Medical

Fleet Surgeons Memo for Offshore Passages

Administrator — Wed, 01 Nov 2017 01:41:10 +0000

Fleet Surgeons Memo for Offshore Passages

Jeffrey Wisch, MD

Administrator Wed, 11/01/2017 - 01:41

Medical

Jeffrey S. Wisch, M.D.

Special acknowledgement to Edwin Garry Fischer, M.D. for
development of the original format and content of this memo

Updated February 2017 (PDF version)

Medical skills, first aid equipment and communication are the essentials of managing a medical emergency offshore. Significant medical conditions of individual crew should be on record and known to the medical officer before departure. The Newport Bermuda Race requires that two members of each crew have valid First Aid and CPR certificates (see Newport Bermuda Race, Notice of Race, Medical Training).

The Injury and Illness Survey of past Bermuda Races lists the extremities, especially fingers and toes, as most at risk for injury. Spine, face, abdominal and head injuries also occurred. Sea sickness and sunburn were common. Infections, migraine headaches, diabetic complications, dehydration, urinary retention and airway obstruction requiring a Heimlich maneuver were also encountered. Pre-race seminars stress the importance of preventing hypothermia, dehydration, fatigue and seasickness.

Conditions not reported in the race surveys must also be considered. The incidence of malignant melanoma, a highly lethal condition, as well as other skin cancers, have increased alarmingly among sailors. Asthma, life-threatening allergic reactions, heart attacks, strokes, seizures, burns and surgical emergencies can be added to the list of things one might have to deal with on an offshore passage. Anticoagulants (blood thinners), which are used to treat recurrent venous thrombosis (blood clots) or cardiac conditions such as atrial fibrillation (abnormal heart rhythm), can turn a minor knock on the head into an untreatable and fatal intracranial hemorrhage. .

A culture of caution and prevention is the best way to minimize the risk of injury and illness. Falling overboard or being hit on the head by the mainsheet or boom during an accidental jibe may be fatal despite one’s best efforts, but such accidents are often avoidable, by always wearing an inflatable harness, in the case of the former, and by a permanently installed and always engaged preventer, in the case of the latter.

Acknowledging that not every medical situation can be handled safely and successfully at sea, a single person, the Medical Officer, not necessarily a medical professional, has the responsibility of caring for the ill or injured crew member at sea and preparing the vessel and the crew for any likely medical emergency, making sure there are on board the following:

Information from each crew member about significant medical conditions, allergies and necessary medications that is easily accessible;
Medical and surgical skills appropriate to the voyage;
Appropriate medical supplies - reference books, a medical/surgical kit and medicines (addenda 1-3), appropriate to the level of medical training on board;
An appropriate emergency communication system as well training of the entire crew as to the proper use of the equipment

Medical training to improve the skills of a lay person who has become a yacht’s medical officer is available in a number of commercial programs aimed at the wilderness adventurer. Such skills are important because although there are rescue services available in many places, even in the best of coastal cruising situations on a small boat there is no “911” as we have come to know it and expect it.

Addendum 1: Reference Books

For Limited Passages

Advanced First Aid Afloat, by Peter F. Eastman, M.D., Fifth Edition: Cornell Maritime Press, Inc, Centreville, MD,

Doctor On Board: A Guide to Dealing with Medical Emergencies, by Jurgen Hauert, M.D.

Sailing and Yachting First Aid, by John Bergan, M.D. and Vincent Guzzetta, M.D., prepared for the United States Sailing Association, Portsmouth, RI

First Aid at Sea, by Douglas Justins and Colin Berry, Adlard Coles Nautical, A&C Black (Publishers) Ltd, 35 Bedford Row, London, WCIR 4JH, 1999 ISBN 0 7136 4922 4

The Onboard Medical Handbook, by Paul G. Gill, Jr., M.D., International Marine, Camden, ME 1997 ISBN 0 07 024274 7

A Comprehensive Guide to Marine Medicine, by Eric A. Weiss, MD and Michael Jacobs, MD, Adventure Medical Kits, Oakland CA 94624, 2005 ISBN )-9659768-2-3

For Extended Passages

The Ship Captain’s Medical Guide, 22nd edition. Crown Copyright 1999. Obtainable from Her Majesty’s Stationary Office, e-mail book.orders@tso.co.uk, fax – 44 (0)870 600 5533; tel – 44 (0)870 600 5522.

