By Dr. John Ross, Medical Director PRAXES Medical Group
The most frequently asked question I get from sailors is – “what are the five ‘must haves’ in terms of medical supplies that I need for a long voyage?”
Of course, that is a tough question, so I canvassed a number of my colleagues who are also sailors to get their input. As a result, I had to make two lists, both of which address the fragility of humans in remote, sometimes hostile conditions. One list is short, one list is long… choose wisely.
Nicotine patches. If there are smokers on board, that is a ridiculous addiction – a long voyage is an ideal time to quit.
0. Okay, starting at “0” is cheating but…one of the most important medical supplies to have on board a marine vessel is ENOUGH WATER. Occasionally skippers miscalculate the volume of water required for an active crew in hot and/or dry climates. Water making machinery can break down. Rationing water can put the whole crew at risk of a variety of problems such as acute kidney injury, fainting with blunt trauma, kidney stones, and others with short-and long-term consequences. If you think you have enough, bring a little extra.
1. Anti-nausea meds. This is a ‘no-brainer’ but also confusing because there are many types available in various regions and countries. Ultimately individuals must find the medication that works best for them. Most have side effects. Drowsiness is an important factor, especially for someone on watch or requiring alertness. Dry mouth, difficulty passing urine, or mental fuzziness are other effects. There are more than 25 different compounds as well as herbal remedies available. A medication with a variety of delivery methods is best, One that is orally swallowed, dissolves under the tongue, per rectum, injectable into muscle or intravenous. Some can be obtained ‘off the shelf’ while others require a prescription.
Commonly used medications include dimenhydrinate (Gravol or Dramamine); meclizine (non-sedating); scopolamine (hyoscine) patches; promethazine; cinnarizine (Stugeron) that is popular with the British Navy, that can be obtained in Europe or Asia but not North America. Anti-nauseants that are effective in other settings such as cancer chemotherapy, post-op, etc. may NOT be as effective for seasickness according to research studies. These include odansetron (Zofran), prochlorperazine (Stemetil), metoclopramide (Maxeran) although some people may find them useful.
Please note, all the above medications are most effective if taken a minimum of 4 and sometimes up to 12 hours BEFORE seasickness sets in. Once symptoms begin, the efficacy of these meds will be variable. Having oral + intramuscular or per rectum dosing is ideal.
2. Pain meds. This should be another ‘no-brainer.’ For long voyages, a variety of substances should be considered. Acetaminophen/paracetamol (Tylenol) is useful for mild to moderate pain.
Anti-inflammatories (also called non-steroidal anti-inflammatories or NSAIDs) can be used as an alternative to acetaminophen in many cases, but because they are ‘anti-inflammatory’ they are particularly useful in musculoskeletal pain due to sprains, strains, and minor trauma. They do however have more potential side effects than acetaminophen. Irritation and occasional ulceration of the stomach or small intestine is possible. They can affect kidney function. They can affect blood clotting. They are generally very safe, and are widely used, but recognizing when to use them, how much, how long, and when NOT to use them is important. Examples are ibuprofen, naproxen, diclofenac, ASA, indomethacin, tenoxicam, ketorolac, celecoxib.
Narcotics such as codeine, morphine, oxycodone, hydromorphone, and other synthetic opioids also have a place when painful injuries or if there is a delay in accessing definitive me
dical care. Please note, using these controlled substances requires a doctor’s order, special prescriptions, a locked and controlled area on the boat, someone accountable for their use, and documentation of how they were used. Unused narcotics must also be accounted for. Some people do not understand these requirements and mismanage these medications. Government narcotic control acts have clearly defined expectations and serious legal consequences for misuse.
3. Antibiotics. These should be part of an extended voyage, but selecting which ones and when to use them can be tricky. Unfortunately, antibiotics, in general, are very overused – a sore throat is equated to ‘strept throat’; nasal congestion to sinus infection; a cough to pneumonia. All of these are VERY common and in adults most often due to viruses that do not respond to antibiotics. However, people take such drugs at the same time as the condition is improving on its own and they equate improvement with treatment.
To further confuse this, each body area requires a group of medications that are specific to the bacteria that are found there. Broad spectrum antibiotics (which cover multiple strains of bacteria) can be used for different body areas at the same time and are sometimes a good place to start, but they have the highest potential for developing resistance and may be less effective than narrow spectrum.
Meds to consider:
Ciprofloxacin – urinary tract infection; travellers diarrhea with fever; combination with metronidazole for select abdominal infections.Clindamycin – dental infections (tooth abscess); some abdominal or genital infections, some skin infections.
Doxycycline – malaria prophylaxis; sexually transmitted infections; pneumonia; some salt water related skin infections; Lyme disease.
Clarithromycin – pneumonia; skin infections (infected cut) (similar drug to Z-pak azithromycin but less resistance)
Metronidazole – combined with ciprofloxacin – if strongly suspect appendicitis or diverticulitis and far from any diagnostic tests or hospital, this MAY temporize.
Over-the-counter eye drops for ‘pink eye’
Ciprodex or Cortisporin ear drops – ‘swimmers’ ear.’
4. Wound Management. Bandaids, steri-strips, larger dressings, wraps, disinfectant solution – essentially a good first aid kit. Wound glue sounds good and can work well but can be tough to use and only selective areas are appropriate. Some cuts can be large. Although most will heal, eventually, having a way of closing larger wounds makes considerable sense in remote, constantly moving, marine settings. A suture kit with multiple sutures and/or a skin stapler with staple removal tool are ideal. One can get some basic teaching in person from someone who knows how to suture wounds. There are also online videos available to view prior to departure. Good wound management in the marine setting, especially in tropical areas, is REALLY important to prevent rapidly developing wound complications. We receive MANY calls related to wound complications.
Another part of wound management is preventing wounds in the first place. Zinc oxide cream, in large amounts, is a critical material to have on board sailing vessels. It is a skin barrier cream. It is good on the face for sunburn prevention. It is really useful in the groin and buttock areas to reduce the negative effects of dampness from sitting on gunwales, hard deck work, and lack of showers, etc.
5. Remote Medical Advice. International laws mandate that countries bordering oceans should have sea rescue centres and be able to provide timely medical advice. Like the wide range of medical kits and trained personnel on vessels, there is a very wide range of on-shore emergency medical advice available. Some understand the rigours of the maritime environment; some do not. Some may be comfortable providing advice for patients they cannot see or interview themselves; many are not comfortable with that. Some have high-quality medical training; some do not. Choose wisely.
It is possible for an experienced physician to provide a very good diagnosis and treatment of a lot of illnesses and injuries, working with non-medical personnel in remote settings. But it requires having a system in place that can quickly access skilled, well-trained doctors who understand the remote setting and can accept the limitations of providing remote medical care. PRAXES does this.