MEDICAL CARE PDF Course Material - Applied Research International

MEDICAL CARE COMPILED & EDITED BY:- DR. SUDHA SOOD DR. MALINI KAPOOR Tel.: 91 - 11- 43158500- 85 Fax : 4 3 1 5 8 5 8 8 Vi si t u s at w ww.ari educo m  MEDICAL CARE FOREWORD In...

MEDICAL CARE COMPILED & EDITED BY:- DR. SUDHA SOOD DR. MALINI KAPOOR Tel.: 91 - 11- 43158500- 85 Fax : 4 3 1 5 8 5 8 8 Vi si t u s at w ww.ari educo m  MEDICAL CARE FOREWORD In the sea of learning ARI shines bright as a lighthouse. It attracts seafarers from far and near as a centre for quality education with individual attention to the needs of each student. As our medical department at ARI enters its 18th year of existence, we feel happy with the appreciation and love showered on us by our students, and feel a sense of achievement. Safety at sea is one of the major concerns of ARI, and where safety fails, only then is First Aid required. In spite of so many checklists and protocols to ensure safety, accidents do happen. Also illnesses and infections can occur on board a vessel. To guide the seafarers to prevent and manage these medical emergencies and illnesses, it is with great pleasure and pride that we bring forward this edition of our Medicare handout. A lot of hard work has gone into this manual, to bring you the updated information in an easily readable form with a lot of diagrams for clarity and understanding. It would not have been possible without the help of many friends and colleagues. At the outset, we must thank our mentors, Auntie Rewari, Mr. Shravan and Ms Naomi Rewari for their unflinching trust and confidence in us and their constant guidance and support. At Saket we are always inspired by Capt. P.K. Sharda, Capt. P.K. Mittal and Capt. P. Sarin who listen to our smallest problem, and solve it instantly with a smiling face. At Chhatarpur, Capt Avasthy and Ms Smita have been ever ready to lend us a helping hand. Our sincere gratitude goes to our medical faculty especially Dr Vinita Lal and Dr Ashish Dixit who helped us through all the chapters. Our heartfelt thanks also to the entire team at ARI, for their inputs in various ways. A special thanks to Mr. Khandpur and Mr. Daniel for their inputs on radio medical advice. This course material is proprietary to ARI. Page 1  MEDICAL CARE This book would have been incomplete without the support of dear Vandana, Rajbir, Kunwar and Khem who helped to put it together at various stages and patiently kept formatting every change we made. Finally our biggest thanks to you the reader who is our greatest inspiration to continue aiming to be the best training Institute in India. Your participation, cooperation and feedback have taught us a lot, and helped us to evolve as better teachers and human beings. We hope you never need to give or receive first aid in your lives. Always remember ‗Prevention is better than cure‘. With Warm Regards, Dr Sudha Sood Dr Malini Kapoor This course material is proprietary to ARI. Page 2  MEDICAL CARE MEDICAL CARE (MEDICARE) COURSE Name of The Course MEDICAL CARE COURSE Name of Institute Applied Research International MTI No. 111022 Training Center D-150/S, D Block, Chattarpur Extension, New Delhi- 110074. India Tel : - 91-11- 43158500/85/86/87 Fax: 91-11- 43158588 Email: [email protected] Head of Institute Mrs. A. Rewari Tel: 91-11-43158585 This course material is proprietary to ARI. Page 3  MEDICAL CARE COURSE NAME: MEDICAL CARE VERSION: 1.0 RECORD OF CHANGES DATE: 01.04.2016 RECORD OF CHANGES NATURE OF S. PAGE CHANGE DATE CHAPTER CHANGES / NO. NO. AUTHORISED BY AMENDMENTS 1 12.07.19 3 INDoS No. Changed Director to MTI No. & address (Modular) This course material is proprietary to ARI. Page 4  MEDICAL CARE Contents GENERAL PRINCIPLES..................................................................... 12 FIRST AID...............................................................................................12 ANNEXURE.............................................................................................17 BODY STRUCTURE AND FUNCTIONS................................................ 21 SENSORY ORGANS..................................................................................26 MUSCULOSKELETAL SYSTEM..................................................................28 JOINTS...................................................................................................31 MUSCLES................................................................................................33 CARDIOVASCULAR SYSTEM (CIRCULATORY SYSTEM)...............................37 RESPIRATORY SYSTEM............................................................................42 DIGESTIVE SYSTEM AND ABDOMEN.........................................................47 THE URINARY (EXCRETORY) SYSTEM.......................................................54 IMMEDIATE ACTION....................................................................... 60 INTRODUCTION.....................................................................................60 WOUNDS AND BLEEDING........................................................................60 SHOCK...................................................................................................67 TRANSPORTATION.................................................................................71 DO NOT...............................................................................................102 TOXICOLOGICAL HAZARDS ABOARD SHIP, POISONING................... 103 WAYS OF POISONING BY TOXIC SUBSTANCES........................................103 DIAGNOSIS OF POISONING...................................................................104 POISONING BY INHALATION.................................................................107 OXYGEN BREATHING EQUIPMENT.........................................................109 SWALLOWED POISONS..........................................................................119 SPECIFIC TOXIC SUBSTANCES...............................................................121 PREVENTION OF POISONING.................................................................126 EXAMINATION OF THE PATIENT.................................................... 129 APPROACH TO A CASUALTY OR A PATIENT..........................................129 PHYSICAL EXAMINATION......................................................................134 This course material is proprietary to ARI. Page 5  MEDICAL CARE DIAGNOSING THE DISEASE OR ILLNESS.................................................139 SPINAL INJURIES.......................................................................... 144 SPINAL INJURY......................................................................................144 SIGNS AND SYMPTOMS OF SPINAL INJURY.............................................145 MANAGEMENT OF A SPINAL INJURY......................................................148 MODIFIED - H.A.IN.E.S. RECOVERY POSITION........................................154 HEAD INJURY........................................................................................158 INJURY TO BRAIN..................................................................................161 HEAD INJURY CHARTING......................................................................166 CAUSES OF NOSE BLEEDS.....................................................................168 FRACTURES, DISLOCATIONS AND MUSCULAR INJURIES................... 175 FRACTURES..........................................................................................175 CLASSIFICATION OF FRACTURES............................................................176 SPLINTS...............................................................................................183 COMPLICATIONS OF FRACTURES..........................................................185 CERVICAL SPINE INJURY........................................................................193 LUMBAR SPINE INJURY..........................................................................195 RIB CAGE AND THORACIC SPINE...........................................................195 PNEUMOTHORAX.................................................................................195 PELVIS..................................................................................................197 FRACTURE HIP TO KNEE.......................................................................199 FRACTURE KNEE...................................................................................200 FRACTURE LEG.....................................................................................201 FRACTURE BOTH LEGS..........................................................................201 FRACTURE ANKLE AND FOOT...............................................................202 DISLOCATIONS.....................................................................................203 STRAINS...............................................................................................205 SPRAINS...............................................................................................205 CRAMPS...............................................................................................206 BURNS, SCALDS AND ACCIDENTS CAUSED BY ELECTRICITY............. 220 BURNS AND SCALDS.............................................................................220 ASSESSMENT OF QUANTITY OF BURN...................................................221 This course material is proprietary to ARI. Page 6  MEDICAL CARE MANAGEMENT OF BURNS.....................................................................225 SUNBURN.............................................................................................230 EFFECTS OF HEAT................................................................................231 FROSTBITE...........................................................................................235 HYPOTHERMIA.....................................................................................239 RESCUE AND MANAGEMENT OF HYPOTHERMIA....................................240 MEDICAL CARE OF RESCUED PERSONS, INCLUDING DISTRESS, HYPOTHERMIA AND COLD EXPOSURE............................................ 