fall, a twist, or a blow. Pain and swelling
will be present, along with marked disability.
. Both legs Treatment. If available, a half-leg, inflatable air
There may be considerable blood loss if both splint should be applied. If conventional splints
legs are broken. Look for signs of shock (see are applied, the ankle should be well-padded
page 17), and if necessary, give appropriate with dressings or a pillow. The splints, applied to
treatment. each side of the leg, should extend from mid-calf
: to beyond the foot (see Fig. 38).
Prepare well-padded stiffish supports reaching
from the thigh to, the ankles for below-the-knee Treat for pain (page 20).

Pads between thighs, knees, and ankles

Padded splints

37

Fig. 37. Casualty with both legs broken: splinting both legs.
ELEMENTARY FIRST AID: COMPENDIUM

Dislocations
A dislocation is present ·when a bone has been
displaced from its normal position at a joint
(Fig. 39). It may be diagnosed when an injury
occurs at or near a joint and the joint cannot be
used normally. Movement is limited. There is
pain, often quite severe. The pain is made
worse by attempts to move the joint. The
affected area is misshapen both by the
dislocation and by swelling (bleeding) which
occurs around the dis location. Except that there
is no grating of bone ends, the evidence for a
dislocation is very simi lar to that- for a
fracture (page 19). Always remember that
fractures and dislocations can occur together.

First aid
Dislocations can be closed or open. If a wound
is present at or near a dislocation, the wound
should be covered both to stop bleeding and to
help prevent infection. Do not attempt to reduce
a dislocation. A fracture may also be present, in

A. Normal B. DISLOCATED

FIG.39 DISLOCATED SHOULDER

38
 CHAPTER 1: FIRST AID

which case attempted manipulation to reduce

the dislocation can make matters worse.

Prevent movement in the affected area by

suit able immobilization. The techniques for im
mobilization are exactly the same as for frac
tures of the same area(s) (pages I 9-37). Look
Ring-pad
out for impaired circulation and loss of feeling
(see page 22). If these are present, and if you
cannot feel a pulse at the wrist or ankle, try to
move the limb gently into a position in which W/1O 861601

circulation can return and keep the limb in this

position. Look then for a change in colour of the
fingers or toes, from white or blue to pink.
Fig. 40. Ring-pad and bandage.
Transport the casualty in the most comfortable
position. This is usually sitting up for upper limb the edge of the dressing. and the pad is held in
injuries and lying down for lower-limb injuries. place by a bandage. The pad should press on the
For further treatment of dislocations, see blood vessels but not on the foreign body or the
fracture.
Chapter 4, page 82.
A ring-pad can be made by passing a narrow
., Head injuries bandage twice around the fingers_ of one hand .I

to form a ring and then wrapping the remainder

Head injuries commonly result from blows to of the bandage around the ring to form a
the head and from falls, often from a height. doughnut-shaped pad (Fig. 40).
Most preventable deaths from serious head in Blast injuries
juries are the result of obstructed breathing and
breathing difficulties, not brain damage. Apart Explosions produce sudden and violent disturb-
from covering serious head wounds, your attention ances of the air. As a result, men may be thrown
should be concentrated on the life-saving down or injured by falling wreckage. In addition,
measures that support normal breathing and the blast of air itself may strike the body with
prevent obstructed breathing (see Airway, such violence as to cause severe or fatal internal
page 7). This will ensure that the brain gets injuries. There may be blast injuries to more than
sufficient oxygen. In this way, you have a good one part of the body; any combination of injuries
to the following sites may be found.
chance of keeping the casualty alive until he can
have skilled medical aid in a hospital. Get RA DIO Lungs
MEDICAL ADVICE.
Blast can damage the small blood vessels of the
See the section on assessing the significance of a lungs so that bleeding takes place inside the
head injury (page 73) for a fuller discussion of lungs. The patient will be shocked, and he will
the subject. have difficulty in getting his breath. together
In the case of some head injuries or where a with a feeling of tightness or pain in the chest; his
foreign body or a fracture is directly below an face will usually be blue, and there may be
open wound, it may not be possible to control blood-stained froth in his mouth. Carry the
bleeding by pressure. In such circumstances a patient into the fresh air if this is reasonably
ring-pad should be used. A paraffin gauze dress possible. Support him in a half-sitting position
ing is placed over the wound, a suitably sized (see Fig. 31, page 33). Loosen tight clothing.
ring-pad is placed around the wound and over

