1. The Injury
2. The Diagnosis
3. Constructing a Treatment Plan
4. Treatment Method A
5. Setting off the EPIRB
6. Treatment Method B
7. Further Treatment Planning
8. Waiting for Sunrise
9. Treatment Method C
11. That’s the Trouble with Adventure…
One of the great solo sailors, Robin Knox-Johnstone, recounts how he was giving a talk to a school assembly about his record breaking trip in which he was the “first single hander” to sail around the world non-stop.
One of the boys was most intrigued and asked how he coped with one hand tied behind his back for all that time, and which one was it?
When told the actual meaning of “single handed sailing”, the boy lost interest.
Last night I dislocated my right shoulder.
I would like to say that it was caused because I was wrestling with a wayward jib sheet in an angry fifty knotter. Or that perhaps I had snagged a massive blue finned tuna and was engaged in an epic Hemmingway-esque battle like the old man and the sea.
It was evening and I was a little tired, the previous night had been a fast downwind section in a following sea with variable winds, and I had been awake since 1:00 AM to keep an eye on things and make sure I didn’t accidently gybe – in those winds it could bring down my rig.
It was cold and I was feeling the effects of loneliness for the first time in my trip.
I had a hot sausage, mash, and mustard dinner, which cheered me up no end.
I got into my bunk, set my leeward board to stop me falling out, reached around over the top of my head to turn off my satellite phone charger, …
… and CLICK! Out came my right shoulder.
I had previously dislocated that shoulder 3 years ago in an aerial swing dance manoeuvre gone wrong, and it had been a tad loose since, but nothing that really gave me serious concerns.
The first thing in a crisis situation that the venerable book “The house of God” counsels (Doctors will know to what I refer), is to first take your own pulse, and establishing that you’re not in a blind funk, then take the patient’s pulse.
Luckily, I could double up on that one. I was neurovascularly intact (fancy words meaning that blood was flowing and nerves were working), which gave me time.
One of the most fascinating things about medicine, something I can never grow weary of observing, is the ‘fight or flight’ response to a medical stressor, be it a heart attack, a lung infection, or whatever.
That innate sense that an experienced clinician develops as to whether a patient is deteriorating, is much about sub-consciously observing the level of the patient’s fight or flight response and correlating it with the level that would be expected from that patient’s presumed current state of health.
Within seconds I was absolutely drenched in sweat.
I was in a small boat in a freezing sea with 2.5 metre waves, there was no flight possible, so it looked like I was up for a fight.
I already knew what had happened, but did my full clinical exam anyway.
Yep, there is the humeral head jammed against the clavicle.
Yep, there is the acromian process without a humerus bone touching it.
There is an eponymous sign for a shoulder dislocation, named after some ancient doctor, in which the deltoid muscle forms a right angle with the top of the shoulder. I forget its name, but I was a text book case.
I re-checked each dermatome. No brachial plexus damage.
Constructing a Treatment Plan
The next step was analgesia. I only had simple stuff. Paracetamol and ibuprofen. Much maligned by drug seeking malingerers in the emergency department, they are reasonable drugs if taken in combination and regularly. And little side effects to worry about in the short term, especially with paracetamol.
I sat down and thought for a moment while loading up my weather and charts on the computer.
I looked at my alcohol stores.
But then thought: no, I have some critical decision to make and I was going still downwind in a reasonable following sea. Not the safest situation, so best to leave my head clear.
I ascertained my position and bearing. I was nearly 400 kms from the nearest point of land. My bearing was taking me about 10 degrees north of the nearest port, but I had set my course conservatively so I wouldn’t have to worry about the steering vane accidently gybing – a situation where the boat swings through the wind and your boom crashes across with the force of several tons.
The wind was about 10 knots apparent and my speed was 7 knots with accelerations to 9 or 10 knots as each wave came through from behind. This gave me a wind speed of 15-20 knots.
I thought about changing my course but decided against it. That would mean that first I would have to climb out into the cockpit, navigate to the stern, lean over the pulpit rail, and twiddle the knob that sets the wind sensor vane. I wasn’t even sure I could climb the ladder to get out of the cabin at this stage.
I decided the best course of action would be to try and reduce the shoulder. I set my alarm for 20 minutes, to maintain some order and protect against task fixation, and set to it.
Treatment Method A
The first method I tried was the old “lie down on the cabin floor, grab your foot and push”.
Laying down was my first challenge, everything on a moving boat is three times as hard as on land, and laying down on land with a dislocated shoulder is no fun.
It was quite the task to navigate my hand to my foot, but after about three minutes, I finally got it there. It was surprisingly painless to push compared to the previous manoeuvres, so I kept at that for a while, but, like a drunk at his favourite bar, the humeral head did not budge an inch.
With patience diminishing for that position, I tried Plan Two.
It was partially pre-mediated, partially ‘make it up as you go’, but essentially involved grabbing the hand rail on the wall, placing one’s feet 30cm below the rail on the wall, and hanging off like a little kid in a playground.
