Medical Emergencies

No cruising emergency terrifies the typical yachtsman quite like the fear of a medical emergency. I believe this is partially true because most skippers fail to prepare for these emergencies with the same diligence that they give to other potential problems. Most prudent skippers give a great deal of thought and preparation to handling engine or rigging failure, but few gives similar attention to planning for medical emergencies. All too often, the medical supply consists of a commercially available first aid kit, which contains six aspirin, a dozen band-aids, a few seasick pills, and a book on first aid. This is equivalent to having a spare impeller on board and believing that one is prepared for engine problems. It seems that most yachtsmen fail in this area because the problem seems insurmountable. This failing is probably more a statement about the apparent aloofness of medicine than of the cruiser's ability. I believe that any captain who can bleed a diesel line, repair a sail, replace an impeller, starter, or alternator; can handle basic medical emergencies. He or she must have the appropriate tools, however. My purpose here is to help you be as prepared for medical emergencies as you are for engine problems.

I will first help you develop a tool and parts list. I will then try to give you basic understanding of the skills you will need to utilize these effectively. In an area such as Abaco, there are generally any number of doctors who are also cruising or chartering and are within hailing distance on the VHF radio. They are almost always willing to give assistance or advice, but rarely have equipment or supplies with them, since they are generally "on vacation"! Again the engine analogy come to mind, frequently you can find a mechanic who can provide mechanical assistance if you have the spare parts on board. If you have no parts or tools you are just out of luck.

I can remember once when we were going into Walker's Cay to pick up a crewman, who was to join us for the passage back to Florida, we overheard a conversation on the VHF radio. There was a nurse on Grand Cay attending a cardiac victim. A doctor was enroute from Sale Cay by speedboat and someone else was frantically searching on another boat for a laryngoscope and endotracheal tube. I never heard the end of the story, but it illustrated very well how the nurses, who may be the principle health care providers in many of the islands can be caught without proper equipment or backup. It further illustrated how some boats may have the necessary equipment, but it may not be in the right place at the right time or in the hands of people who know how to use it. The moral of that story is to have some medical emergency equipment on board, even if you don't know how to use it all! If you can learn the basics of how to use your medical equipment, then so much the better! You'll be better prepared longer voyages where professional help may not be quite so nearby.

The list of supplies in Table # 1 should serve as a guide for stocking the well found yacht. The prudent skipper will pick and choose from this list according to the needs of the crew and the cruising ground. Basically, the list includes those items necessary for any cruise. The quantities of the various supplies and medications will of course vary depending upon the time and distance from professional medical help. The skipper cruising the Abacos, who may at the most be three days from a doctor need fewer supplies than the boat who is three weeks from the Azores. The nature of the supplies and the skills necessary are basically the same. The charterer can usually relax and not worry quite so much. The charter company almost always maintains a chase boat which can rapidly reach your location, and except in the most adverse weather, arrange an evacuation to a medical facility. The basic first aid kit is probably appropriate in these circumstances.

The items included in Table # 1 include many over-the-counter medications (OTC), several prescription items (Rx), and a few controlled substances (C). Naturally, the OTC medications do not require a prescription, but in most cases care should be taken to store them out of the reach of children. Generally, no special precautions need be taken in keeping the drugs on board. The prescription items have to be prescribed by a physician, and it would be a good idea to keep a copy of the original prescription. Theoretically, the label on the bottle meets this legal requirement in most places, however if for any reason the medications are not stored in their original containers, you might asked to prove that a licensed physician prescribed them. Your personal physician should be your best resource person in obtaining these supplies. If your doctor is personally involved in boating or cruising, he or she will readily understand your need as long as the quantity of your request is consistent with the duration of your cruise, the size and health of the crew. The list included is intended to be a guide for your physician as well as for you. It will save him or her a great deal of time and perhaps help prevent oversight. Your personal physician may also wish to make additions or deletions base upon knowledge of your individual situation or newer better products that are constantly being introduced. Some products, which have in the past been by prescription only, are occasionally being changed to OTC.

The items, which are classified as controlled substances, are generally those which have some abuse potential and therefore require some special attention. First of all, you'll have to have a physician who is comfortable with your "potential" need for these supplies and who trusts you to be responsible for their use in his absence. They should be locked, preferably double locked, with access restricted to the captain or other responsible crewperson. Hopefully, these medications will never be utilized. If this is so, when they expire they should be returned to the pharmacist or physician for proper disposal. You should obtain a receipt for their return and provide the prescribing physician a copy of this record indicating the ultimate disposition of these controlled substances. He will appreciate this sort of record keeping on your part if you ever need to ask him to prescribe these substances again! If you utilize the medications, a careful log should be kept. A separate log would be appropriate on a cruise ship with a sick bay, but on a small private yacht, an entry in the captain's log is probably sufficient. Copies of the log and any medical records documenting any professional medical treatment later will again be appreciated in your physician’s chart.