39
ELEMENTARY FIRST AID: COMPENDIUM

Keep him warm. Encourage him to cough and Internal bleeding can be concealed or visible.
spit out any phlegm. Morphine must not be Bleeding round a broken limb may be concealed
given. Artificial respiration by the mouth-to-mouth but may be detectable because .it causes a swell-
method should be given if breathing fails. ing, the size of which shows the amount of the
bleeding. Bleeding into the chest or abdominal
Head cavities may be revealed if blood is coughed up
Blast injuries to the head are rather like con or is vomited. Stab and puncture wounds can
cussion (page 74). In some cases, there may be cause serious internal bleeding.
paralysis of the limbs due to damage to the The casualty will be shocked. At first, he will be
spinal cord. The patient may be completely un pale, giddy, faint, and sweating. His pulse rate
conscious or extremely dazed. In the latter case and respiration rate will rise. Later his skin will
people may be found sitting about, incapable of become cold, and his extremities will become
moving and taking no notice of what is going on. slightly blue. The pulse will become difficult to
Although often to all outward appearances un feel and very rapid (Fig. 41). The breathing will
injured, they have no energy or will to move. be very shallow. He will complain of thirst and
They are momentarily ""knocked silly" and may nausea, become restless, and complain that he
behave very foolishly. For example, although cannot breathe properly ("air hunger"). These
there may be an easy way of escape from a three signs show that bleeding is still occurring.
sinking ship, they may be too dazed to take it, Later he will cease to complain, lose interest in
or, if one of them should fall, he might drown his surroundings, and become unconscious.
from immersion in only 20 cm of oil ,or water
because he has not the sense to get up. The most important indication of continuing
If patients are unconscious, treat them accord bleeding is a rising pulse and falling blood pres
ingly (page 3). sure. Anyone in whom internal bleeding is sus
pected must therefore have his pulse rate and
lf they are dazed, take them by the hand and blood pressure recorded at fixed and frequent
lead them to safety. Tell them firmly everything intervals, say, every 5-10 minutes. After about
that they must do. Think of them as very small an hour of such recording it should be clear
children. By acting in this manner, you may save whether or not he is bleeding internally. If the
many lives. For example, you may prevent men patient's blood pressure remains about normal,
going down with the ship when they have not the and the pulse rate falls or remains steady, he is
sense to abandon it. not bleeding.
Abdomen People who have concealed internal bleeding
may need a blood transfusion. Get RADIO
Bleeding is caused inside the abdomen by blast
1

MEDICAL ADVICE.
damage to the organs there. Such damage is
usually due to the effects of underwater ex It is -important to keep what blood is available
plosions on men in the sea. Shock and pain in circulating around the lungs and brain. Lay the
the abdomen are the chief signs they may ap pear casualty down with a slight head-down tilt.
sometime after the explosion. For treatment, see Raise the legs to divert the blood out of the legs
Injury to the abdomen (Internal in juries, page towards the brain and lungs. Maintain this
73) and Internal bleeding (below). position when transporting the casualty to the
ship's hospital or to a cabin. If he is restless or
in severe pain, morphine may be given (page
Internal bleeding 305).
Internal bleeding may result from a direct blow
to the body, from strains, and from diseases such Bleeding from the nose
as peptic ulcer. Pinch the soft part of the nose firmly for IO
minutes while keeping the head well forward

40
 CHAPTER 1: FIRST AID

Fig. 41. Hemorrhage: F F i g . 4 1 H e m o r r h a g e the falling temperature and the rising pulse rate.

over a basin or bowl. The pinching is most easily done Instruct the casualty not to blow his nose for the
by the casualty himself. At the end of I 0 minutes, next four hours and to refrain from violent nose
slowly release the pressure and look for drips of blood blowing over the next two days.
in the basin or bowl. Absence of drips will show that
bleeding has stopped (Fig. 42). If bleeding has not stopped. continue pressure on
the soft part of the nose for a further I 0

41
ELEMENTARY FIRST AID: COMPENDIUM

each side to help maintain pressure and stop the

fingers slipping. Pressing is usually most easily
done by the casualty himself under the direction
of another person or with the aid of a mirror
(Fig. 43).