243 ABANDONMENT OF VESSEL..................................................................243 IMMEDIATE MEDICAL PROBLEMS ABOARD SURVIVAL CRAFT..................246 COLD EXPOSURE INJURIES.....................................................................252 CONGELATION OR FROSTBITE..............................................................254 DEHYDRATION AND MALNUTRITION....................................................255 HEAT EXPOSURE...................................................................................256 SEA SICKNESS.......................................................................................257 PSYCHOLOGICAL AND EMOTIONAL PROBLEMS ON A LIFEBOAT.............258 RADIO MEDICAL ADVICE.............................................................. 260 MEDICAL ADVICE BY RADIO AND URGENT MEDICAL ASSISTANCE..........260 MEANS OF COMMUNICATION...............................................................261 MARITIME RADIOCOMMUNICATIONS PROCEDURES FOR TELEMEDICAL ADVICE........................................................................................262 INFORMATION TO HAVE READY WHEN REQUESTING RADIO MEDICAL ADVICE........................................................................................267 IN CASE OF INJURY...............................................................................269 HELICOPTER EVACUATION....................................................................271 COMMUNICATING WITH DOCTORS.......................................................274 PHARMACOLOGY......................................................................... 278 PHARMACOLOGY.................................................................................278 VESSEL CATEGORIES.............................................................................279 BASIC RULES FOR MANAGING THE MEDICINE CHEST.............................279 ANAPHYLAXIS......................................................................................281 DRUG RASH AND OTHER DRUG-RELATED SKIN PROBLEMS....................281 CONTROLLED DRUGS...........................................................................282 This course material is proprietary to ARI. Page 7  MEDICAL CARE SHIPS CARRYING DANGEROUS GOODS..................................................283 DRUG LIST ON BOARD, USAGE AND DOSAGES:.....................................283 FIRST AID KITS.....................................................................................298 LIFEBOAT KITS.....................................................................................300 STERILIZATION............................................................................ 303 CLEANLINESS AND STERILIZATION........................................................303 TABLE: DISINFECTION AND STERILIZATION............................................304 CLEANING A WOUND............................................................................305 BANDAGES...........................................................................................311 SECURING ROLLER BANDAGES..............................................................315 ELBOW AND KNEE BANDAGES...............................................................318 HAND AND FOOT BANDAGE.................................................................320 TUBULAR GAUZE..................................................................................321 UNIVERSAL PRECAUTIONS....................................................................322 PREPARATION FOR PUTTING ON SURGICAL GLOVES..............................325 STEPS FOR REMOVING THE GLOVES SAFELY..........................................325 CARDIAC ARREST, DROWNING AND ASPHYXIA............................... 327 ASPHYXIA............................................................................................327 CAUSES OF ASPHYXIA...........................................................................328 DROWNING..........................................................................................330 CHOKING..............................................................................................332 HEIMLICH‘S MANOEUVRE (ABDOMINAL THRUSTS).................................334 SELF HEIMLICH.....................................................................................335 CARDIAC ARREST.................................................................................335 RESPONSIVENESS..................................................................................338 AIRWAY................................................................................................339 BREATHING..........................................................................................342 CIRCULATION......................................................................................348 CPR (CARDIO - PULMONARY RESUSCITATION)......................................348 PRACTISING CPR..................................................................................352 DEFIBRILLATOR....................................................................................354 MANAGEMENT OF ACUTE ABDOMINAL CONDITIONS...................... 355 This course material is proprietary to ARI. Page 8  MEDICAL CARE What is the Abdomen?.........................................................................355 TECHNIQUES OF SEWING AND CLAMPING, MINOR SURGICAL PROCEDURES............................................................................... 376 CLOSURE OF WOUNDS BY SUTURE........................................................376 DEEP AND GAPING WOUNDS THAT CANNOT BE SUTURED.....................379 ASPECTS OF NURSING (INJECTIONS, BP)......................................... 385 PREPARING THE HOSPITAL ROOM.........................................................385 RECEIVING A PATIENT IN THE HOSPITAL ROOM..................................385 PRINCIPLES OF NURSING.......................................................................386 CARING FOR A PATIENT.......................................................................387 MONITORING VITAL SIGNS...................................................................390 BODILY FUNCTIONS.............................................................................398 EXAMINING FAECES, URINE, SPUTUM, VOMIT........................................401 CARING FOR MENTALLY DISTURBED PATIENTS.....................................403 CARING FOR AN UNCONSCIOUS PATIENT.............................................405 GIVING COLD AND HOT FOMENTATION................................................408 CATHETERIZATION...............................................................................411 DISPENSING MEDICINES........................................................................417 ROUTES OF ADMINISTRATION..............................................................418 INJECTABLE..........................................................................................419 TYPES OF INJECTIONS...........................................................................421 SUB-CUTANEOUS.................................................................................426 INTRA-MUSCULAR...............................................................................427 INTRA-VENOUS....................................................................................428 EYE MEDICINES.....................................................................................432 EAR MEDICINES....................................................................................435 DISEASES OF VARIOUS SYSTEMS, TROPICAL AND INFECTIOUS DISEASES, PREVENTION OF DISEASES............................................................ 437 DISEASES OF VARIOUS SYSTEMS,..........................................................437 WORMS................................................................................................452 RESPIRATORY SYSTEM..........................................................................456 CARDIOVASCULAR SYSTEM..................................................................466 This course material is proprietary to ARI. Page 9  MEDICAL CARE DISORDERS OF THE CENTRAL NERVOUS SYSTEM –SYNCOPE, CONVULSIONS, STROKE, COMA....................................................476 GENITO-URINARY SYSTEM....................................................................487 DIABETES.............................................................................................497 TROPICAL AND INFECTIOUS DISEASES..................................................500 YELLOW FEVER.....................................................................................533 DISEASE PREVENTION...........................................................................535 STIS, SKIN DISEASES, HIV/AIDS..................................................... 544 STIs....................................................................................................544 URETHRAL DISCHARGE.........................................................................546 VAGINAL DISCHARGE...........................................................................548 GENITAL ULCER....................................................................................551 PAIN IN SCROTUM................................................................................554 SWELLING IN THE GROIN......................................................................556 PELVIC INFLAMMATORY DISEASE..........................................................557 PUBIC LICE...........................................................................................558 AIDS....................................................................................................560 COMMON SKIN INFECTIONS.................................................................565 ALCOHOL AND DRUG ABUSE........................................................ 