You can't possibly remember how to use all of these products, even if you are a physician or nurse. I carry two basic references on my boat, the Merck Manual and the Physician's Desk Reference (PDR). I would recommend them highly to you. They are generally available at most large bookstores. You may be able to buy them at a steep discount if you can be content with last year's edition. Your physician may even give you an older PDR, since they are generally provided to physician’s offices free of charge.

Your doctor can also assist you is selecting a few minor surgery instruments. I would recommend, at least, a scalpel, a hemostat, a needle holder, some suture, a pair of tissue forceps, and some tissue scissors. The doctor's office will probably be willing to sterilize these instruments for you if you ask. Additional minimal equipment should include a blood pressure cuff, a stethoscope, and a thermometer.

If you are planning to do extended cruising, I would recommend that as part of your preparation, enroll in a paramedical course at a local community college. You won't need to know all of the material, like the people who intend to work in a rescue vehicle, but it will give you valuable background for dealing with most emergencies! This curriculum is the best thing going for the layman with no medical experience.

Hopefully, you will go to all this trouble and never need any of these supplies. In my experience, you will however find frequent use for the more minor supplies. Rarely, will you need this medical kit to "save a life", but frequently, you will be able to relieve significant pain, prevent a minor infection from becoming major, and generally make your crew more comfortable.

Now let's deal with some specific medical problems which you may encounter!

HEART ATTACK

The potential problems which seems to command the most interest in discussions of medical emergencies at the local yacht club are heart attacks and appendicitis. If viewed rationally, neither of these problems truly deserve the fear they generate! We will help you be prepared for both, although you'll likely never need to deal with either.

In order to properly manage the victim of a heart attack, one really needs a cardiac monitor, in order to detect and treat arrhythmias. These are electrical disturbances of the heart muscle, causing the heart to beat irregularly. These irregular heartbeats result in a loss of pumping capacity of the heart. If this pumping capacity drops below some critical level, vital organs begin to suffer and death may occur. It is impractical to keep these monitors on the typical cruising boat. In the absence of these devices even doctors are quite limited in their ability to care for the victim of a myocardial infarction (or M.I. the technical term for "heart attack").

Before you can treat this or any condition you must diagnose it! Before you can diagnose it you must suspect it! There is an old saying in medicine, "when a young man complains of his heart--think of his stomach, when an old man complains of his stomach--think of his heart!" Although, you need to know a little more than that, it will help keep you from ignoring a serious "stomach ache." Generally, heart attacks occur more frequently in men than women, and usually in middle age or older men. They frequently follow physical exertion or severe mental stress. Often, there will have been warning pain in the chest, called "angina", for months or even years. Most patients will describe a "crushing" chest pain that is more severe than their usual angina. I've heard it described as like "like an elephant sitting on my chest". Others like my own father experience "silent infarcts" and have NO pain. In addition to the pain, the heart attack will sometimes be accompanied by a change in skin color. This change, called cyanosis, gives the skin a dusky gray or bluish appearance and is do to poor blood flow or poor oxygenation. High blood pressure ( > 140/90) or cardiac shock (blood pressure < 90/40) also sometimes accompany the myocardial infarction. The hypertension (high blood pressure) should be treated as discussed elsewhere.

Based on these criteria, if you suspect that an infarction has occurred, I would encourage you to arrange evacuation if at all possible. If evacuation is not possible, and there are no trained professional available, review the appropriate section in the Merck Manual and precede with the best treatment you can provide.

The first and most immediate threat to the heart attack victim is the potential for cardiac arrest. The management of this particular complication requires a working knowledge of cardiopulmonary resuscitation (CPR). Completion of a course in basic CPR is one of the requirements for the Coast Guard's captains license, but private yachts have no such requirement. The prudent skipper will, of course, hold himself to the same standard. As for me, I prefer to have a second person with CPR training as well. There is an advanced course in CPR available, which teaches the use of medications during the resuscitation effort. I have found it quite helpful, and would recommend it highly. It of course, is most useful to health care professionals and paramedics.