That also got old quite quickly.
By that time 20 minutes was up, but I gave myself an extension to try the correct method dictated by the textbooks.
“With the patient laying supine, grasp the patient’s affected limb, flex the elbow to 90 degrees, gently apply external rotation to the shoulder joint while applying inward traction to the elbow”.
I sat at the table, tied my hand to wall, tied my elbow to my side and rotated my whole body.
They say that renal colic, the pain from a kidney stone jammed in the tube running down to the bladder, is the most painful thing known to mankind.
I remember when I was a sweet little intern, I cared for a rotund middle-aged tradesman in emergency with his first episode of renal colic. He was crying as he faced that gaze into the bowels of hell, the despair that comes with the loss of control that pain brings.
He was laying on a tiny leather examination couch, (all the beds were full that evening, like every evening), and the sight would have been grotesquely humorous if it not were for that raw human element on display.
I filled him up with morphine, until he stopped crying, and returned 15 minutes later to find his diminutive wife standing at the head of the sloped examination table trying to stop him sliding off as he lay there in a blissful stupor.
His wife thought it was the funniest thing she’d ever seen, probably helped by the fact that the stress was now gone.
I was horrified that an only slightly-excessive amount of morphine could do that to such a mound of a man in such a world of pain.
Chalk that one up to experience. There is always naloxone which reverses the effects of these strong pain killers.
Some junior doctors will happily sit there and watch a patient in pain, while they are comfortable with not having to worry about having ‘narked’ a patient.
I really dislike this.
Acute pain is always treatable, and better that I should be a little more stressed and have to check on a patient a little more often, than to have a patient suffer. Mercy must be at the foremost of our practice. We are here for the patients, not to worship at the shrine of the God of medicine.
Anyway, no cigar with tradition either. I thought that perhaps I was not applying enough inward traction on the elbow, so I set up the long rod on my boat hook to act as a lever – but no worky either.
Setting off the EPIRB (Emergency Position Indicating Radio Beacon)
Needing a break and out of immediate options I decided to bring in the big guns: I rang my mother on my sat phone.
“Hey Mum, Andrew here, how’s it going?”
A fundamental rule of telephone communications as a resident is to display no emotion regardless of what is being said on the other side. Firstly, the resident is the rock of the wards and must be seen to be settled at all times. Secondly, it prevents you saying things you regret when you’re having your first meal break in 10 hours and a nurse bugs you about speaking to a patient’s second cousin, twice removed, who wants an immediate update at 10pm on Sunday. Thirdly, being mysterious is fun, and you need something to keep you entertained on a long weekend shift.
I thought I had pulled it off pretty well.
My mother is a wise woman and is not easily fooled. “Yes Andrew?”
“I’m safe, my boat is safe, but unfortunately I just dislocated my shoulder”
I truly regret some of the white hairs I’ve given mum, but adventure has a beguiling call and I am addicted to the sweet pitch of its sirens. Deep down inside I think she likes it.
I then called the New Zealand rescue authorities. A lovely calm man with a lovely New Zealand exsunt.
We had a chat and I told him the situation and he told me to set off my EPIRB while he set to looking for nearby ships.
I was still well out of helicopter range and besides, that would mean abandoning Perpetual Succour. A loathesome thought.
I’ve always wanted to set off an EPIRB. It is the small things that make life worth living.
I then started my pilgrimage out of the cabin and to the rear of the cockpit. They say Odysseus had a difficult journey!
I got to the task of adjusting my course. The waves had the tendency to yaw the boat safely back into the wind, but there was an occasional cross wave that sent it the other way. Still worried about accidentally crash gybing, I set my boat as close to dead downwind as I dared. I was running a preventer, but still didn’t want to risk it.
I then returned to the cabin (easy to say indeed), and set about the science of shoulder relocation.
Treatment Method B
I got onto my lovely sister, a very talented vet, and she set about proposing methods.
We tried everything.
“Lay on your back and twist with your arm in an uncomfortable position”
“Grasp your ipsilateral knee and think of England.”
The funny thing about the shoulder joint is that it is very open. This gives it an amazing amount of manoeuverability, but means that a set of intricate muscles and ligaments must be continuously working to keep the head of the arm bone set hard into the socket of the shoulder joint.
Essentially, they must exert a force greater than the force that you are applying to the joint, otherwise your shoulder would dislocate every time you played tug ‘o war.
Having failed me once, these ignorant little buggers were keen for redemption. Firmly they jammed my humeral head into the clavicle, and firmly it remained there.
Eventually I realised that in a battle of brute force, I was always going to lose.
By this time the New Zealand authorities got back to me and advised that I was all alone in a radius of 400 kms. He suggested that I make myself comfortable (he was thoughtful enough to add “as possible”), keep the boat safe, and wait for sunrise in 6 hours to reassess.