International Medical Guide for Ships, Third Edition, World Health Organization, 1988, reprinted 1994 ISBN -10 92 4 154231 4, order number 11502078 (go to publications at www.who.int )

The Ship's Medical Chest and Medical Aid at Sea, DHHS Publication(PHS) 84-2024 Government Bookstore, O'Neil Building, 10 Causeway, Boston, MA 02222 (telephone 617 565 6680) and www.fas.org/irp/doddir/milmed/ships.pdf. Comprehensive and contains an extensive list of medical references.

Merck Manual of Diagnosis and Treatment, 18^th Edition, Editors Mark H Beers, Robert S. Porter, Thomas V. Jones, Merck Research Laboratories, Division of Merck & Company, Inc., Whitehouse Station, NJ 08889-0100, 2006

Wilderness, first aid and emergency medicine texts are also available.

Addendum 2: Sample Equipment List

Note: Medical kits must meet the objectives of the intended voyage and the abilities of the ship’s medical officer. Commercially available medical kits vary in complexity and if used their contents should be reviewed to be sure they meet the objectives of the voyage. The items below, or appropriate substitutes, are recommended however are not intended to be a substitute for proper consultation with a medical provider.

Airway kit: Oral airways (small, medium and large), Ambu bag, CPR mask

Bandages/ Minor Trauma/ Burns:

Adhesive tape 1”
Sterile dressing sponges (4X4) Ice bags
Band-aids
Non-adhesive dressings (Telfa) Steri- strips (1/2”)
Roll Gauze (2” and 4”)
Ace bandages (2,4, and 6”)
Triangle bandages (for sling and swath) Large abdominal/ trauma dressing
Finger splinting material (tongue depressors, aluminum splint) Xeroform gauze/ Vaseline impregnated gauze (large)

Surgical Kit/ Major Trauma:

Laceration tray (1% lidocaine, syringe, needles (18 and 25 gauge), hemostat, needle driver, forceps, gauze sponge, iodine prep stick)
Suture material – 5.0/ 4.0/ 3.0 nylon, 4.0 vicryl, 4.0 chromic
Dermabond
Skin Stapler
Clozex (for skin closures)
Sterile gloves (7,7.5,8)
Suture removal kit/ Staple removal kit
Scalpel – 11 blade (incision and drainage kit – can use laceration tray) 14 gauge angiocath (3”)

ENT/ Eyes/ Dental

Sterile irrigation fluid for eye wash
Nasal packing (merocel nasal tampons, 1 inch Vaseline gauze) Calcium hydroxide dental paste

Splints:

Inflatable (or other) splints for arms, legs, tongue depressors, cervical spine collar

Catheter: Bladder catheterization kit

Exam tools: BP cuff, stethoscope, thermometer Intravenous fluid administration kit

Addendum 3: Suggested Medications

Note:

Medicines should be assembled with the help of a physician, and those selected will depend on the nature of the voyage, the type of vessel and crew and the expertise of the ‘medical officer.’.
Prescription medications are in italics; "over the counter" medicines in regular type.
Prescription medicines should be given only on the recommendation of a physician.
Know about a crew member’s medical conditions, current medications and allergic or adverse reactions before giving medication.