The basic treatment of the myocardial infarction consist of REST, pain relief, and treatment of arrhythmias. The rest is obvious, but make sure that the individual actually remains still. The pain relief requires you to utilize the morphine or Demerol. This condition is one of the few that justifies your having and using these drugs. Consult the Merck manual for exact dosages, but 10 mg. of morphine is an average size dose for a typical person in severe pain. This dosage is usually repeated every four hours by intramuscular injection. Severe pain may require more frequent dosages, which I believe is preferable to going to higher dosages. If you have the capability of starting and maintaining an intravenous line, this is generally the preferred route of administration. If this is the case cut the dose in half and give it more frequently. If you have access to nitroglycerine tablets, this medication is also useful in relieving cardiac pain. I did not include it in Table # 1simply because it is such a specialized medication and does not store well. I tried to select those medications that have broad applications for a number of conditions.

If you have the capability of maintaining the intravenous line, arrhythmia prophylaxis is justified. Lidocaine is a relatively safe drug and in the setting where you have no way to monitor for the presence of arrhythmias it is probably safer to give the medication. Refer to your Merck manual for dosages and do your arithmetic carefully. If you don't have a Merck Manual, 1 mg./kg. given by intravenous "push" is a good loading dose. One-half of this amount should be repeated in ten minutes. A maintenance dosage of 2-4 mg./minute should given by an intravenous "drip". As an example, a man weighing 154 lbs (70 kg.) would require 70 mg. of lidocaine. This would be 7cc. of the commonly supplied 1% solution (do not use the ones containing epinephrine) initially, followed by one-half of this dose in ten minutes. For the maintenance dosage, one liter of intravenous fluid with 1100 mg (110 cc) of lidocaine added, will make a solution containing approximately 1mg. /cc. If this is run at 120 cc./hr., 2mg./ min. will be supplied. This will also supply the fluid need for the average situation.

I did not include emergency oxygen in my list. I considered it impractical to carry more than a few minutes supply on a small yacht. If you happen to have included it in your kit--use it now!

You should also listen to the lungs periodically with your stethoscope. If you hear any "bubbling" or "gurgling" in the lungs, this probably represents fluid overload. In this case the diuretic Lasix should be started.

Check the blood pressure frequently. If you consistently find an elevated pressure you should begin one of the anti-hypertensive medications. The new class of medications known as calcium channel blocker ( Procardia, Calan ) is particularly safe and effective. Their purpose here is to reduce the strain on the heart and therefore reduce the workload of the heart. This brings us quite naturally to a discussion of hypertension.

HYPOGLYCEMIA

This particular malady occurs with sufficient regularity in some diabetics that you as the captain need to know if your guests or crew have diabetes. It occurs almost exclusively in patients on insulin. I have included it here in this discussion because it is so simple to treat, if recognized. It is also very dangerous or even deadly if not recognized!

The problem typically presents itself when the diabetic changes their activity level or diet, both likely on a cruise! Initially the hypoglycemic patient will feel weak, "shaky", or faint and dizzy. In more pronounced hypoglycemia the affected individual may demonstrate slurred speech, appears intoxicated, pass out or progress into a coma and become unresponsive to painful stimuli.

In all cases the individual needs sugar rapidly. In the patient is still awake, you can simply give candy, coke, orange juice with sugar added, etc. The unconscious patient deserves an intravenous infusion of a glucose solution if you have it and if you can access the veins. Realize that diabetics frequently have very poor veins, so if you're not experienced at starting an i.v., this is not a good place to be learning. You can probably get enough sugar into the individual to sustain life and ease the emergency by carefully placing sugar cubes in the victims cheeks. You should place the victim on their side and remain with them constantly to prevent aspiration (sucking the sugar cube down their lungs). You should also take special care to make sure they don't BITE the doctor as they wake up. Probably a rolled gauze or face towel placed between the teeth will give sufficient protection.

URINARY INFECTIONS

This is one of the most common simple medical problems, and one you are likely to encounter. It is simple to treat when simply involving the bladder (called cystitis). Pyelonephritis (kidney infection), is a related problem but is more serious.

Initially cystitis usually presents itself with burning upon urination, frequent urination, and sometimes a little blood in the urine. If treated early, a simple inexpensive antibiotic such as ampicillin, will usually provide adequate therapy. Five hundred milligrams of ampicillin given orally four times daily for seven days is sufficient for most cases. Pyridium 200 mg. given three times daily for the first three days will ease the burning or stinging. Be cautioned that this medication will give an orange tint to the urine. This color is an effect of the medication, not a worsening of the condition.

