First aid and beyond.
• Health matters certainly even more when professional help is not directly physically at hand although today professional advice will be available even in the remotest of places over long-range radio or through satellite connection.
• All crew members should start a passage in good health and endeavour to stay healthy for the duration of the passage if not the whole cruise.
• All crew members should have followed a first aid course or attended a demonstration of cardio pulmonary resuscitation CPR.
Prevention is paramount.
Prevention of illnesses should start with having all the
• Required vaccinations for the countries to be visited.
• Have an up to date tetanus vaccination as a minimum.
• A yellow fever vaccination will be required when visiting affected countries.
• Consult government websites on travel advice.
It also means that anybody using drugs for a chronic condition needs to make sure they are available when needed or have enough for the duration of the trip.
Prevention of accidents and injuries is an important part of staying healthy.
• Sensible footwear should be worn not only ashore but also when walking in shallow water or on a reef as well as on deck to avoid badly stubbed toes and lacerations which are easily infected in the tropics.
• Use sun screen extensively to prevent UV damage to the skin. A mostly forgotten area is the top of the feet and the back when swimming.
• Wear a T-shirt when snorkeling!
Drugs and wound materials.
To deal with non chronic health matters or accidents the skipper needs to organise a supply of drugs and materials.
To concentrate the mind and make storage of supplies oversee-able one could discriminate between First aid and Second aid and store materials and drugs in boxes labelled as such.
First aid box to contain wound treatment and skin disinfection materials and some drugs to treat most frequently encountered minor problems such as cuts, scrapes, burns, insect bites and stings. Maybe not so minor for the sufferer also sea sickness and diarrhoea treatment and common pain killers and other OTC drugs
The second aid box to contain all drugs to treat more serious infections, malaria drugs. and drugs needed for serious conditions. Also injections, with a variety of syringes and strong pain killers only available on prescription.
For suggestions see at the end of this discussion.
Each box should have its own drugs list including details of how many of each drug and their expiry dates. (see later on expiry dates)
Skin wounds and burns are most commonly encountered.
Treatment of wounds:
•Open wounds cuts and scrapes especially in the tropics can easily become infected and can develop into more serious conditions. Proper care to avoid infection or contamination caused by visiting flies is essential.
• Open wounds should not be allowed to dry out, they should be cleaned, disinfected and covered. The quickest way to heal wounds is to retain a balanced moisture environment with a hydrocolloid plaster. Stop bleeding if present with a clean bandage.
• Clean the wound with clear water or anti septic wipes (Savlon etc.)and remove any particles or debris with tweezers. An oozing wound should be cleaned till the oozing stops.
• Apply an anti septic (Savlon cream) or antibiotic (Flammazin cream or Bactroban cream) particularly on wounds on the foot to prevent infection.
• Cover the wound with a non adherent dressing (Savlon hydrocolloid or similar) or a fatty ointment gauze (Tulle Gras or Povidon-iodine gauze or similar) Ideally the wound should heal in about 5 days after which the skin has reformed and the dressing can be removed.
• When infection occurs or is suspected-re-clean the wound and apply an antibiotic creme (Flammazine, or Bactroban) and re-dress.
• When the infection does not subside and appears to get worse an antibiotic treatment with a small spectrum penicillin:Flucloxacillin 500 mg capsules twice daily for 5- 7 days may be necessary.
• Minor cuts can be held together with adhesive strips (Steristrip) or tape but deep cuts of more than 6 mm or where muscle is protruding or with jagged edges require stitches.
• Irritating itch after insect bites or jelly fish stings is best treated with a local anaesthetic (Solarcaine or Nestosyl) or with non-drowsy making antihistamine tablets (Claritin or Zirtec). This stops rubbing the itching spot and prevents opening wounds that would certainly get infected.
Burns.
Burns come in classes from first degree minor burn up to very serious third degree burns.
• All burns should be cooled for an extended period up to 30 minutes in cooled clean water or a cold compress to prevent deeper tissue damage. Even some time after the event the burned area should be cooled. Keep a cooling bandage in your fridge .
Minor first degree burns caused by exposure to hot metals or fluids or over exposure to the sun or sometimes by a slipping sheet through the hand show as:
• Skin is red but intact
• Pain or sensitivity to touch.