575 ALCOHOL AND DRUG ABUSE................................................................575 PSYCHIATRIC EMERGENCIES.................................................................592 MENTAL HEALTH..................................................................................592 MENTAL HEALTH AT SEA......................................................................596 DEPRESSION AND MANIA......................................................................597 SUICIDE................................................................................................602 SCHIZOPHRENIA...................................................................................604 STRESS.................................................................................................606 POST-TRAUMATIC STRESS DISORDER...................................................612 DENTAL CARE............................................................................. 614 DENTAL EMERGENCIES.........................................................................614 GYNAECOLOGY, PREGNANCY, CHILDBIRTH.................................... 623 MENSTRUATION...................................................................................623 This course material is proprietary to ARI. Page 10  MEDICAL CARE DEATH AT SEA, ENVIRONMENTAL CONTROL ON BOARD SHIP......... 638 DEATH AT SEA.....................................................................................638 DISPOSAL OF THE BODY.......................................................................647 ENVIRONMENTAL CONTROL ON BOARD SHIP........................................649 KEEPING OF RECORDS, REGULATIONS........................................... 667 This course material is proprietary to ARI. Page 11  MEDICAL CARE GENERAL PRINCIPLES 1 GENERAL PRINCIPLES FIRST AID Definition: First aid is the initial and immediate temporary care/help given to a wounded, injured or sick person before the arrival of medical assistance. Importance of first aid: (The three ‗P‘S) a) To Preserve and save life: e.g. when a person is choking or has a heart attack. b) To Promote recovery: By reassuring and giving support. c) To Prevent complications or worsening, e.g.:  Shock due to excessive blood loss and pain,  Dehydration and collapse due to severe fluid and electrolytes loss, increase of severe diarrhea and vomiting,  Asphyxia and stoppage of breathing due to choking from foreign body in the upper respiratory tract and poisonous gases.  Blindness after injury to the eye with a foreign body. On finding a casualty:  Look to your own safety: do not become the next casualty;  If necessary, remove the casualty from danger or remove danger from the casualty (but see observation on a casualty in an enclosed space, given below).  If there is only one unconscious or bleeding casualty (irrespective of the total number of casualties), give immediate treatment to that casualty only, and then send for help.  If there is more than one unconscious or bleeding casualty: This course material is proprietary to ARI. Page 12  MEDICAL CARE GENERAL PRINCIPLES  Send for help; Then start giving appropriate treatment to the worst casualty in the following order of priority:  Stopped heartbeat  Stopped breathing  Unconsciousness  Severe bleeding  If the casualty is in an enclosed space, do not enter the enclosed space unless you are a trained member of the rescue team acting under instructions.  Send for help and inform the master.  It must be assumed that the atmosphere in the space is hostile. The rescue team MUST NOT enter unless wearing breathing apparatus which must also be fitted to the casualty as soon as possible.  The casualty must be removed quickly to the nearest safe adjacent area outside the enclosed space unless his injuries and the likely time of evacuation make some treatment essential before he can be moved. Priorities of First aid: A First Aider should always be Cool and Calm, Caring, Confident and act with Common sense in a crisis, and of course should have done the first aid ‗Course‘. (The five ‗C‘s of first aid) DR ABC is the Golden Rule in First Aid.  ―D‖ - Danger to self and to the casualty. Safe environment to be provided.  ―R‖ - Responsiveness to Sound, Touch and Pain.  ―A‖ - Airway is not blocked by tongue, secretions, food, teeth or foreign body. If blocked, open it by Head tilt Chin lift or other techniques. This course material is proprietary to ARI. Page 13  MEDICAL CARE GENERAL PRINCIPLES  ―B‖ - Breathing to be checked by ‗look, listen, feel‘ method; if absent 2 Artificial Respiration to be given immediately.  ―C‖- Circulation to be checked by the Carotid Pulse of the patient. If negative, give 15 chest compressions.  Give 15 chest compressions and 2 artificial respirations (single rescuer) and 5 compressions followed by 1 respiration (two rescuers) in case of cardiac arrest (No heartbeat or pulse). This combination is called Cardio Pulmonary Resuscitation (C P R) Place him in the recovery position if unconscious but breathing and with pulse intact. FIRST ACTION CHART LEVEL OF BREATHIN HEART RESPONSIVENESS ACTION CONSCIOUSNESS G BEAT Look for 1. + Conscious + + injuries Observe; 2. +/- Semi-conscious + + Treat shock Recovery 3. - Unconscious + + position Artificial 4. - Unconscious - + respiration 5. - Unconscious - - CPR Check for injuries:  Arrest /control any severe bleeding immediately by applying pressure – either direct or indirect.  Immobilize fractured limb / part of body by adequate support, and splinting.  Cool burns. This course material is proprietary to ARI. Page 14  MEDICAL CARE GENERAL PRINCIPLES  Guard against shock –  Handle the patient as little as possible and gently. Keep the patient warm with blankets. Reassure.  Do not massage hands and feet.  Put him in a position of comfort, by head down and raising the feet 25 – 35 cm.  Loosen tight clothing around neck and abdomen.  Prevent crowding around the patient. Let him get plenty of fresh air.  Do not give any alcohol.  Relieve pain by pain-killers.  Treat eye, ear and nose injuries.  Tie bandages and dressings over wounds.  Transportation of patient to hospital room or shore at the earliest. The stretcher used on board is the Neil Robertson stretcher.  Never give up until you are sure the patient is dead i.e.  No pulse felt (Radial and Carotid Pulses);  No heart sounds heard by putting your ear over heart region;  No breathing;  Pupils of the eye fully dilated and fixed and  Progressively increasing coldness of body.  Cardio-pulmonary resuscitation should be continued for at least 30 minutes, or until RMA (Radio medical advice) instructs to stop.  All the above will be discussed in detail in later chapters. Scope of First Aid:  To determine the nature of accident/illness. (Diagnosis)  Decide at once the character and extent of treatment or first aid – until medical aid is available. (Treatment) This course material is proprietary to ARI. Page 15  MEDICAL CARE GENERAL PRINCIPLES  Arrange for the evacuation of the casualty for getting proper medical aid. (Evacuation) Basic medical aid for day to day minor illness  Stick to usage of Medicines as per ―The first schedule part 1‖  Avoid indiscretion, negligence, over enthusiasm and misuse of these drugs.  Watch for toxic side effects while administering these drugs daily. Withdraw immediately as soon as any toxic side effects are noticed.  Avoid intravenous (i.v.) and intramuscular (i.m.) injections unless advised by a Doctor or in an acute emergency. Prevention of some diseases:  Many diseases like Dysentery, Typhoid, and Malaria can be prevented by simple measures like:  Proper sanitation and hygiene on the ship. Avoid stagnation of water which breeds mosquitoes.  Provision of adequate and pure drinking water, and water for bathing and washing purposes. Adequate chlorination and proper storage of drinking water.  Proper storing, cooking and distribution of food.  Personal hygiene of cooks and other food handlers and their regular vaccination (TAB and Cholera, etc.)  Adequate and properly ventilated living accommodation for the crew. No overcrowding.  Proper sanitation of toilet / bath rooms.  Proper clothing for the crew during cold and hot weather. New Guidelines for CPR: This course material is proprietary to ARI. Page 16  MEDICAL CARE GENERAL PRINCIPLES The American Heart Association (AHA) has revised its guidelines on CPR in October 2010. These changes are given in the Annexure below. The main change that is important is a change in sequence from DRABC to DRCAB. This is valid for all cases of sudden cardiac arrest. Here the first thing done is chest compressions if no pulse is found (C), followed by clearing and opening of airway (A) and giving artificial respiration (B). However, if the case is one of asphyxia (choking, drowning, toxic gas exposure, etc) the ‗CAB‘ means checking the circulation first and if there is no pulse, the A and B are managed before giving the compressions. Also the ratio is 30:2 irrespective of number of people. The following is only for information. However on the ship the earlier guidelines or flag state guidelines should be followed. ANNEXURE The 2010 guidelines issued by the American Heart Association (AHA) have made a few changes in the sequence and process of CPR (Cardio Pulmonary Resuscitation). Summary of Key Issues and Major Changes in CPR Key issues and major changes for the 2010 AHA Guidelines for CPR and ECC recommendations for lay rescuer adult CPR are the following:  Initiation of CPR to be started if the victim is unresponsive with no breathing or no normal breathing (i.e., victim is only gasping). RECOMMENDATIONS COMPONENT ADULTS CHILDREN INFANTS Recognition Unresponsive (for all ages) This course material is proprietary to ARI. Page 17  MEDICAL CARE GENERAL PRINCIPLES No breathing or no No breathing or only gasping normal breathing No pulse for 10 seconds (for all ages) CPR Sequence C-A-B Compression At least 100 per minute Rate At least 1/3 AP At least 1/3 AP Compression At least 2 inches (about diameter about diameter about depth 5 cm) 1.5 inches (4 2 inches (5 cm) cm) Chest wall Allow complete chest recoil between compressions. Rotate recoil every 2 minutes. Compression Minimize interruptions between chest compressions. Do Interruptions not exceed 10 secs. Airway Head tilt-chin lift except in spinal injuries (jaw thrust) Compression 30: 2 (1 or 2 30:2 (1 rescuer) 15:2 (2 to ventilation rescuers) rescuers) ratio Ventilation (untrained Compressions only (100/minute) rescuer) This course material is proprietary to ARI. Page 18  MEDICAL CARE GENERAL PRINCIPLES  ―Look, listen, and feel for breathing‖ has been removed.  