When treating a bladder infection, you should check for fever and for back pain. A temperature greater than 100.0 F or severe back pain where the lower ribs meet the backbone suggests that infection may be involving the kidneys. If so ampicillin is still an appropriate first choice of a medication. However if the patient is getting worse during the first forty eight hours, additional or more potent antibiotics are in order. My next choices form the list provided, would be Bactrim DS or Ceclor.

When treating these infections, you need to pay particular attention to any allergies that your patient may have. For these conditions we use a lot of penicillin (ampicillin) and sulfa drugs (Bactrim DS), these are two of the most common drugs to cause allergic reactions!

If fever is present, try to keep the fever down with aspirin or Tylenol. Increasing the fluid intake of the patient is particularly important if fever is present.

GASTROINTESTINAL DISORDERS

Judging from the frequency with which yachtsmen ask about certain medical problems, I'd say that the fear of appendicitis is second only to the fear of heart attack. This particular fear is probably much less justified than the former. Occasionally, people will even ask if they should have their appendix removed before a trip, just in case. I certainly think that such drastic prophalaxis is not justified. Even though we think of appendicitis as a surgical disease, and indeed it is probably best to treat it surgically, I am reasonably sure that a number of cases have been successfully managed medically.

Appendicitis should be suspected if your crewman or guest complains of persistent, worsening right sided lower abdominal pain. It is usually accompanied by a low grade fever (100.0-101 or sometimes higher) and may be preceded by a poor appetite for a day or two. In the earlier stages of the evolution of the disease the pain is usually NOT localized to the right lower abdomen and may actually be located more in the upper portion of the abdomen, near the stomach! As the condition worsens, peritonitis begins. This is a general inflammation or infection of other organs and structures in the abdomen. It is characterized by a rigid abdomen, intense guarding with the abdominal muscles, and rebound tenderness. Rebound tenderness is that pain generated by suddenly releasing manual pressure on the abdomen. To test for rebound tenderness you should very gently press in on the abdomen with your hands, approximately 1"-2" and then quickly release the pressure. Your patient will probably not let you do this more than once.

If you determine that appendicitis is a likely possibility, you should attempt to arrange evacuation, if possible. If this is not possible, you should keep the person at rest, treat their pain, and begin antibiotics. From the list I've provided you, the combination of Cleocin and Ceclor would make a lot of sense. I'd use Cleocin 300mg. by mouth every six hours and Ceclor 250 mg. by mouth, also every six hours. You should alter your course if necessary to get to a proper doctor as soon as possible.

Although much less dramatic, a much more common gastrointestinal disorder, is seasickness. People are not uniformly susceptible to seasickness, but almost no one is immune. Hopefully, you will have previously sailed with anyone who might accompany you on a long cruise. This should give you a good idea how they will respond to the motion of the sea. Seasickness is one of those conditions easier to prevent than to treat. For this reason, I try to insist that every one on my boat wear one of the scopolomine patches from the beginning of the trip. Naturally, this is a little difficult to "enforce" without seeming to be a Captain Bligh. Most people have a natural tendency to avoid taking medication unless absolutely necessary. The other side of this problem, however, is that if they don't accept this prophylaxis they often won't be able to stand their watch. This situation forces someone else to double up on duty--threatening the safety of the vessel and crew if the on duty watch is less alert than they should be!

Again my philosophy is prevention rather than treatment, I've had excellent results prescribing Transderm Scop. This patch should be placed behind the ear and replaced every third day. You should allow someone else to place it on your skin. It is imperative that you avoid getting any hair under the patch. I have actually seen the system fail because the user had attached it to the hair than DIRECTLY on the skin! After touching the patch you should wash your hands carefully. The only significant complication I've encountered is that some people will encounter sufficiently blurred vision to interfere with their ability to read day markers from a distance. Practically speaking this is not really much of a problem, because if you're running where there are a lot of these kinds of navigational aids you are not likely to have much of a sea running.

For your crew who are skeptical of the scopolomine, I'd recommend Sea Bands. These are elastic bands, worn around the wrists, which work on the principle of acupuncture. Although I am not an expert on acupuncture, I've read studies from the United Kingdom where these bands were used successfully in pregnancy to prevent the nausea of pregnancy. Furthermore, I've seen them work quite well on my own boat.

Reglan is a medication I've recently added to my list not because I've had sufficient experience with it at sea, but because we've had such good success with it in combating the nausea associated with cancer chemotherapy.