Bleeding from a tooth socket

See Dental emergencies, page 184.
Bleeding from the ear passage
This is usually caused by a head injury or by
blast. Place a large pad over the ear and bandage
it in position. Keep the affected ear downwards.
If the casualty is unconscious, place him in the
unconscious position (see Fig. 3, page 6) with the
affected ear downwards. Never plug the ear
Fig. 42. Bleeding from the nose. Pinch the soft part of passage
the nose firmly with cotton wool or other material. Get
for 10 minutes.
RADIO MEDICAL ADVICE.

Choking
Choking is usually caused by a large lump of
food that sticks at the back of the throat and
thus stops the person concerned from breathing.
The person then becomes unconscious very
quickly and will die in 4-6 minutes unless the
obstruction is removed.
Choking can be mistaken for a heart attack.
The distinguishing features are:
■ the person who is choking may have been seen
to be eating.
■ the person who is choking usually cannot
speak or breathe; this is not the case if the
person is having a heart attack.
■ the person who is choking will turn blue and
lose consciousness quickly because of lack of
oxygen.
■ the victim of a choking incident can signal his
distress (he cannot speak) by grasping his
Fig. 43. Bleeding from the lip. Maintain pressure this way.
neck between finger and thumb. This is
minutes and release slowly again. If bleeding has known as the ''Heimlich sign" and if it is
not stopped after 20 minutes, it may be necessary understood by all personnel the risks involved
to pack the affected side of the nose with strip- in choking should be reduced.
gauze. ff the casualty is conscious, stand behind him,
place your closed fist (thumb side) against the
Bleeding from the lip, cheek, place in the upper abdomen where the ribs di
vide. Grasp the fist with your other hand. Press
and tongue suddenly and sharply into the casualty's
Press on both sides of the lip. cheek, or tongue to
stop bleeding. Use a piece of gauze or a swab on

42
 CHAPTER 1: FIRST AID

abdomen with a hard quick upward thrust. Re

peat several times if necessary (Fig. 44).
For self-treatment, try to cough forcibly while
using your own fist as described above; alter
natively, use the back of a chair, the corner of a
table or sink, or any other projection that can be
used to produce a quick upward thrust to the
upper abdomen.
If the casualty is unconscious, place him on his
back and turn the face to one side. Kneel astride
him and place one hand over the other with the
heel of the lower hand at the place where the ribs
divide. Press suddenly and sharply into the
abdomen with a hard quick upward thrust. Re
peat several times if necessary (Fig. 45). When
the food is dislodged, remove it from the mouth
and place the casualty in the unconscious position
(see Fig. 3, page 6).

Suffocation
(See also: Ventilation, Chapter 15, page 283.)
Suffocation is usually caused by gases or smoke.
Remember that dangerous gases may have no
smell to warn you of their presence. Do not enter
enclosed spaces without the proper precautions.
Do not forget the risks of fire and/or explosion
when dealing with inflammable gases or va
pours.
Fig. 44. Heimlich man oeuvre (rescuer stand­ing and victim standing or sitt
First aid
Get the casualty into the fresh air. If necessary,
· give artificial respiration and heart compression
and place in the unconscious position (see Fig. 3,
page 6).
Administer oxygen (see page 51).

Strangulation
Hanging is one form of strangulation and is
fortunately rare on-board ship. It is not always
deliberate but can be an accident. It is impor tant
to have a clear mental picture of the scene, so
that your evidence is helpful at any later inquiry.
The face in hanging is dark blue from
Fig. 45. Heimlich manoeuvre (rescuer kneeling and victim lying on his bac
interference with blood supply to the head, the
eyes protrude, and the face and the neck are
swollen.