AILMENT or PROBLEM	MEDICATION
Allergic Reactions	Benadryl, prednisone (oral), Epipen
Antihistamines	Benadryl, Claritin
Antispetic Solutions	Betadine, Alcohol, Hibiclens
Asthma	Albuterol inhaler, prednisone
Burns	Bacitracin ointment, Silvadene cream, Vaseline
Cardiovascular/ ACLS	Epipen, Sub-lingual nitroglycerin, Aspirin (325mg)
Constipation	Dulcolax suppository/ oral, Fleets enema, Colace
Cough	Robitussin DX
Diarrhea	Imodium, Kaopectate, Oral rehydration solution
Diabetic Emergency	D50 IV, oral sugar solution
ENT/ Dental	Corticosporin Otic Suspension, Sudafed, Calcium Hydroxide dental paste, Afrin nasal spray
Eyes	Erythromycin ophthalmic ointment, Ocuflox Ophthalmic drops, tetracaine ophthalmic, Artificial Tears
Gastritis	Maalox, Zantac, Prilosec
Hemorrhoids	Preparation H, tucks pads
Infections:
Urinary Tract	Ciprofloxacin, Bactrim DS
Respiratory	Azithromycin, Levofloxacin
ENT/ Dental	Augmentin, Clindamycin
Skin/ soft tissue	Keflex
Gastrointestinal	Flagyl, Cipro
Essential antibiotics:	Cipro, Azithromycin, Keflex, Augmentin
Intravenous Antibiotics	Ceftriaxone (2gm)
Intravenous Fluids	Normal Saline (sterile 0.9% saline), D51/2 NS
Inflammation/ Pain	Tylenol, Ibuprofen
Local Anesthetic (injectable)	Lidocaine 1% (with and without epinephrine)
Narcotic pain medication	Oxycodone 5mg, Vicodin 5/500
Skin/ Rash	triamcinolone acetonide 0.1%, Nystatin topical Hydrocortisone 1% ointment
Sea sickness **	scopalomine transdermal patches, Dramamine, Stugeron (cinnerazine, which is over the counter in UK, Spain, Bermuda, Ireland, etc), Compazine Rectal Suppositories
Sleeping	Benadryl, lorazepam , Ambien
Sunburn	Topical aloe, Solarcaine

** In the case of sea sickness medications, it is imperative due to potential side effects that these medications be trialed on shore prior to use on board.

Seasickness: Prepare for It, Treat It

Administrator — Thu, 10 Aug 2017 21:42:11 +0000

Seasickness: Prepare for It, Treat It

Jeffrey Wisch, MD

Administrator Thu, 08/10/2017 - 21:42

Medical

Seasickness

The Bermuda Race’s medical chair (a race skipper) describes the causes, prevention, and treatment of this all-too-common and potentially dangerous condition.

The medical reports submitted by crews after recent Newport Bermuda Races usually include more than 50 cases of seasickness. I suspect that this number significantly underestimates the actual incidence of this illness. Seasickness may present in a full range of stages, ranging from slight queasiness to severe nausea and vomiting, so it is likely that mild cases were not formally logged and that some of the cases occurred without any thought toward preventative measures.

As a community, we pride ourselves in taking safety seriously. Race participants and organizers spend considerable time preparing for events that are unlikely to happen but that (should they occur) could be catastrophic. Potential problems include such scenarios as dismasting, blown sails, failed through-hulls, sinking, losing one’s rudder, and man overboard situations.

While preparation for the Newport Bermuda Race usually is detailed and labor intensive, there is one problem that sailors do not seem to take as seriously as they should

Make no mistake about it, seasickness can be life-threatening. In the 2012 race, seasickness precipitated evacuation of a crewmember from a competing boat, and another vessel on the return trip was also abandoned with seasickness playing a major role in the event. Seasickness can create a danger not only for the victim but for the rest of the crew, too.

Causes of Motion Sickness

Nobody is completely immune to motion sickness. This sickness occurs when our visual cues are mismatched with what our brain perceives. This is precipitated when we are unable to anticipate or line up visual cues with a particular, or perceived, motion. An excellent example is when sailors have to spend time in the bilge, say, while repairing an engine. Our brain senses a motion (the vessel’s movement) but the associated visual cues are absent. Add the smell of diesel fuel and the rest is readily predictable.

Motion sickness can also affect an individual in the absence of motion, as may occur while viewing an action packed video game. Additional factors that contribute to seasickness include lack of sleep, anxiety, poor hydration, foods difficult to digest, certain smells, and learned behavior. When one crewmember becomes seasick, the likelihood of others on board developing the illness increases. Continued seasickness may lead to severe dehydration, an inability to function, and, if untreated, possible death.

Symptoms and Prevention

Victims might also feel a sense of impending doom.

Symptoms of motion sickness include apathy, inability to focus, cold sweats, anorexia, excess salivation, yawning, belching, headache, pale complexion, and finally, nausea and severe vomiting. Victims might also feel a sense of impending doom.

Although thresholds vary from person to person, given the right circumstances, everyone is susceptible. It is also very difficult to predict who will and will not become ill. The illness may be recurrent during a voyage, although most people will adapt to conditions after 36 to 72 hours at sea.