Dramamine is an over the counter remedy for motion sickness. I try to avoid it at all costs on my boat because it makes most people so sleepy that they are useless as crew. Phenergan, particularly the rectal suppository, has a special place on my formulary because you can get it into your patient's system even when they can't keep anything on their stomach! It seems to be less sedating than Dramamine.

In addition to the drug therapy discussed, remember that certain other actions can reduce the impact of the motion sickness. Placing the individual near the center of the vessel will minimize their motion, therefore minimizing the nausea. If yours is a sailing vessel, make sure that you have up sufficient sail to at least minimize the rolling action of the waves. Try to get the crewman back to duty as quickly as possible. It seems that having a duty, something to keep the mind "occupied" helps. I've noticed that the helmsman rarely gets sick. I think it is some combination of duty and looking at the horizon.

Traveler’s diarrhea is less of a problem on a cruising boat, than for other travelers, but only to the extent that you cook and drink on your own boat. When eating or drinking ashore, this is frequently a problem, although I've never had a problem anywhere in the Bahamas. Again, I'd recommend prevention! According to The Medical Letter Bactrim DS provides excellent prophylaxis. I recommend it to all of my patients who travel, unless they are allergic to sulfa drugs. If you don't take my advice on the prophylaxis, Pepto-Bismol (OTC) is reported to provide moderately good results. Imodium (Rx) would be a better choice if you have it available. If the diarrhea should continue for a prolonged period of time, you should take special care to replace the fluids lost by the diarrhea. Gator-aid is a commercially available product specifically designed for oral replacement of the body's electrolytes.

BURNS

Burns can range from the simple and merely annoying to the very complex and life threatening. In order to evaluate the burn, you must know that doctors grade burns into 1st, 2nd, and 3rd degree burns.

Granted, I may oversimplify here but basically, first degree burns are those such as a sunburn. These are characterized by redness and pain. These rarely become serious, but may require pain relief. Topical anesthetics may provide some relief but one more time prevention is better then treatment! I'd recommend liberal use of the sunscreens.

Second degree burns may occur from a severe sunburn, or other burns such as contact with a hot liquid. Blistering and pain may characterize these. Care should be taken to prevent these burns from becoming infected! An infection can convert a second degree burn to a third degree burn! Frequently, the blisters may need to be "unroofed" so that the trapped fluid does not form a focus of infection.

Third degree burns are those kinds of burns encountered in a blaze from a flammable substance. If the victim survives the risk of smoke inhalation, the burn chars the skin, producing a black escar much like a piece of steak or chicken left on the grill too long! These burns may be painless, because the nerve endings are destroyed. This lack of pain does not in any way diminish the seriousness of the condition! This constitutes a serious medical emergency! It requires a level of care that taxes most general hospitals! The manpower and quantity of supplies to care for these patients can be enormous! The initial therapy must consist of: 1) debride the escar and other dead tissue, 2) prevent infection, by good sterile technique and antibiotics, 3) clean and dress the wounds twice daily with silvadene cream, and 4) do the best you can to relieve pain and replace fluids! These victims probably need evacuation even more than your cardiac patients!

LACERATIONS

The sailor is probably better prepared to handle this emergency than most others. If significant bleeding exists, try direct pressure for at least five minutes. If direct pressure does not stop the bleeding, you may need to apply a tourniquet. Your blood pressure cuff makes a very nice tourniquet, because you can apply a precise, measured amount of pressure over a wide area. This sort of pneumatic tourniquet is much less likely to induce additional tissue damage than a tourniquet fashioned out of a handkerchief and a stick, "boy scout style".

The combination of direct pressure and a pneumatic tourniquet may permit you to identify any specific, persistent "bleeder". Once identified, you may be able to grasp this vessel with your hemostat and ligate it with chromic suture.

If possible, before you do anything to a laceration you should clean it with water or preferably saline. Phisohex is probably the cleansing agent of choice, and Betadine is frequently used in the emergency rooms. If I were caught in a bind in a cruising situation, I wouldn't hesitate to use Joy. Once the wound is clean, you should anesthetize it before you attempt to suture it. I prefer lidocaine 1 % for most applications.

If the laceration is superficial, no suturing should be necessary. These superficial cuts can be managed by cleansing the wound and applying some steri-strips and a bandage. If the wound is a deeper, involving muscle or deeper structures, then sutures will be required. In general, we use absorbable suture (such as chromic) in the deep layer and a non-absorbable suture (such as nylon) in the skin. The non-absorbable sutures will have to be removed in seven to ten days. I remove sutures around the face, ears, and neck after four days.

If you keep in mind that, once anesthetized, suturing the skin is just like doing sail repair it may seem easier.