43
ELEMENTARY FIRST AID: COMPENDIUM

Transporting a casualty
The rem6val of a sick or injured person either
from the site of an accident or ashore is a
matter of importance, since his life may
depend on the arrangements made, particularly
if he has spinal injuries, a heart condition, or a
severe fracture, with any of which he is likely
to be suffering from shock. So, use the utmost
gentleness, re assure your patient, try to have a
clear picture in your mind of the nature of the
disability you are dealing with, and exercise
common sense.
Unless there is danger from fire, explosion, or
toxic substances, do not move a casualty until:
Fig. 46. A standard dressing being applied to a wound ■ suspected fractures have been immobilized;
and
■ severe bleeding has been stopped.
Then check out the best route for transport, lift
First aid the casualty gently and carry him smoothly -
I. Cut and remove the noose, while supporting remember that every jolt causes him unnecessary
the body. Loosen all constricting clothing. Give pam.
treatment for unconscious casualty (see page 3). The method of transport will depend on the
situation of the casualty and the nature of the
2. If breathing has ceased,
injury.
start artificial respiration and. if
the heart is not beating, carry If the ship is in port, it is usually best to await the
out heart compression (page 9). arrival of an ambulance because the attendants
When breathing is restored, will be expert in handling casualties. You can
administer oxygen (see page assist them and give them the benefit of your
51). knowledge. For instance, if a patient has fallen
to the bottom of a hold, the best procedure is to
3. Maintain a constant watch on the patient until take down a stretcher, give first-aid treatment,
you are able to hand him over to the care of the then place the stretcher on a hatch cover or
doctor. This is necessary, partly for medical similar flat platform and have the patient lifted
reasons. partly because a suicide attempt might by ship's crane over the side. This lift can be a
be repeated. frightening experience for a helpless and
I
shocked person, and he will be reassured if the
Standard dressing person in charge stands on the hatch cover with-
This consists of a pad of sterilized gauze at legs astride the stretcher, maintaining balance by
tached to a bandage. The pad is near one end of holding on to the guy wires. Similarly, if the
the bandage. It is sterile, i.e., free from germs, so patient is on deck and the gangway is narrow or
do not allow it to touch anything (including your unsteady, it may be far less unnerving for him if
own fingers) before placing it on the wound, as he is lowered over the side on a hatch cover or
shown in Fig. 46. something similar.

Note Manhandling
■ Always select a dressing with a pad larger than Ordinary manhandling may be possible, in which
the wound to be covered.
■ Hold the bandage taut as you put it round the

limb, head, or body, so as to secure the pad case two helpers carry a casualty, with each one
widely and firmly. using an arm to support the casualty's back and

44
 CHAPTER 1: FIRST AID

In a narrow space, the simple fore-and-aji carry

WHO 861610?
may be best. One helper supports the patient
under his arms, and the other under his knees.
Fig. 49. Fireman's lift, third stage.
Other
The methods
helper stretches himself. of manhandling
stands upright are so that h
and shifts the casualty
demonstrated in Fig. 47-55.
One advantage of the three-handed seat (Fig. 50
and 51) is that one of the helpers has a free arm
and hand that can be used either to support an
injured limb or as a back support for the
shoulders and his spare hand to hold the casualty’ casualty. Which of the two helpers has the free
s thighs. If conscious, the casualty may help to arm will depend on the nature of the injury?
support himself with his hands on the shoulders
As a last resort, the drag-carry method may have
of the helpers.
to be used in narrow spaces, particularly where
The simple pick-a-back method is useful only there is wreckage following an explosion and
where the casualty is conscious and able to hold where it may be possible for only one man to
on by putting his arms round the carrier's neck. reach a trapped patient and rescue him. After

45
 ELEMENTARY FIRST AID: COMPENDIUM

a.
WHO 861611?

WHO 861613?

Fig. 51. Three-handed seat.

The spare hand or arm of a helper supports the casualty's injured leg, and the

the initial rescue, two men may be able to

under take further movement through a narrow
space. The method is demonstrated in Fig. 53
b.
and Fig. 54. Ensure that the tied wrists do not
inter fere with any breathing apparatus the
rescuer may be wearing.
NeiI-Robertson stretcher
(Fig. 56)
A number of modifications of this type of
stretcher exist under various names.
A good general-purpose stretcher for use on
board ship, it is easily carried, gives firm
support to the patient, and is particularly useful
in narrow spaces, when difficult corners have
 to be negotiated, or when the patient has to be
hoisted.

Fig. 50. Three-handed seat.

at How the wrists are held.
b Carrying the casualty, his uninjured arm round the shoulder of one of the helpers.

46
 CHAPTER 1: FIRST AID

Fig. 54. Drag-carry manhandling in a confined space, after rescue using dra
The casualty's hands are still strapped together around the helper's neck.

Fig. 52. Four-handed seat.

The stretcher is made of stout canvas stiffened

by sewn-on bamboo slats. The upper portion
takes the head and neck, which are steadied by
a canvas strap passing over the forehead. The
middle portion is wrapped round the chest and
has notches on which the armpits rest. This part
has three canvas straps which are used for fas
tening the stretcher round the chest. The lower
portion folds round the hips and legs down to
the ankles.