Continued emphasis has been placed on high-quality CPR (with chest compressions of adequate rate and depth, allowing complete chest recoil after each compression, minimizing interruptions in compressions (not more than 10 seconds), and avoiding excessive ventilation).  There has been a change in the recommended sequence for the lone rescuer to initiate chest compressions before giving rescue breaths (C-A-B rather than A-B-C). The lone rescuer should begin CPR with 30 compressions rather than 2 ventilations to reduce delay to first compression.  Compression rate should be at least 100/min (rather than ―approximately‖ 100/min).  Compression depth for adults has been changed from the range of 1⅟2 to 2 inches to at least 2 inches (5 cm). These changes are designed to simplify rescuer training and to continue to emphasize the need to provide early chest compressions for the victim of a sudden cardiac arrest. A Change from A-B-C to C-A-B Most victims of out-of-hospital cardiac arrest do not receive any bystander CPR. There are probably many reasons for this, but one may be the A-B-C sequence, which starts with the procedures that rescuers find most difficult, namely, opening the airway and delivering breaths. Starting with chest compressions might encourage more rescuers to begin CPR. If a bystander is not trained in CPR, the bystander should provide Hands- Only (compressions-only) CPR for the adult victim who suddenly collapses, with an emphasis to ―push hard and fast‖ on the center of the chest. The rescuer should continue Hands-Only CPR until medical help is available to take over care of the victim. All trained rescuers should, at a minimum, provide chest compressions for victims of cardiac arrest. In addition, if the trained rescuer is able to perform rescue breaths, compressions and breaths should be provided in a ratio of 30 compressions to 2 breaths. The rescuer should continue CPR until medical care is available. This course material is proprietary to ARI. Page 19  MEDICAL CARE GENERAL PRINCIPLES Hands-Only (compression-only) CPR is easier for an untrained rescuer to perform and can be more readily guided. In addition, survival rates from cardiac arrests where the heart has a problem are similar with either Hands- Only CPR or CPR with both compressions and rescue breaths. However, for the trained lay rescuer who is able, the recommendation remains for the rescuer to perform both compressions and ventilations. (Adapted from Guidelines © 2010 American Heart Association) This course material is proprietary to ARI. Page 20  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS 2 BODY STRUCTURE AND FUNCTIONS The study of the body and its parts is called anatomy. The functioning of the body is known as the physiology. The building blocks of the human body are the cells – all body tissues and organs are made up of millions of cells. Some of these keep dividing and regenerating all through a person‘s life whereas some of them lose their ability to divide. Nearly all cells consist of a cytoplasm and a nucleus. An exception is the red blood cell of the human body that lacks a nucleus. The genetic material is contained in the nucleus of a cell. The cytoplasm contains water and that is where most of the body water is present. Cells of the same type join together to form tissues e.g. muscle tissue or nerve tissue; tissues combine to form organs. An organ is a body structure that is made up of at least two types of tissue functioning together for a common purpose e.g. the skin which comprises the different tissue layers of epidermis, dermis and subcutaneous layer is the largest organ in the human body! Organs in turn combine to form the various systems that are present in the human body. In this chapter we will learn, in brief, about various important systems and their functions.  The framework of our bodies is made up of bones.  These are covered by muscles, which enable these bones to move.  Covering the bones and muscles is the skin, which covers our full body.  The bones, bony cavities and muscles, protect the soft organs in the body. The human body can be divided into various regional parts as shown in Fig 2.1 and 2.2. These are: - This course material is proprietary to ARI. Page 21  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS  Head and neck ( skull, brain, cervical spine)  Upper limb ( Hand, wrist, forearm, elbow, arm, and shoulder)  Thorax ( rib cage, thoracic spine, lungs, heart, diaphragm, major arteries and veins)  Abdomen ( stomach, intestines, liver, pancreas, gall bladder etc)  Spine ( vertebrae, sacrum, coccyx, inter-vertebral disc and spinal cord)  Pelvis ( pelvic bones, uro-genital organs, part of the intestines)  Lower limb ( hip joint, thigh, knee, leg, ankle and feet) Chest Cavity or Thoracic Cavity  This is formed in front by the breastbone, and front and sides by 12 pairs of ribs and behind by 12 vertebrae called thoracic or dorsal vertebrae, and below by a muscular structure called the diaphragm. The chest cavity has important organs like lungs, heart, food pipe, wind pipe. This course material is proprietary to ARI. Page 22  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS Fig 2.1: Parts of the Human Body (Front) This course material is proprietary to ARI. Page 23  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS Fig 2.2: Parts of the Human Body (Back) Ribs There are 12 pairs of ribs.  True Ribs – first 7 pairs directly attached to the sternum or breastbone.  False ribs – Next 3 pairs, attached to the 7th rib.  Floating ribs – unattached in front, last 2 pairs to protect the kidneys from behind. Back Bone or Spinal Column This course material is proprietary to ARI. Page 24  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS  This is attached to the skull above and the pelvis below and gives attachment to ribs in the chest. Between 2 vertebrae are cushion like cartilages called intervertebral discs. They allow movement and act as shock absorbers. If the disc gets displaced, the result is a slip disc. This often occurs because weights are not lifted properly – Remember to always bend at the knees when lifting weights. Functions of the Spinal Cord  It is the connection of the brain and body by millions of nerves.  It is the continuation of the brain. It allows sensory fibres to take messages to the brain and motor fibres to carry orders from the brain  Each segment supplies nerves for sensation to one part of the body.  Paraplegia is a condition in which the lower limbs, bladder and bowel do not function due to spinal cord injury at the waist.  Quadriplegia is a condition in which both - the upper and lower limbs, bladder and bowel do not function due to spinal cord injury at the neck.  Hemiplegia is a condition where the face, upper limb and lower limb on the same side of the body are paralysed and numb due to a problem on the opposite side of the brain, often a stroke or brain haemorrhage. Abdominal Cavity  This is bounded above by the diaphragm, which moves during respiration, below by the pelvis, behind by the vertebrae and in front by strong muscles.  Organs in the abdomen can be divided by systems  Digestive system – stomach, liver, pancreas, gall bladder, intestines, colon, rectum.  Genito Urinary system – 2 kidneys, 2 ureters, urinary bladder, adrenal glands, urethra, prostate/uterus, 2 ovaries( in females) Mouth Cavity This course material is proprietary to ARI. Page 25  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS  Mouth Cavity is formed by upper jaw and lower jaw (mandible). The roof of the mouth is called the palate, which separates it from the nose.  The mouth has a tongue, gums, teeth, salivary glands, tonsils, pharynx (throat). SENSORY ORGANS There are 5 sensory organs namely, Ear, Eye, Nose, Tongue and Skin. SKIN: The Layers of Skin: (Fig 2.3) The human skin has 3 main layers:  Epidermis: is the outermost layer which protects the body from germs and infection. It also is responsible for giving pigmentation and colour to the skin.  Dermis: is the second layer which has sweat glands, blood vessels and nerves.  Hypodermis or subcutaneous tissue: is the third layer comprised of fat and stores water. Water is the most important ingredient of our body. Blood is 83% water, muscles 75% and bone 22%. Approximately 65% of our body weight is water. Functions of the skin are:-  Covers whole body as a protective layer  Secretes sweat for body temperature regulation. Normal human body temperature is 37deg C or 98.4 deg F.  The layer of fat below the skin, acts as an insulator and preserves body heat. It also acts as a cushion and gives it smoothness.  Store house of water  Sensory organ for touch, pain and pressure  Conveys emotions and age.  Has a forensic importance with finger prints as an identification mark This course material is proprietary to ARI. Page 26  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS Fig. 2.3: The Human Skin EYE: (Fig 2.4)  The eye is like a camera.  