PREVENT Medical Emergencies

Prevent_Medical Emergencies
by John H. Wright, MD

Health and safety at sea, particularly under the stress of racing, requires planning and preparation for ultimate success. It is quite important to acquire an appropriate medical kit and know how and when to use it. It is more important to prepare so that it will not be needed; -i.e., “an ounce of prevention is worth a pound of cure.”

Know yourself and your crew-strengths, weaknesses, and special needs. It may well be advisable for all or some of the crew to visit with their doctor to explain that they will be isolated from usual medical care for a period, to obtain medication or advice concerning any ongoing health problems, and the skipper should be fully knowledgeable of these problems. A visit to your dentist may be equally useful. Certainly crew selection must consider health deficiencies. For instance, I regularly sail with an insulin-dependent diabetic crew member and our kit has insulin. The member and the skipper know when and how to use this. It might be unusually hazardous for someone who requires close, regular medical attention to be isolated for two weeks or more, and their doctors could so advise. Some illnesses are likely to become significantly worse under the stress of fatigue, seasickness, or physical demands not normally encountered. Ischemic heart disease (angina), diabetes mellitus, seizure disorders (epilepsy), many psychological disorders, drug or alcohol dependence, peptic ulcer disease, migraine (headaches), irritable colon problems, and even rheumatoid arthritis are only a few which are recognized to be frequently worse with stress. Perhaps, in a specific instance, none of these would disqualify a known and valuable crewmember, but medical advice is needed and planning for special care or medication required. Certainly ideal low risk crew health would be important to consider in crew selection.

Frequently, little attention is given to crew physical conditioning. We hear of some conditioning by Olympic sailors or by dinghy sailors or 12-meter contenders but seldom by others. Again, serious consideration to physical conditions should be given. A strong crew person with good cardiovascular reserve and stamina is much less likely to be injured or become ill. If possible, a regular exercise program with aerobics for two or three month’s pre-race would pay dividends in safety, enjoyment and performance. An additional benefit might be some weight loss (who needs a heavy crew for a long, downwind ride).

This brings up diet (pre-race). I have seen some articles in sailing magazines recommending training diets. I am not saying these might not be useful, but I would be satisfied for my crew to be on an established, usual, nutritionally sound diet (weight reduction if overweight), with great attention to adequate fiber intake for regularity and a reduction to a minimum in alcohol or other drug use for two weeks prior to the race. Vitamin supplements should be considered before and during the race.

Prevention of seasickness also begins prior to sailing with diet and avoidance of alcohol or much caffeine, spices, or fatty or heavy foods prior to departure. The use of anti-motion sickness drugs should be considered. The most effective items are prescriptions and must be obtained from a doctor. I like Transderm Scopolamine patches, but some in my crew prefer oral medication. We have had reasonable success with Phenergan and ephedrine in individual doses. I caution that these should only be used if tried previously, as the best anti-motion sickness medications all have some undesirable side effects – often sleepiness or dizziness.

Some instances of drug interaction with other medications exist and require individual doctor’s advice. Much of the prevention of seasickness lies with good physical conditioning and proper diet. Lack of fatigue, adequate warmth, how one is positioned on the boat, visual clues, lack of head motion and each individual’s means of dealing with unaccustomed visual clues versus vestibular clues (balance, acceleration, gravity) affects one’s responses. Most of us with any ocean time are familiar with this. We also know how handicapped one may be if significant “mal de mer” occurs. Again, this factor should be addressed in crew selection; however be aware that if serious seasickness does occur, the crew member will need care and on rare occasions, could become so dehydrated from vomiting and the inability to retain oral fluids that medical/hospital care for intravenous fluids may be required.

In consideration of health, maintenance and the prevention of problems, it is not often recognized, except in aviation circles, that smoking results in significantly poor night vision as well as all the other known effects on the lungs, throat, and heart and blood vessels.

At least two crewmembers should have knowledge of at least basic First Aid. Red Cross courses are not expensive, are readily available, and are useful. If possible, a course in CPR (cardiopulmonary resuscitation) should be obtained for two crewmembers. Of course, should you have a doctor or nurse as crew you would benefit.

If you are well prepared with knowledge, plans, good physical condition, and select crew, you may never even have to use your first aid kit. If you do, it will most likely be needed for common injuries.

One of the most common and preventable is a burn. “Sunburn” or ultraviolet injury, totally preventable, is best treated by absolute limitation of any more exposure, increased fluid intake, aspirin or Tylenol, and skin cleansing, particularly blistered. Thermal burns from hot liquids could be serious and, if a large area of skin is involved, could result in shock, later infection, or even death. The seriousness of a burn is related to both the area involved and the depth of tissue involved-i.e. first, second, or third degree. If the throat or lungs are involved, it can be a serious emergency. All except the most superficial and small area burns may disable a crewmember due to pain, shock, or infection.