If the patient is unconscious, place him on his

back and tie his ankles and feet together with a
figure-of-eight bandage, and his knees with a
Fig. 53. Drag-carry. broad-fold bandage; also, his wrists (Fig. 57).
The helper crawls along carrying the casualty between his legs; the casualty's hands are strapped together around the helper's neck.

47
ELEMENTARY FIRST AID: COMPENDIUM

Fig. 56. The Neil-Robertson stretcher.

with one hand and, with the other, slides the

stretcher under the patient, at the same time
opening out the flaps. When the stretcher is in
Three persons are required to carry out the lift. position, No. I give the order to lower and all
No. I take charge he stands astride the patient's lower together.
legs, with his right hand under the left calf and The stretcher is now strapped up and the patient
his left hand under the right thigh ( Fig. 57). is ready for removal (Fig. 59); this can be done
No. 2 stands astride the chest and clasps his most conveniently with four bearers (Fig. 60).
hands underneath the patient. No. 3 places the
patient's wrists (tied together) round No. 2's The Neil-Robertson stretcher can also be used to
neck. If the patient is conscious, he may remove casualties virtually (Fig. 61).
himself be able to clasp his hands round the
neck of No. 2. The stretcher, with all straps First aid satchels or boxes
unfas tened, should be positioned close to the These should contain iodine solution, a large
head of the patient. If spinal injury is suspected, standard dressing, 2 medium standard dressings,
extreme care should be exercised in moving the 4 small standard dressings, 8 triangular ban
casualty (see page 28). dages, some cotton wool, safety pins, sticking
No. I now give the order to lift, while No. 3 plaster, scissors, and a pencil and paper.
supports the head of the unconscious patient One box should be included in the ship's
medicine locker for swift transfer to the site of an
accident. Others placed at strategic positions,
particularly in a large ship, can be an aid to
prompt action if the crew are made aware of

48
 CHAPTER 1: . FIRST AID

Fig. 57.Transport by Neil-Robertson stretcher. Preparing to lift.

49
ELEMENTARY FIRST AID: COMPENDIUM

Fig. 59. Transport by Neil-Robertson stretcher. The stretcher is strapped up and the patient is ready for removal. The arms can be strapped inside

Fig. 60. Transport by Neil-Robertson stretcher. Patient strapped into stretcher and ready. If neck may be hurt, take great care not to bend it.
50
 CHAPTER 1: FIRST AID

their location and contents. These extra boxes

are, however, liable to be thoughtlessly used for
minor unreported casualties and, in some in
stances, are subject to pilfering. Routine check
ing of their contents is therefore essential.

Emergency medical outfits

There is a special need on merchant vessels, and
on medium-sized and large fishing vessels with
crews numbering over 20, for an emergency
medical outfit readily accessible for use if the
medical cabinet should be destroyed or made
inaccessible by fire. The emergency outfit should
be sited well away from the ship's medical cabi
net or the ship's hospital.

Oxygen administration
(oxygen therapy)
Oxygen is essential to life. It is given for
treatment when the body is unable to get enough
oxygen from the air because of damage to the
lungs or for other reasons, such as suffocation
(see page 43) or carbon monoxide poisoning
(page 58).
Oxygen must be given with care since it can be
dangerous to patients who have had breathing
difficulties for a number of years due to lung
disease, particularly chronic bronchitis.
Oxygen should be given only were advised in
this guide. Usually, it is given to a patient who
is breathing without assistance but is uncon
scious or cyanotic (has bluish skin); also, oxygen
should be given to all patients suffering from
carbon monoxide or other toxic gas poisoning
even when they are conscious.
There are two stages at which a patient may
require oxygen: (I) during rescue from the place
of an accident, and (2) when the patient is in the
ship's sick bay.

During rescue from the place of

mask placed over his face. The oxygen valve
an accident should be turned on and oxygen administered
During this time the patient should be connected until
Fig. 61. the patient stretcher
Neil-Robertson is transferred to thevertically
Moving a casualty ship's sick
to the portable oxygen apparatus through a Note.
bay. To steady the stretcher's movement . d rope goes from the foot of the stre