The external object is seen like the camera takes the picture of any object. Light enters the eye through a small hole called the pupil and is focused on the retina, which is like a camera film.  Eye also has a focusing lens, which focuses images from different distances on the retina.  The colored ring of the eye, the iris, controls the amount of light entering the eye through the pupil. It closes or constricts the pupil when light is bright and opens or dilates it when light is dim.  A tough white sheet called sclera covers the outside of the eye. The front of this sheet (sclera) is transparent in order to allow the light to enter the eye; this is known as the cornea.  The cornea is the transparent membrane outside the iris which allows all light to enter the eye. It is the only part of the eye which can be donated and transplanted. This course material is proprietary to ARI. Page 27  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS Fig. 2.4: The Eye MUSCULOSKELETAL SYSTEM The bony framework is called the skeleton. Its functions are  To give basic structure to the body  To afford attachment to the muscles, and help in movement (because of the joints)  To protect important organs like the brain, heart, spinal cord.  To produce RBC, WBC and platelets from the bone marrow. There are 206 bones in the human body as shown in Fig. 2.5 This course material is proprietary to ARI. Page 28  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS Upper limb bones are -  Shoulder girdle - Clavicle, scapula  Arm – Humerus  Forearm - Radius and Ulna  Wrist - carpal bones  Hand – metacarpals  Fingers – Phalanges Lower limb bones are:-  Hip - pelvic girdle  Thigh – Femur (longest, strongest and heaviest bone in body), Knee cap  Leg – Tibia and Fibula  Ankle –Tarsals  Foot –Metatarsals  Toes - Phalanges This course material is proprietary to ARI. Page 29  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS Fig 2.5: Skeletal system (Front View and Side View) Kinds of Bones: Bones are typically classified into five main categories: long bones, short bones, flat bones, irregular bones and sesamoid bones.  Long Bones - Long bones are greater in length than in width and are slightly curved for strength. They are thin, hollow and light. Both ends are covered in cartilage to help with shock absorption. These bones This course material is proprietary to ARI. Page 30  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS work as levers and play a key role in all types of movements. Some examples include the femur, tibia, fibula, humerus, ulna, and radius.  Short Bones - Short bones are relatively the same length as they are in width and are cube-shaped. The ankle bones and wrist bones are two examples. The kneecap is also considered a short bone.  Flat Bones - Flat bones have a thin shape and structure and are bones that provide mechanical protection. The flat bones are strong, but elastic, allowing room for movement such as in breathing. They protect organs in the body and attachment of muscles. The highest amounts of red blood cells are formed in flat bones. Some examples include the ribs, cranial bones, and shoulder blades.  Irregular Bones - Any bone that doesn't fit into the above categories is considered an irregular bone. They vary in size, shape, and surface features. Some examples are bones of the vertebrae and a few bones in the skull including facial bones.  Sesamoid Bones - Sesamoid bones are bones that could develop in some tendons where there is an extra amount of friction, tension, or stress. The kneecap is a common place where a sesamoid bone may develop. Functions of Bones  They are the busiest living organ equal to the heart since they are the factory which manufactures RBCs and WBCs and platelets throughout the day. Every minute about 180 million RBCs die and have to be replaced.  They store Calcium (Ca) and Phosphorus (P). Ca and P are necessary for clotting of blood, for beating of the heart, control of muscles, function of nervous system, etc.  Medico legal – help in distinguishing male and female; the age of a child, and also various diseases like rickets and scurvy. JOINTS Where two or more bones of the skeleton meet, a joint is formed. They are of three types as shown in Fig. 2.6: - This course material is proprietary to ARI. Page 31  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS  Immovable – e.g. Skull  Movable -  Ball and socket – Hip  Hinge – Elbow  Pivot – wrist, neck  Partially movable: e.g. the backbone (many vertebrae) and the rib cage (many ribs) Features of Joints:  Movement in different directions possible.  Joints are protected and covered by muscles, capsule, ligaments, synovial membranes, etc.  All bones end in cartilage or soft bone. This course material is proprietary to ARI. Page 32  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS Fig. 2.6: Types of joints MUSCLES Types of Muscles: These are masses of red flesh. They are of 3 types.  Voluntary muscles – mostly in the limbs; are under our control and will.  Involuntary muscles – around the organs of the body; not under our control.  They are of 2 types.  Cardiac muscle – Heart muscle; not under our control. Has to work constantly.  Smooth muscle – Around organs like stomach, intestine, etc. Names of Muscles: There are more than 600 muscles in the human body. The names of the important muscles of the human body are shown in Fig. 2.7 and 2.8. Functions of Muscles:  To give shape and contour to our body  To support entire bones of the skeleton  To perform movements  Protect bones, organs  Maintain BP by their pumping action A tissue which joins a bone to a bone at a joint is called a ligament. When it gets injured, we get a sprain e.g. ankle, wrist. This course material is proprietary to ARI. Page 33  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS A tissue which joins a muscle to a bone is called a tendon. Injury to a tendon results in an injury called a strain (muscle pull). This course material is proprietary to ARI. Page 34  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS Fig. 2.7: Muscular System (Major Muscles-Front View) This course material is proprietary to ARI. Page 35  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS Fig. 2.8: Muscular System (Major Muscles-Back View) This course material is proprietary to ARI. Page 36  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS CARDIOVASCULAR SYSTEM (CIRCULATORY SYSTEM) This is made up of the  Heart  Blood vessels - These can be arteries, veins or capillaries  Blood THE HEART  The heart is about the size of a fist and is covered by a protective covering called the pericardium.  It is placed in the centre of the chest and is usually tilted towards the left side. Since the breastbone covers it at the centre it is usually felt on the left side. It is surrounded on either side by a pair of lungs i.e. right and left lungs - it is placed diagonally, pointing more towards the left breast.  The Heart is formed of very strong and specialized cardiac muscles, so layered and interwoven that they can squeeze, twist and literally wring out the contents of their chambers at every contraction.  It is divided into four chambers i.e. a) Right atrium b) Left atrium c) Right ventricle d) Left ventricle  The Right Atrium opens into the Right Ventricle through the Tricuspid valve and Left Atrium opens into Left Ventricle through another valve – Mitral valve.  The right side of the heart receives the venous (deoxygenated) blood coming back to it from the body and pumps it to the lungs. Here it takes up a supply of oxygen and returns it to the left side of the heart from where it is pumped to all parts of the body. The Heart as a Pump: This course material is proprietary to ARI. Page 37  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS  The heart‘s contractions are controlled / initiated by an organ known as the pacemaker which is situated inside it. The normal rate of heart contraction is between 60-90/min, average being 72/min. It beats nonstop during rest, sleep, and heart rate increases during running, fear, fever, fight, love and shock.  In about 70 years of an average life span, the heart has made about 2,500,000,000 beats (Two thousand, five hundred million beats).  The Systemic circuit starts from the Left Atrium, which pushes the pure oxygenated blood into the Left Ventricle and then the entire body through the aorta for the purpose of oxygenating its tissues. It then returns the deoxygenated blood to the Right Atrium, which pumps the blood to the Right Ventricle.  The Pulmonary circuit is short and independent and goes from the Right Ventricle of the heart to the lungs by the Pulmonary Artery to let the blood discharge its carbon dioxide and pick up life renewing oxygen, and returns it to the Left Atrium via the Pulmonary Vein.  Arteries:  These are the strongest blood vessels, elastic in nature, which have to withstand the high pressure of blood with each powerful contraction of heart. They carry blood away from the heart.  All arteries carry bright red oxygenated or ‗pure‘ blood, except the Pulmonary Artery, which is the only artery in the body which carries deoxygenated blood.  Arteries have three linings i.e. outer, middle and inner.  They are deep seated and are better felt than seen. This intermittent expansion and return to normal, is called the pulse. These arteries go into each and every part of the body, dividing, sub-dividing into smaller and smaller vessels, which are known as capillaries. Pressure Points:  The points at which these pulses can be felt are called ‗pressure points‘. These are usually felt at joints where the artery is relatively superficial and lies directly on a bone. They are like the mains of a tap and help to stop the flow of blood when pressure is applied on them. (Fig 2.9a) This course material is proprietary to ARI. Page 38  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS Criteria of pressure points:  They are arteries  They are superficial  Their pulse can be felt easily Pressure point application -  In situations where bleeding cannot be controlled by direct pressure and elevation pressure points can be used to constrict the major artery which feeds the point of the bleed. The various pressure points of the human body are shown in Fig. 2.9b.  