Cuts (or lacerations) are also common. Most occur on the hands and face or scalp, and all may have worrisome bleeding which can be stopped best by direct pressure applied to the wound with fingers and a bandage. Usually a large bandage will maintain enough pressure if property placed. If the laceration gapes, some physicians might use adhesive “Steri-Strips” to bring the edges together. The main principles of wound care are: 1) do no more harm; 2) clean the wound, and remove foreign matter and dead tissue; 3) bring the edges together; 4) protect with a sterile dressing (wet dressing is no longer sterile or protection). Antibiotic ointment is sometimes used but is no substitute for the above principles. The best method of wound cleaning is gentle washing with an antiseptic soap such as Betadine or Hibiclens.

Fracture of the ribs, fingers, or forearm bones could occur with a fall or with a runaway winch. Fractures of the thighbone (femur) or the leg (tibia) are common on the ski slope but unusual on sailboats. Penetration of skin by bone ends or a laceration over the bone results in a “compound” injury, which is more severe because of infection danger. All fractures (except a single finger) are likely to disable a crewman for the duration. All must be treated by placing the affected part at rest (splitting) with adequate padding (swelling will occur) and any available material to keep broken bones from moving. I have used a rolled magazine or large cushion with battens or commercial splint. Fingers may be taped to other fingers or taped to a cloth (bandage) roll in the fist. Sprains (torn ligaments) and strains (muscle injuries) may also be treated with splitting. Larger bone fractures could cause a lot of blood loss into the surrounding tissue and, with pain, result in shock.

Shock is a condition characterized by falling blood pressure: symptoms include cold, moist skin; rapid, weak pulse; nausea; thirst; fear or even loss of consciousness. It may accompany many injuries especially particularly severe, extensive burns; considerable bleeding; severe infections (sepsis); prolonged vomiting or diarrhea; heat prostration; or hypothermia. Usual treatment of shock is aimed at increasing intravascular volume so that more blood will be returned to the heart, allowing an increased stroke volume and output, thereby increasing blood pressure and circulation; hence, the administration of IV fluids is a standard treatment. On a racing yacht, this may be impractical unless trained people and adequate equipment are carried; however, blood return to the heart can be improved by first aid means. Have the victim lie down with legs elevated; keep him warm; splint fractures; dress burns; stop bleeding; and, when he is able, give him liquids containing calories and salt such as broth, and ease pain with medicine. The presence of shock usually means a serious illness or injury that will require medical advice and likely more care than available aboard.

A head injury may result from a fall or a blow by an object such as the spars or winch handle and unconsciousness is quite serious if it occurs more than briefly. Scalp lacerations may be very bloody and can lead to shock. Serious head injuries with brain tearing or bleeding inside the skull are often fatal, even with prompt, expert care; however, basic first aid should be begun in all cases. Treatment is similar to that of shock but the victim is best placed on one side or prone since vomiting is common.

Breathing may be compromised by relaxation of the jaw and tongue, and airway maintenance is vital. Unconsciousness may be accompanied by seizure or unconsciousness may follow a seizure for some minutes. Medical help is necessary for any episode of unconsciousness beyond a very few minutes.
A multitude of minor, but in the circumstances important and disabling, illnesses might strike. Most require little more than symptomatic care but could disrupt the crew duty assignments. One could foresee flu, colds, sore throats, minor intestinal upsets, toothaches, urinary tract infections, minor vaginal infections in the female crew members, or (as has in the past occurred) drug or alcohol withdrawal or toxicity or psychiatric illness (psychosis). Some of the latter can be quite seriously disruptive and hard to deal with.

As a rule, significant medical illnesses such as hepatitis, pneumonia, heart attack, and stroke are unlikely if crew selection is good but if these occur would require medical help. I have often been concerned in a young group about appendicitis with its characteristic abdominal pain and vomiting but this seems to be very rare in the racing or cruising groups. Again, medical help by radio and rapid evacuation of the ill person may prove necessary. The characteristic pain and tenderness localized finally to the right lower area of the abdomen is the usual indicator for suspecting this diagnosis.

A crewmember overboard, particularly in the cold, coastal North Pacific (even if recovery is prompt) may experience hypothermia. This condition, a result of heat loss and a fall in body temperature, may be recognized by the victim’s confusion, blue lips, shivering, and muscular incoordination. Shock or heart beat (pulse) irregularities may occur and CPR training may come to use. The symptoms may be somewhat delayed at the onset. Any person overboard in cold water should be suspect. Treatment consists of warming, drying, and resting the patient. The skin should only be heated by placing the person in a sleeping bag or blankets and another person may supply heat by joining the patient in the bag (body contact). Avoid alcoholic beverages but when the patient is alert and not sick, warm liquids may be given. Seasickness is not an unusual accompanying complication.

In summary, many problems that could require treatment or even patient evacuation, can be prevented by crew selection, physical (doctor’s) evaluation, and conditioning. Safe practices and proper equipment can prevent many injuries. Planning and preparation can boost confidence and allow appropriate treatment of many conditions. A proper kit and the training to use it are indicated. A first aid course (Red Cross) and CPR training for two members is advised.