51
ELEMENTARY FIRST AID: COMPENDIUM

When the patient is in the ship's 2. All other patients should be given 35%
sick bay oxygen, using an appropriately designed
The procedure set out below should be followed. mask, with the flowmeter set at 4 liters per
minute.
The unconscious patient 3. The mask should be placed over the
patient's mouth and nose and secured in
1. Ensure that a clear airway has been estab
place.
lished (see page 7) and an airway (see page 4. The patient should be placed in the high
104) has been inserted.
sitting-up position (see Fig. 31, page 33).
2. Place over the nose and mouth a dispos 5. Check that the equipment is correctly
able mask designed to give 35% oxygen assembled according to the manufac
to the patient. Ensure that it remains se turer's instructions and that the cylinder
curely in place. Check that the equipment contains sufficient oxygen.
is correctly assembled according to the 6. Turn on the oxygen flowmeter at 4 liters
manufacturer's instructions and that the per minute.
cylinder contains sufficient oxygen.
3. Connect the mask to the flowmeter, using Oxygen therapy should be continued until the
the tubing provided, and set the flow meter patient no longer has difficulty in breathing
to 4 liters per minute. Administration of and has a healthy colour.
oxygen should continue until the patient no If the patient has difficulty in breathing, or the
longer has difficulty in breath ing and has face, hands, and lips remain blue for longer
a healthy colour. than 15-20 minutes, he probably has one of the
fol lowing complications: bronchitis (see page
The conscious patient 177), pneumonia (see page 221), circulatory
1. Ask the patient whether he usually suffers collapse in congestive heart failure (see page
from severe difficulty in breathing and a 205), or pulmonary oedema. In such a case, seek
chronic cough, i.e., chronic bronchitis (see RADIO MEDICAL ADVICE.
page 178).
If the patient has severe chronic bron
chitis, then he should be given only 24%
oxygen, using an appropriately designed WARNING. Smoking, naked lights, or fires
mask, with the flowmeter set at 4 liters per must not be allowed in a room where oxygen is
minute. being administered, because of the risk of fire.

52
 Annex 1 joined to one another except for the lower jaw,
which moves at joints just in front of the ears.
Anatomy and The skull rests on the upper end of the back bone,
physiology which is made up of a series of small bones
placed on top of each other. These bones are
Treatment of illness on board ship requires some called vertebrae and collectively compose the
understanding of the anatomy and physiology spinal column, within which is housed the spinal
of the human body. cord: nerves emerge from the cord at the level of
each vertebra. At the lower end of the backbone is
The principal bones and muscles of the body are the pelvis, formed by the hipbones, one on either
shown in Fig. 147 and Fig. 148, the position of side, which together form a basin to sup port the
the main arteries and veins in Fig. 149, and the contents of the abdomen. On the outer side of either
contents of the chest and abdomen in Fig. 150 hip is a cup-shaped socket into which the rounded
and Fig. 151. head of the femur (or thigh bone) fits, forming a
ball-and-socket joint. The
The skeletal system
·femur ends at the knee, where it forms a hinge
The skull forms a case that contains and like joint with the strong tibia (shinbone) which
protects can easily be felt under the skin. On the outer
the brain. It consists of many bones, firmly
53
ELEMENTARY FIRST AID: COMPENDIUM