The carotid artery in the neck is used as a pressure point only under extreme circumstances of bleeding from the brain. Special care is taken here – pressure is put only on one side and for only one minute - as the brain is sensitive to lack of oxygen and brain damage can result within minutes of application of pressure.  Pressure should not be applied for more than 10 minutes as there is a risk of tissue damage and death if pressure is prolonged. Fig. 2.9a: How a pressure point works This course material is proprietary to ARI. Page 39  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS Fig. 2.9b: Arterial pressure points This course material is proprietary to ARI. Page 40  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS Veins:  They are formed by the joining together of the capillaries. They carry blood back to the heart.  Veins do not contain much muscular tissue like an artery. Veins have two linings outer and inner.  Most veins have cup like valves, which allows the blood to flow only in one direction i.e. towards the heart.  Veins do not give a pulse.  All veins carry dark red or maroon blood which is deoxygenated (impure), except the Pulmonary Vein, which is the only vein in the body which carries oxygenated blood.  Veins are superficial and can be better seen than felt. CAPILLARIES  These are the smallest sub-division of blood vessels which surround each cell.  They connect the arteries and veins.  Their average diameter is 1/3000 of an inch (the finest hair).  They do not have outer and middle layer, only the thinnest inner coat is left, which allows the passage of nutrients and diffusion of gases to and from the tissue cells. BLOOD AND ITS FUNCTIONS:-  Blood is the fluid connective tissue in human body which helps in the transport of different vital elements.  The average human body has 5 liters of blood ( 4-6 L)  It has living cells, namely RBC‘s, WBC‘s and platelets, suspended in the fluid plasma. The RBCs are responsible for transport of oxygen. The WBCs are the ‗fighters‘ and give immunity, and the platelets help in the clotting process.  55% is plasma and 45% is composed of cellular elements.  In 24 Hrs, the heart receives and pumps out 8-10 thousand litres of blood. This course material is proprietary to ARI. Page 41  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS Functions of blood are: It transports the following:  Dissolved gases (oxygen, carbon dioxide)  Waste products like urea, ammonia  Hormones  Enzymes  Nutrients ( glucose, amino acids, micronutrients)  Plasma proteins (associated with defense, such as blood clotting and antibodies).  Blood cells Maintains body temperature Removes toxins from the body. Kidneys filter all the blood in the body 36 times every 24 hours and the toxins are excreted in the urine. They are also excreted in small quantities in the sweat. RESPIRATORY SYSTEM This comprises of the following parts as shown in Fig 2.10: 1. Nose Airway passage including the trachea, larynx and bronchi Two lungs Diaphragm – a membrane which separates the chest from the abdomen. Lungs:  Lungs are essential organs of respiration.  They are two in number i.e. right lung and left lung. They are placed in the right and left side of the chest.  Pleura is a thin membrane for protection and cushioning of the lung and is divided into 2 – first, which covers the surface of the lung and is called VISCERAL PLEURA and the second covers the inner surface of the chest wall and is called PARIETAL PLEURA. The pleural space in This course material is proprietary to ARI. Page 42  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS between has a negative pressure, as shown in Fig. 2.11, which is responsible for the suction force required for breathing.  Each lung has its own pipe or bronchus, which goes into each and every part of the lungs. These branch off like a tree and their job is to push in air into the smallest air sac of the lungs. They are about 750,000,000 (seven hundred fifty million) air sacs called Alveoli. These air sacs are full of capillaries. Through their permeable wall the blood in the capillaries gives up carbon dioxide and takes up fresh oxygen. This process of exchange of gases and purification of blood from dark red to crimson red goes on day and night, uninterrupted, by inhaling and exhaling.  Lungs breathe air in and out i.e. inspiration and expiration at the rate of 15-18 times a minute. It is more during exercise.  With each inhalation we take in about 500 ml of air.  Respiration is controlled by respiratory center located in the base of brain called ―medulla oblongata‖. Respiratory Rate:  The normal respiratory rate is 15 – 18 / minute. It is an important vital sign to be monitored regularly in every patient.  A rapid respiratory rate (tachypnoea) is seen during exercise, shock, exertion, stress, fear and panic situations. It results in shallow breathing very often from the mouth which leads to drying of the mouth. The respiratory muscles tire faster and can lead to stoppage of breathing.  A slow respiratory rate (bradypnoea) is seen during hypothermia and head injury (compression). It leads to less oxygen intake, and dizziness.  Apnoea is the term given to stoppage of breathing. It is treated by giving artificial respiration.  Some people may have apnoeic spells where they are gasping with prolonged intervals of no breathing. They should have oxygen supplementation and artificial respiration if required. Functions: This course material is proprietary to ARI. Page 43  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS  The nose regulates temperature of air that is inhaled.  The nose filters inhaled air (of dust, dirt and germs).  The hairy (Cilia) lining of the Bronchi clear the air of dust, dirt, irritants which are thrown out as sputum by coughing.  The lungs oxygenate the de-oxygenated blood of the body. RESPIRATION consists of 3 phases: Inspiration i.e. inhalation Expiration i.e. exhalation A pause between the two phases.  Inspiration: During this the diaphragm contracts its dome shape center, becomes flat and thus the capacity of the chest increases from above and below. Negative pressure is increased inside the chest as shown in Fig 2.12.  Ribs that are normally inclined downwards and forward, rise outward and upwards thus increase the capacity of chest from front to back and from side to side.  Intercostal muscles between the ribs help during inspiration by helping the rib movements.  Lungs – When the capacity in the chest increases, a suction force is created and the Lungs expand because of their elastic structure and also with the help of pleura. Air is therefore drawn in. This is an active process.  Expiration: The whole process of inspiration is reversed i.e. relaxing of diaphragm, ribs, rib muscles occurs and as a result of this the lungs contract and air is pushed out. This is a passive process.  Muscles of the abdominal wall also play a part in Expiration i.e. when diaphragm comes down, the abdominal muscles relax to allow room for abdominal organs to go down and up during inspiration and expiration. Respiratory centre: is located in the brain at the base (medulla oblongata). This controls the respiration. This center reacts to various forms of This course material is proprietary to ARI. Page 44  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS stimulation, the most important being carbon dioxide. Morphine injection suppresses this centre. Hence morphine should NOT be given in cases of head injury and situations where respiration has been affected. Composition of Inspired and Expired air: The following table shows the difference in the composition of inspired and expired air: S. NO. ITEM INSPIRED AIR EXPIRED AIR 1. Temperature Atmospheric temperature Body temperature 2. Humidity Atmospheric Humidity Nearly 100% Atmospheric Impurities 3. Purity Nearly pure present 4. Oxygen Approx 21% 16 – 18% Carbon 5. 0.01 - 0.03% 1 – 3% Dioxide 6. Nitrogen Approx. 78% Approx. 78% These figures are important to understand the basis of giving artificial respiration. We do not breathe out only carbon dioxide. The last column above showing the composition of expired air is the air given to a patient by mouth to mouth/ nose respiration. The casualty‘s expired air will then contain about 11 – 13% oxygen and 6 – 8 % CO2. If the rescuer keeps his nose near the face of the casualty he will breathe this air and his levels of oxygen in the body will drastically fall. Hence always breathe in fresh air while giving artificial respiration and breathe out into the mouth/ nose of the casualty. This course material is proprietary to ARI. Page 45  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS The bronchi: These branch from the windpipe then divide and sub-divide to form tiny air passages (bronchioles) that terminate in the alveoli The lungs: These two spongy structures contain millions of tiny air sacs. The average man‘s lung holds about 6 litres of air, a woman‘s 4 litres. Fig. 2.10: Respiratory System structures contain millions of tiny air sacs. The average man‘s lung can hold approximately 6 litres of air, a woman‘s 4 litres. Fig. 2.11 Negative pressure in chest cavity This course material is proprietary to ARI. Page 46  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS Fig. 2.12: Breathing in - The expansion of the chest sucks air in via the windpipe. DIGESTIVE SYSTEM AND ABDOMEN  Digestive system consists of all organs concerned with chewing, swallowing and digestion of food, absorption of food and the elimination of waste material from the body, as shown in Fig2.13 and 2.14.  