Seasickness Prevention

Be honest about your personal threshold to get sick

Be well rested prior to going offshore

Trial seasickness remedies before going offshore checking for side effects

Start your choice of medication the night before sailing

No alcohol the night before sailing

Eat easily digestible foods the night before sailing and for the first 24 hours

Try to remain topside as much as possible when not getting rest for the first 24 hours

Adhere to a strict watch schedule and get plenty of sleep when off watch

Stay well hydrated

When You Feel Sick

Go topside and hook your safety harness tether to the boat

Let your watch captain know you feel sick and inform them of any other personal illness

If you are not taking any seasick medications, start immediately

Try to focus on the horizon and if possible and appropriate take the helm

Do not try to read or attempt close visual work

Try hydrating slowly with an electrolyte solution such as Gatorade or Pedialyte

Saltines, ginger ale and Coca Cola may help settle your stomach

Stay attached to the vessel in the event that you need to vomit

If you need to vomit try to do so on the leeward side

Crewmates help secure the affected individual

If You Become Seasick and Vomit

Try using a rectal suppository such as Phenergan or Prochlorperazine

If not available try a small sip of an electrolyte solution with a pill (Stugeron, Dramamine etc.)

Try chewing the seasick pill and let the pieces melt in your mouth and under your tongue. This may help absorption into your system if pills are vomited up

Apply a Scopolamine Patch if suppositories/pills are not available or if you vomit the pills up however take care so as not to overmedicate with pills and a patch

Try to lay down and if possible attempt to sleep in a secure place

Do not try to take fluids or eat anything until you feel better and have given the medications a chance to work.(Usually within 30-60 minutes)

When feeling better repeat some of the items in # 2

Be reassured that most people improve within 24-48 hours

Seasickness that Resists Treatment (Refractory Vomiting)

Assess the victim’s condition

If the pulse is weak, or if the victim feels as if he or she will pass out upon sitting or standing, or if there is a change in mental status – then consider evacuation and contact the U.S. Coast Guard or other emergency service

While awaiting advice, keep the victim lying down in a secure place with head slightly elevated and turned to the side in the event that they vomit

Do not force oral fluids

Keep the victim warm

Reassure the victim that you are getting help

Before Heading Out

Knowing your limitations and propensity for seasickness is critical. Because seasickness is far more common than the more dramatic disasters we prepare for, you and your crew should plan ahead on how to deal with it. The boat should have a well thought-out management plan that includes careful planning by the entire crew.

I know many well-respected sailors who routinely take preventative medications for the first 24 to 48 hours of a voyage. Try any preventative medications before going offshore to choose the medicine with the most tolerable side effects. Start the treatment before heading out, continue for at least the first few days, and be on the lookout for signs and symptoms of early seasickness even if medication is already being used.

Medications

Anti-seasickness drugs include scopolamine patches as well as medications like Dramamine, Bonine, and Stugeron (cinnarizine). Scopolamine patches may cause dry mouth, headaches, blurred vision, urinary retention, and hallucinations. Dramamine and Bonine can be extremely sedating. Stugeron, a very effective agent (available only in or from Bermuda, Canada, and the UK) also has potential side effects such as drowsiness and tremors.

My personal favorites are scopolamine patches and Stugeron, but they may not be your favorites, too. Before choosing a medication, try several of them out on land prior to the voyage to see how they affect you as an individual. In addition, check with your physician to see if there are any contraindications to any of the drugs depending upon your personal medical history.

I strongly suggest that each crew member and the boat’s medical officer familiarize themselves with the potential side effects of medications, and have that information available onboard in order to recognize a problem, should it occur.

Alternative remedies that have been advocated include the use of ginger, wristbands, acupuncture, and magnets. I believe these interventions are of limited efficacy. So one should not rely on them as the sole source of treatment.

A final thought

For those crews who stubbornly choose to ignore the possibility of seasickness until their time comes, they might take to heart my favorite quote as they look for the silver lining in the storm cloud of this humbling experience: “This is one of the compensations of the seasick. The extraordinary humiliation which accompanies their sufferings is very good for their moral characters.” (James Owen Hannay, 1926)