side of the shinbone is attached the slender tached nearer to one another. The brain controls
fibula. In front of the knee-joint lies the patella such movements.
(kneecap), the shape of which can be easily felt.
At the ankle the foot is joined to the lower ends Involuntary muscles are found in the stomach
of both the tibia and fibula by another hinged and intestines, heart, blood vessels, and other
joint. The foot is made up of many small bones internal organs of the body. As the name indi
of different shapes. There are two bones in the cates, they are not under the influence of the will,
great toe and three in each of the other toes. but function on their own, day and night.
Twelve ribs are attached to the backbone on
either side. Each rib, with the exception of the
two lowermost on either side, curves round the
chest from the backbone to the sternum (breast The circulatory system
bone) in front. As can be seen from Fig. 147, the (heart and blood vessels)
lowermost ribs have no attachment to the ster
num in front. The ribs form the chest and The body contains about five liters of blood,
protect the lungs, heart, and other internal or which circulates to all the tissues of the body
gans. When you take a deep breath, your ribs (Fig. 149). It is kept moving round the body by
move slightly upwards and outwards so as to the heart, a muscular pump about the size of a
expand your chest. The sternum, flat and dag ger- clenched fist situated in the chest behind the
shaped. lies just under the skin of the front of breastbone, lying·between the lungs, rather more
the chest, and to its upper end is attached the on the left than on the right. The heart has two
clavicle (collarbone). On either side this bone sides; the right side receives the venous blood
goes out horizontally to the point of the shoul der coming back to it from the body in general and
and acts like an outrigger in keeping the shoulder pumps it through the lungs, where it passes
in position. The outer end of the collar bone joins through minute tubes, gives up carbon dioxide,
with the scapula (shoulder-blade), which is a and takes up a supply of oxygen. The oxygenated
triangular bone lying at the upper and outer part blood now passes to the left side of the heart,
of the back on either side. Each scapula has a which pumps it to all parts of the body through
shallow socket into which fits the rounded upper the arteries. This blood carries oxygen, food,
end of the humerus (arm bone). At the elbow the water, and salts to the tissues; it is bright red in
arm bone forms another hinge like joint with the colour. It also conveys heat to all parts of the
radius and ulna (the forearm bones). and these body and contains various substances to coun
join with the hand at the wrist. The wrist and teract infections in the tissues. The arteries are
hand. like the foot, are made up of(many small like thick-walled tubes and decrease in diameter
bones. There are two bones in the thumb and away from the heart. In the tissues the smallest
three in each finger. blood vessels are very minute and are called
capillaries. The blood, having supplied the tis
sues with oxygen and other substances and re
moved the carbon dioxide that has accumulated,
The muscular system becomes darker in colour. The capillaries take it
into the veins, thin-walled tubes that carry the
Voluntarr muscles are found in the head. neck. blood back to the right side of the heart.
limbs.Back and walls of the abdomen (
Fig. 148). They are attached to bones by fibrous
Some of the blood passes to the stomach and
tissue which is frequently in the form of a cord
intestines and, having taken up food products,
and is then called a tendon or leader. When a
carries them away to be stored in the liver. Blood
muscle contracts in response to an impulse sent
is also taken by arteries to the kidneys and there
to it through a nerve. it becomes ·shorter and
gets rid of waste products, which are passed in
thicker and draws the bones to which it is at-
the urine.

54
 ANNEX 1: ANATOMY AND PHYSIOLOGY

Sternocleidomastoid
._,,,,,,Trapezius

Deltoid - ­ -- Deltoid
Pectoral ---1, 1:---
Biceps -
Triceps
--'-+--
Latissimus dorsi

Rectus .femoris
Vastus lateralis Vastus medialis

a. Front b. Back

Fig. 148. Major muscles of the body.

As the blood passes along the arteries, they pul

The respiratory system
sate at the same rate as the heart is pumping. The
average normal pulse rate is about 70 per minute,
Every time a breath is taken, the air (containing
but it increases with exercise, nervousness, fear,
oxygen) passes through the nose or mouth and
fever, and various illnesses. The pulse is usually
past the larynx or voice-box into the windpipe.
counted by feeling the artery at the front of the
The windpipe divides into two main tubes called
wrist just above the ball of the thumb.
bronchi, each of which then divides up into

55
ELEMENTARY FIRST AID: COMPENDIUM

56
 ANNEX 1: ANATOMY AND PHYSIOLOGY

people think that it is the ribs moving in and out

that produce the act of breathing. Rib move-
ment does in fact play quite a big part, but the
main work is done by the diaphragm moving up
and down. The diaphragm is a large dome
--------- Pharynx
shaped muscle which separates the chest from
+7"'"-Tongue the abdominal cavity. When the diaphragm
muscle contracts, its dome becomes flattened
and draws down the lungs, causing air to enter
them; when it relaxes, the lungs become smaller
and the air in them is expelled. The muscles of
the abdomen also help in breathing. When they
tighten, they press the abdominal contents
against the diaphragm and help in expelling air
from the lungs, and when they relax, they assist
Pleura
the diaphragm in drawing down the lungs in
breathing in.
The normal rate of breathing at rest is 16 to 18
Pleural space
times a minute, but it increases considerably
with exertion and also with certain diseases,
especially those affecting the heart and lungs.