I got back out, turned off my EPIRB , trimmed the sails and self steering, restocked on paracetamol and ibuprofen, and thought about my next step.
Further Treatment Planning
The basic principle of shoulder reduction in clinical practice is to sufficiently sedate the patient to relax those pesky muscles and then the shoulder clicks back into place with the correct force.
Ideally, you want a shoulder relocated as quickly as possible to give it the best chance of healing. More than 24 hours and an operation gets more and more likely.
I needed sedation to relocate it. Otherwise I would be left with waiting 36 hours before I could land the boat and get assistance on shore.
The plan was to sedate myself, lay face down on the outside cockpit bench with a 5 kilo weight attached to my arm which would be dangling down into the cabin. The theory is that the weight will cause the muscle to tire, and the shoulder will slide back in after a few minutes.
I decided that this was a job for morning. I had to plan out how to sedate myself safely.
Like any good anaesthetist, I was worried about the risk of vomiting and aspirating it. No one wants to go out like the former lead singer of AC/DC.
“Drowned in his own vomit” is not an epitaph to make the parents proud.
I set myself “nil by mouth”.
A good sedative agent has a fast onset and a fast offset. I didn’t have propofol. I didn’t have midazolam, I didn’t have fentanyl.
But I did have Bicardi rum.
I’m not too sure about its pharmacokinetics, but I figured pre and post hydration would shorten the sedative phase.
I cannulated myself. I primed a line and set normal saline running to the horrified chorus of ICU specialists. (There’s nothing normal about normal saline. All hail the Gods of lactate.)
I then waited out the night. I truly have no idea if I slept. I would put even money that I didn’t.
Waiting for Sunrise
Roll. Roll. Roll.
You can tell when a big one is coming as the boat falls away, steadies, then lurches into it. It’s nice to have a warning.
I tried laying prone and supine, I tried sitting, I tried standing. Each has its respective short-lived merits.
Eventually morning came and I made my update to the authorities. They offered to divert a tanker which was 100 miles north of me. He pointed out that I would have to somehow get up on the tanker, abandon my boat, and then spend three days sailing to Sydney at the mercy of the crew.
Treatment Method C
I rang Mum and said my final goodbyes. I prepared the weight, which was my emergency flares container filled with 5 litres of water, and got out the rum.
I probably should have positioned myself before indulging, but I have a romantic side to me and staring at the morning horizon while swigging rum is an opportunity not to be missed.
I figured that 6 standard drinks stat should be the approximate dose, but I titrated the input like any good proceduralist.
“Am I looking forward to this? Nope? Righto – another swig.”
Eventually a third of the bottle was gone and I was ready.
My arm felt pretty good and I actually checked to make sure it hadn’t already migrated its way back in.
Ever the scientist, I set the timer on my watch.
I lay down on my face, lashed myself in, tied an undexterous knot from my hand running to the weight, and slowly let it slide into the cabin.
Bugger, too long. I had failed to account for my disgustingly long arms. I’d make a horrible hangman.
I winched it back up with my good arm and shortened the rope.
“My arm makes a pretty good pendulum.” In my comforted state, this seemed to be the funniest thing I had ever experienced.
I feel asleep and my watch tells me that I woke up 15 minutes later.
I felt my shoulder and I could feel the head right on the edge of the joint. I gently massaged it with thumb and forefinger and it slid in. No click. No pain. Just happiness.
I rang the family, I rang the authorities.
I think I may have been a bit emotional and my siblings are now making drunken sailor jokes.
That’s the Trouble with Adventure…
I awoke nearly four hours later with a full bladder. I rang the authorities – they had gently insisted that I ring with an update in a few hours for some reason.
He had a glint of humour in his voice that I think I failed to observe the last time I rang him.
“How’s the, uh, medicated state going”?
I claim to never get hangovers and lived true to my claim. The IV fluids helped no doubt.
I now have my arm in a sling, I can safely manage sails, and the weather forecast is reasonable.
I manoeuvred Perpetual Succour through a gybe, and went to the foredeck to reset the preventer.
All without issue. A storm would be a different matter.
I should get to Wellington in 24-48 hours where I will lick my wounds, get an xray, and make decisions from there.
My beautiful boat has an amazing heart. She knew I suffered. I gave her the reins and she set a course for the shore which was stunningly rapid.
For this entire trip, my boat has not travelled further over a period of 12 hours as she did during this ordeal.
The ‘Stimsons’ technique for shoulder reduction worked well, although I am claiming the pendulum swing as my own modified version. Hopefully the textbooks will take it up!
I prayed like I have never prayed before, and was given much strength. God is Good!
The other aspects of solo sailing, that which don’t involve having dislocated shoulders, seem quite mundane now.
That’s the trouble with adventure, it turns the once exciting into the mundane.
Latitude: -39.521837, Longitude: 171.138193, Time: 07:00:53 03-04-2018 UTC