ClipperTelemed+ and PRAXES Medical Director, Doctor John Ross, shares his top five essential medical supplies he recommends every sailor carry on-board their vessels for long voyages.
A question frequently comes in to me from sailors. They want to know what are the ‘must haves’ in terms of medical supplies that should be stocked for a long voyage at sea. Of course, that is a tough question. So, I canvassed a number of my colleagues who are also sailors, including Clipper Race 2013 – 14 winning skipper, Eric Holden, 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.
- Nicotine patches. If there are smokers on board, that is a ridiculous addiction – a long voyage is an ideal time to quit.
- This is cheating by slipping an extra item in, but one of the MOST important medical supply to have on board a marine vessel for long journeys 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 problems such as acute kidney injury, fainting with blunt trauma, kidney stones and others with short and long term consequences.
- Anti-nausea meds – This is a ‘no brainer’ but also confusing because there are so many available or not available, in various regions and countries. It seems individuals must find the medication that works best for them. Most have side effects. Drowsiness is an important factor to consider, 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, that is orally swallowed, dissolved 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 but also marketed as Sleep Eze and other sleeping meds); meclizine (non-sedating); scopolamine patches; odansetron (expensive) and a few others that can be obtained in Europe or Asia.
- 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) can be used as an alternate 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. However, they do 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 and celecoxib.
Narcotics such as codeine, morphine, oxycodone, hydromorphone and other synthetic opioids also have a place when painful injuries or medical problems arise and there is a delay to accessing definitive medical care. The use of these controlled substances require 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 consequences for misuse.
- Antibiotics – There is no question antibiotics are grossly overused around the world. People believe that a stuffed nose is bacterial sinusitis, a sore throat is strep throat, a cough is pneumonia, diarrhea requires treatment and so on. All these are rare to uncommon. Humans have excellent immune systems that can, if given a chance, respond to all sorts of challenges. Sometimes doctors do not take time to counsel people and explain illnesses that get better on their own, or patients demand a pill as a ‘quick fix.’ Patients end up taking an unnecessary antibiotic while they are getting better anyway and they attribute the cure to the pill – a false association. But it leads to thinking a visit to the doctor and a pill are required when similar symptoms occur again. Diarrhea, vaginal infections, rashes, antibiotic resistance are all side-effects.
Nevertheless, there are times when they do have a role:
- Sore throat + fever + tender, swollen lymph nodes in the neck only (if there are swollen nodes in many body locations it is probably something else) plus white material on the tonsils is probably ‘strept throat.’ However, even then, there is controversy about use of antibiotics.
- Green mucus, fever, frontal headache is probably bacterial sinusitis.
- An increasingly painful tooth that is starting to cause facial swelling is probably a bacterial dental infection.
- Fever, cough, productive yellow/green sputum, maybe one sided chest pain is probably pneumonia.
- Burning, frequency, urgency, passing small amounts of urine is probably a urinary tract infection.
- A cut three days ago that is getting redder and leaking some fluid is probably infected.
- A generalized abdominal pain that has localized to the right lower area that hurts with every wave bump, associated with a mild fever, nausea and loss of appetite may be appendicitis.
Each area of the body is prone to different types of bacterial infections. Specific antibiotics treat certain areas better than others – some may not work at all in one area and be first choice in another. So a well-stocked ship should ideally carry a few different choices that can be used if indicated. Randomly using antibiotics or relying on ‘cure all’ broad-spectrum drugs is not ideal. Discussion with someone with experience prior to antibiotic use is recommended. They can suggest what to take with you, when to use them, and what to watch for.
- Wound Management Supplies – Band-Aids, steri-strips, wound glue (sounds good and can work well but can be tough to use and only selective areas are appropriate), larger dressings, wraps, disinfectant solution – essentially a good first aid kit. 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 on-line videos available to view prior to departure. 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, lack of showers, etc.
- On-line Medical Advice – Crew on large container ships and freighters, fishing vessels in international waters, large yachts and a wide range of vessels have a variety of medical kits that range from extremely basic to very extensive WHO kits. Captains, skippers, and crew have a broad range of medical or first aid training. International laws mandate that countries that border oceans should have sea rescue centers 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 rigors 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.
With current medical knowledge and using modern telecommunication systems, it is possible for an experienced physician to provide 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.
Ship and boat owners spend large sums of money on high tech equipment and yet medical care of the crew is an afterthought. In 2015, it is possible to provide rapid access high quality advice using standardized well-stocked medical kits designed by the on-line doctors and this is a service that Praxes Medical Group provides.