Digestive tube or alimentary canal is about 9 meters long and extends from mouth to anus and is lined with mucus membrane.  There are 32 teeth and they cut food into small pieces. This food is mixed with the saliva produced by three pairs of salivary glands and by this time, it is quite soft and is pushed through the pharynx and the food pipe into the stomach.  From the stomach after 3-4 hours of digestion with hydrochloric acid, food is passed into small intestine where more digestive process takes place. Absorption of important and valuable contents from the food into the blood vessels and lymph vessels takes place from the small intestine.  The remaining waste products are passed into the large intestine where water is reabsorbed and solid waste matter is stored in the rectum as faeces or stools and excreted from the anus whenever possible. This course material is proprietary to ARI. Page 47  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS Accessory organs of digestive system:  Teeth – which break the food and mash it. This process is called mastication.  Salivary Glands – They are 3 pairs in number called Parotid, Sub- Mandibular, Sub-Lingual. The enzyme in saliva is known as ptyalin. Saliva helps to digest food, liquefy food and keep the mouth clean and moist, preventing thirst.  Liver and Pancreas – These are two large glands in the abdomen. Their secretion of Bile and Pancreatic juice/ Insulin/ Glucagon plays a very important role in the digestion of food.  Tongue - a muscular organ needed for taste, speech and swallowing. Stomach:  Stomach is a strong muscular pouch about 16‖ long.  Here the food is churned, kneaded by strong contracting movements of the stomach, and mixed with hydrochloric acid and enzymes produced by the glands of the stomach. Liver:  Liver is the largest of all glands and forms 1/40th of the total body weight.  It is dark red in colour, dome shaped, situated beneath the diaphragm and on the right side of abdomen and is protected by the bony cage of ribs and strong muscles of the abdomen.  Weight in Males – 1.4 to 1.6 kg; in Females – 1.2 to 1.4 kgs. It is divided into two lobes i.e. right and left lobe. Composition:  Liver is made up of millions of tiny cells arranged in tiny cords, one cell in thickness.  It is known as the master laboratory of the body. This course material is proprietary to ARI. Page 48  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS Functions of the liver: The liver regulates most chemical levels in the blood and secretes a product called bile, which helps to break down fats, preparing them for further digestion and absorption. All of the blood leaving the stomach and intestines passes through the liver. The liver processes this blood and breaks down the nutrients and drugs in the blood into forms that are easier to use for the rest of the body. More than 500 vital functions have been identified with the liver. Some of the more well-known functions include the following: 1. Production of bile, which helps carry away waste and breaks down fats in the small intestine during digestion. 2. Production of certain proteins for blood plasma. 3. Production of cholesterol and special proteins to help carry fats through the body. 4. Converts excess glucose into glycogen for storage. This glycogen can later be converted back into glucose for energy though slowly in routine life but with lightening speed in an emergency. 5. It converts amino acids into albumin, which regulates balance of salt and water. 6. It regulates blood clotting. 7. It removes toxins produced by foodstuffs, medicines and viruses and bacteria producing diseases. 8. Resisting infection by producing immune factors and removing bacteria from the blood stream. 9. Clearing the blood of drugs and other poisonous substances e.g. alcohol. 10. It helps store fats as a reserve food in the body. 11. Stores vitamins and minerals. When the liver has broken down harmful substances, they are excreted into the bile or blood. Bile by-products enter the intestine and ultimately leave the body in the faeces. Blood by-products are filtered out by the This course material is proprietary to ARI. Page 49  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS kidneys and leave the body in the form of urine. Gall bladder:  Gall Bladder is a small pear shaped glistening blue green sac situated in the upper right side of the abdomen attached to the under surface of the liver and is connected to the liver by a series of ducts.  It also is connected with the duodenum i.e. first portion of the small intestine by a duct.  Gall Bladder is the storehouse of bile, which is bitter in taste and green in colour. This fluid is essential for the digestion of fats. Pancreas: This is a tongue shaped organ lying behind the stomach. Pancreas produces three types of secretions. 1. One of these juices goes into the intestinal canal for digestion - pancreatic juice. 2. The second juice called insulin goes into the blood. This is an important hormone for regulation of blood sugar and converting glucose to glycogen. Lack of insulin leads to diabetes mellitus. 3. The third juice called glucagon goes into the blood and converts glycogen to glucose. Gastro intestinal tract or the Digestive tract is divided into 4 parts. 1. Esophagus i.e. gullet or food pipe. 2. Stomach – This receives the food from the gullet and churns the food to a milky white state. It secretes hydrochloric acid, which sterilizes the food. It secretes certain protein enzymes for partly digesting proteins. 3. Small Intestines – In this part, the properly churned and partially digested food from the stomach comes and is further digested and absorbed. This is the portion of the gut that is totally sterile. This course material is proprietary to ARI. Page 50  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS 4. Colon - It eliminates the residue from the body as excreta or stool and is responsible for water and mineral absorption. The time taken for the food to leave the stomach is 4-6 hours and 30-48 hours to pass through the remaining 30 feet of the tract. Vermiform appendix: This is a small appendage attached to the beginning of the colon on the right, lower abdomen. In human beings, it is a vestigial organ- a remnant from our ancestors, and has no function. Acute Appendicitis:- It is a condition characterized by inflammation of the appendix. It is a medical emergency and many cases require surgical removal of the inflamed appendix. Untreated, risk of dying is high, mainly because of the risk of rupture leading to peritonitis and shock. It has been recognized as one of the most common causes of severe acute abdominal pain worldwide. This course material is proprietary to ARI. Page 51  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS Fig. 2.13: Organs of chest and abdomen. This course material is proprietary to ARI. Page 52  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS Fig. 2.14: Back This course material is proprietary to ARI. Page 53  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS THE URINARY (EXCRETORY) SYSTEM (Fig 2.15) The Urinary System is formed of 1. Two Kidneys – Right and Left 2. Two Ureters – Right and Left 3. One Urinary Bladder 4. One Urethra Kidneys and Urinary bladder:  Kidneys are two in number located inside the abdomen, on either side of the spine, at the level of lowest ribs – Right Kidney is lower than the Left Kidney.  Kidneys are bean shaped and brown in colour  Kidneys are composed of millions of filters called nephrons.  They only allow waste and excessive water into the ureter at the rate of 1-2 liters a day.  These ureters are like drainpipes and push the water downward towards the urinary bladder, by their wave like contraction movements.  The Urinary Bladder acts like a storage tank. It is a small bag like structure triangular in shape, its base pointing upwards and the apex pointing downwards.  On either side of the base, there are small openings for the right and left ureters to enter and discharge the water collected from the right and left kidneys.  The apex has an opening for the urethra to discharge out urine i.e. urine passes out of the body through an opening called external urethral meatus. Capacity of the urinary bladder is approximately 400-600ml. However, it varies from individual to individual. This course material is proprietary to ARI. Page 54  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS Kidney s Bladder Fig. 2.15: The urinary system This course material is proprietary to ARI. Page 55  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS Urethra: The urethra is the final outlet pipe from the bladder to the exterior. Size – from the outlet in the urinary bladder up to external urethral opening:  Males - about 8 inches long  Females - about 1.5 inches long Functions of Kidneys: Kidneys are the body‘s master chemist and its filtration plant. 1. They maintain the water and mineral balance of the blood. 2. They Control Acid – Alkali balance in the blood. 3. They help in disposal of waste products of blood not required by the body e.g. urea, creatinine. Stones in the kidney are formed due to low intake of water, and other causes. A stone in the kidney rarely causes any symptoms. However, once the stone enters the ureter it causes a lot of pain, which radiates from the back to the front (loin to the groin). There is usually no problem in passing urine. It is treated by giving pain killers and plenty of fluids. A stone in the urethra will cause pain in the lower abdomen and groin and causes inability to pass urine. A few drops of blood may come out on straining. The patient will be extremely anxious and distressed due to his full urinary bladder. Here fluids should be stopped and RMA taken. The Nervous System (Fig 2.16): The Nervous System can be divided into 3 parts: The Central Nervous System (CNS) Comprising of  Brain  Spinal cord Injury to the CNS can result in deep unconsciousness called coma. Until the brain revives itself, a person can remain in coma for months. This course material is proprietary to ARI. Page 56  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS The Autonomic Nervous System (ANS) – discussed later The Peripheral Nervous System (PNS). -- This is made up of  Sensory nerves – these carry messages from the body to the brain through the spinal cord.  