The digestive system and

abdomen
Fig. 150. Respiratory system. Food in the mouth is broken up by chewing and
tongue movements and mixed with saliva (spit
tle), which lubricates it and starts the digestive
processes. When it is in a suitable state it passes
to the back of the throat, where muscular action
forces it down the oesophagus, or gullet, a
many smaller bronchial tubes that pass into the muscular tube in the neck behind the windpipe.
lung tissue. The air breathed in passes through The gullet runs down the back of the chest
these small tubes into minute air cells called between the two lungs, then passes through the
alveoli. each of which is surrounded by capil-
I

dia phragm into the stomach.

laries. The blood in the capillaries gives up car
bon dioxide and takes up oxygen. In breathing As may be seen in Fig. 151, the stomach lies
out. the air passes back along the same respiratory mainly in the left upper part of the abdominal
passages and is breathed out through the nose or cavity, partly behind the lower left rib cartilages
mouth. and just under the heart. When food enters the
stomach, various digestive juices act upon it,
Each lung is covered by a lubricated membrane and the stomach muscles contract and relax,
called the pleura. The inner side of the chest wall mixing it thoroughly. The capacity of the adult
is lined with the same kind of membrane. These stomach is about one litre.
two layers of pleura are in contact and slide
Still only partly digested, the food passes into
smoothly over one another during breathing.
the small intestine, where more digestive juices,
The lungs are rather like elastic sponges. and the especially those from the liver and pancreas, mix·
many air cells in them expand with breathing in with it. Nourishment and fluids are absorbed
and are compressed with breathing out. Most from this coiled-up tube, which is about six

57
ELEMENTARY FIRST AID: COMPENDIUM

Left lung

Large intestine

Appendix

WHO 87407?

a. Front

Fig 151 Organs of chest and abdomen

58
ANNEX 1: ANATOMY AND PHYSIOLOGY

59
ELEMENTARY FIRST AID: COMPENDIUM

meters long, and the residue of the food passes through the incoming (sensory) nerves and the
into the large intestine, or colon, at a point in the special nerves connected with sight, smell, hear
lower part of the right side of the abdomen, close ing, etc., deciding on the action necessary, then
to where the appendix is situated. In the large sending out orders to the various parts of the
intestine more moisture is extracted from the body by the outgoing (motor) nerves.
food residue. At its far end, the large intestine
joins the rectum, and here the unwanted. food The spinal cord is composed of similar tissue;
residue collects and is passed out of the body by it leaves the under-surface of the brain through
the back passage or anus. an opening in the base of the skull and passes
down a canal in the vertebral column. To
The liver secretes the important digestive juice pursue the analogy with a computer, it contains
called bile (a greenish/brownish fluid) and, on its the trunk lines running between the brain and
surface, has a small reservoir called the gall the various parts of the body and also a number
bladder, where a supply of bile is kept available. of local nerve centers. At intervals down the
The liver also deals with, and stores, digested spinal column, nerve trunks issue from the
food materials. spinal cord containing both motor and sensory
The spleen ( Fig. 151) is a solid oval-shaped fibers; these nerves make contact with the
organ in the upper part of the left side of the· muscles, which they cause to contract, and
abdominal cavity at the back of the stomach, with the skin and other organs, where the
just above the kidney. Its functions are largely sensory messages to the brain and spinal
connected with the blood, and it may be enlarged column start.
in certain diseases.
Autonomic nervous system
The urinary system This is a fine network of nerves which help con-
trol the functions of various organs in the body.
(See Fig. 140, page 236) It, too, has local nerve centers, such as the solar·
plexus, which is situated in the upper part of the
abdomen behind the stomach. Although
The kidneys are at the back of the upper part of connected with certain parts of the brain, it is
the abdominal cavity, one on either side of the not controlled by the will but functions
spine. They remove water and certain waste automatically day and night. It regulates the rate
products from the blood and produce urine. at which the heart pumps, in accordance with
Urine leaves each kidney by a small tube called the demands of the various bodily systems at any
the ureter. the two ureters entering the back of particular time. It also helps control the muscles
the bladder. which is a muscular bag situated in
1

of the stomach and intestine and the rate and

the front part of the cavity of the pelvis. Urine depth of breathing.
collects in the bladder and is expelled from it
through a tube leaving its under-surface. This
tube is called the urethra and in the male is
Skin
contained in the penis. The skin covers and protects the body. It con sists
of two layers. The outer layer is hard, contains no
blood vessels or nerves, and protects the inner
The nervous system layer, where the very sensitive nerve endings lie.
The nervous system consists of the brain, the The skin contains numerous sweat glands, the
spinal cord. and the nerves that issue from roots of the hair, and special glands that lubricate
them. The brain. in the cavity of the skull, is a the skin and the hair.
mass of nervous tissue. The coordinating
Sweat consists of water, salt, and other sub
center of the body, it acts like a computer,
stances. Sweating cools the body and helps to
receiving messages
regulate its temperature.

60