Motor nerves – these carry commands from the brain to the body.  Mixed nerves – these nerves have both motor and sensory fibres. Functions of Brain: 1. Thought functions: This deal with intelligence, memory, cognition (thinking), creativity, etc. 2. Motor functions: All voluntary movements are controlled and initiated by the brain –located in the cerebrum of the brain. Right side Cerebrum controls the left side of the body and the left side Cerebrum controls the right side of the body. 3. Sensory functions: These include sensations like touch, pain, and temperature. Brain is the final center for Vision, Hearing, Speech and all other functions. Autonomic Nervous System: This is not under our control and is situated deep inside the brain stem. It controls all involuntary functions of our body. It therefore controls our heart beat, respiration, etc. The day our Autonomic Nervous System stops functioning we die. It is divided into: Sympathetic functions: This course material is proprietary to ARI. Page 57  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS  Increases heart rate, raises blood pressure, relaxes the smooth muscles of bronchi i.e. wind pipe branches.  Pupil or the window of the eye is dilated.  Constriction of blood vessels of skin.  Dryness of mouth.  Frequency of urination.  Prepares the individual for emergency conditions such as a ‗fight‘ or ‗flight‘. Parasympathetic functions:  This slows the heart rate, contracts the pupils – increases the intestinal movements.  The parasympathetic system normally predominates in happier times such as in games, sleep etc.  Normally sympathetic and parasympathetic functions act in a balanced manner. This course material is proprietary to ARI. Page 58  MEDICAL CARE BODY STRUCTURE AND FUNCTIONS The brain This complex network consists of many millions of interconnecting nerve cells (neurons), along which electrical impulses travel, conveying signals. The cranial nerves: Twelve pairs of nerves emerge directly from the base of the brain, and travel to the organs of the head. The spinal cord Composed of millions of nerve cells, the brain controls all bodily Peripheral functions and interprets nerve sensations. Though cushioned by the cerebro-spinal fluid, it can be damaged by violent movement and is vulnerable to pressure changes within the skill. Vertebra This mass of nerve cells and fibers runs from the base of the The peripheral nerves: back. It controls signals that travel between the brain and These emerge in pairs from the the peripheral nerves. It is spinal cord and pass to all parts of protected by the vertebrae the body. They are like telephone cables, consisting of bundles of to and fro fibers. Sensory nerve fibers carry information received by the senses to the brain, motor Reflex actions: fibers carry ―orders‖ sent by the These automatic, involuntary brain to the muscles responses are produced by signals that ―short-circuit‖ in the spinal cord. They include withdrawal from painful stimuli and such reflexes as the knee jerk. This course material is proprietary to ARI. Page 59  MEDICAL CARE IMMEDIATE ACTION Fig 2.16 Nervous System 3 IMMEDIATE ACTION INTRODUCTION The priorities of First Aid (DR ABC) have been learnt in chapter 1. When a casualty has been found to be conscious, his injuries have to be managed. As has been seen before these are bleeding and wounds, fractures, shock etc. We will revise how to manage these and finally how the casualty can be transported safely. WOUNDS AND BLEEDING Wounds - Any break in the continuity to skin or mucous membrane is known as a wound. A wound can be closed or open. Closed wounds result in internal bleeding which may be visible as a colour change in the skin e.g. in a contusion or bruise. An open wound has a great risk of infection. Types of wounds This course material is proprietary to ARI. Page 60  MEDICAL CARE IMMEDIATE ACTION WOUND CLASSIFICATION TYPE CAUSE EXAMPLE WHAT IS SEEN FIRST AID Contusion Blunt blow Punch; Rupture of Apply an ice pack (bruise) with heavy, Boxing; capillaries beneath for smooth Bump on skin surface. Blood 10 – 15 object like head; Black leaks out causing a minutes. Do NOT the floor, eye ‗Colour change‘ rub or apply a wall or from red to blue to balm or heat. ceiling, or a purple to black. Colour becomes fist. Severe contusion normal in 7 to 10 indicates deeper, days. hidden damage. Abrasion Scraping of Sliding fall; Only skin surface Wash all the dirt (graze) top layer of Friction burn; affected with with soap and skin fall on a scratch marks and water. Apply rough surface small bleeding antiseptic on This course material is proprietary to ARI. Page 61  MEDICAL CARE IMMEDIATE ACTION TYPE CAUSE EXAMPLE WHAT IS SEEN FIRST AID like the road points. Lots of dirt wound. Inj. TT if or a field. in the wound. required. Incision (cut) Sharp Blade; Broken Can be minor or Control bleeding. edged glass; major cut. Smooth Wash the wound. object scissors; edges of wound. Dressing of the shaving. Severe bleeding wound. May sometimes. require stitching, Tendons may be Inj. T.T., cut. Antibiotics Laceration Tearing of Machinery; More tissue Control bleeding. (rough tear) soft body Road traffic damage than Wash the wound. tissues. accidents incision. Danger Dressing of the Wound of infection since wound. May irregular. contamination require stitching, with bacteria and Inj. T.T., dirt. Veins and Antibiotics. arteries affected. Puncture Sharp Nail; Animal Small site of entry Do not remove wound pointed bite; Knife but deep track of the piercing (stab) object injury; rod internal damage object. Apply piercing the at times. Danger Ring bandage. skin of infection. Do Inj. T.T., not bleed Antibiotics. excessively outside. Gun Shot Bullet injury Bullet Point of entry small Cool the area. and neat. Point of Stop bleeding exit large and and treat shock. ragged and Do not disturb blackish with the bullet, if bleeding inside. Avulsion Machinery, Explosives Skin tissue torn off Control bleeding. (torn off) explosives or left hanging like Avulsed part to be and skin flap a flap. Severe stitched back. This course material is proprietary to ARI. Page 62  MEDICAL CARE IMMEDIATE ACTION TYPE CAUSE EXAMPLE WHAT IS SEEN FIRST AID injury bleeding seen. Healing depends on blood supply of flap. Amputation Machinery, Hanging Part dangling by Put part back and (partial) whiplash finger nail skin. Bleeding in stitch. Stop injury, 50% of cases; bleeding. tearing of extreme pain in Bandage well. part of limb 50% of cases. Painkillers. Treat which is Shock is always shock. dangling seen. Amputation Severing of Back-lashing Can be clean cut or Treat shock. (complete) part of limb. of wires and crush amputation. Apply Tourniquet ropes; Part of body if bleeding. Pain machinery; missing. Bleeding killers. Preserve crush with and/or severe pain amputated part heavy object in 50% of cases. in polythene bag. like a Shock is always Place this bag in banging seen. ice. Store at 2-40 door. C temp. Stitch back if possible. Crush Injury Heavy object Banging of Bleeding and/or Treat shock. Stop falling on heavy door or severe pain in 50% bleeding. part of the cargo or of cases. Shock is Painkillers. body machinery on always seen. Can Splint and hand/foot/ lead to a ‗frozen Bandage in the body. limb‘ ‗functional position‘ ‗Sucking‘ Open wound Stab on chest Can hear a sucking Immediately seal chest wound on chest sound of air at the the wound with a site of injury. Can cloth and then lead to collapse of make a 3 way lung and death airtight seal. Give 100% Oxygen. Needs evacuation. This course material is proprietary to ARI. Page 63  MEDICAL CARE IMMEDIATE ACTION BLEEDING Bleeding can be of 3 types: 1. Arterial - bright red blood, pulsatile bleed against gravity 2. Venous - dark red, continuous stream of blood with gravity 3. Capillary - oozes out slowly. Different ways to control bleeding are: - 1. First 10 minutes:  Direct continuous sustained pressure  Elevation  Ice Pack 2. Next 10 minutes  Direct pressure with a Pressure Bandage  Indirect pressure at the Pressure points as shown in Fig. 3.1  Elevation 3. Next 10 minutes  Direct pressure with a second reinforcing Pressure Bandage  Indirect pressure with a Pressure Bandage at the Pressure Point  Elevation 4. Next 10 minutes  Tourniquet: As in Fig 3.2. The rules of a tourniquet are:  Keep it exposed so it is visible  Write ‗TK‘ on the patient‘s forehead to indicate that a tourniquet has been tied.  Always record the time over it  To be tied with Radio Medical Advice and once tied, NOT to be opened till medical aid/advice is available. This course material is proprietary to ARI. Page 64  MEDICAL CARE IMMEDIATE ACTION 5. Reassurance 6. Cold compresses 7. Management of shock Internal Bleeding - when the skin is intact and there is some bleeding in the skin or internal organs. Check for the following:-  Bruise or contusion of the skin or discoloration  Painful, tender, rigid, bruised abdomen  Weakness, dizziness and fainting  Rapid pulse  Cold, moist skin  Vomiting or coughing up blood  Stools that are black or contain bright red blood  Signs of shock This course material is proprietary to ARI. Page 65  MEDICAL CARE IMMEDIATE ACTION Fig. 3.1: Commonly used Pressure points Fig. 3.2: Applying and securing a tourniquet for an amputated limb. Note: Never