• Swelling may occur but without blisters.
Treatment
• After the initial cooling apply carefully a local anaesthetic (Solarcaine gel or Nestosyl creme) and cover the burn with a sterile gauze bandage or non adherent plaster (Melolin).
• If needed take a painkiller (Paracetamol Ibuprofen Diclofenac or others.
• Minor burns should not require further medical attention unless they involve a substantial part of the feet, face, the groin or buttocks or a major joint. Then seek medical help as a matter of emergency.
Second degree burns are deeper into the skin, through the outer layer.
• Skin colour can vary between intensely red and grey
• Severe pain and swelling.
• Blisters develop
Treatment
• Start with cooling the burn until the pain subsides.
• Do not puncture the blisters.
• Prevent infection by covering with Povidon Iodine impregnated gauze dressing or apply Flammazine creme
• Cover the wound with a sterile gauze dressing. In case of an open wound disinfection is a must.. Covering it helps the pain, and keeps bacteria at bay.
• Any open wound should be checked for infection
• Take pain killers if required
Third degree burns involve all layers of the skin and result in permanent tissue damage.
• The area of the burn can be black or white,
• No pain because all nerves are destroyed
• Immediate specialised hospital treatment is required.
Sea-sickness.
Sea sickness is caused by a clash in the brain between conflicting signals received from the equilibrium organ in the ears and visual signals from the eyes. This clash can result in a general alarm phase of the body with yawning as the first sign, then lethargy and shortly later vomiting. It seems 10 % of the population gets never sea-sick, 10 % will always be sea-sick and the rest will experience sea-sickness in varying degrees and recover of it after a short time or get immune to it.
Lying in a bunk with closed eyes or sitting in the cockpit concentrating on the steady horizon helps to diminish the eye signals mitigates the clash and hence sea sickness
Treatment, preferably prophylactic is sensible since the sickness is quite debilitating.
• Anti-emetic drugs, of the antihistamine class such as cinnarizin (Stugeron) claim a name for themselves as anti sea sickness pills but are sedatives. The non sedative antihistamines (Claritin, Zirtec, etc) do not claim to be effective in this field rightly so.
• Always start antihistamine tablets 6 hours or more before departure and take the next dose every 8 hours. When vomiting occurs the next dose will not stay long inside and end up in the sea.
• Scopolamine is the more effective drug and can be taken by mouth (Kwells) or can be applied as a plaster (Scopoderm TTS, Transderm Scop, Transderm-V) and absorbed through intact skin into the blood stream. The plaster is not affected by vomiting and becomes effective within 6 hours and remains effective for 3 days.
• For children I would cut the plaster in a part that would suit their body weight relative to a 80 kg adult. There is no need to attach the plaster behind the ear although it allows checking if it is still in situ. All it needs it a dry patch of intact skin where it can stay for 3 days. Unpleasant side effects such as sleepiness, vertigo and blurred vision should lead to peeling off the plaster. One might not need a second or third plaster on a longer voyage since most people get used to the motion after some time and stop reacting to it.
Be aware that vomiting not only dehydrate but also has an effect on regular medication such as oral contraceptives that may be vomited out and hence will not be effective.
Diarrhoea.
Diarrhoea, projectile vomiting and nausea not caused by sea sickness are signs of food poisoning.
All foods contain small amounts of infectious organisms, bacteria or toxins that not normally cause any problems. Poor hygiene when preparing food or inadequate storage can result in multiplication of unwanted bacteria to a level where they cause illness especially when natural resistance or the immune system is inadequate as is often the case with elderly people or babies.
Treatment depends of the cause of the poisoning and should start immediately
• Replace lost fluid (First sign of dehydration is lethargy and dark urine) with Dioralite solution or as many sips of water until the urine becomes clear.
• When diarrhoea remains persistent start a course of wide spectrum antibiotics, Ciprofloxacin (Ciproxin) 500 mg twice daily for 3 days.
• Use of anti diarrhoeal drugs (Imodium or Lomotil) is best avoided since it stops clearing your system of the unwanted bacteria or toxins which could prolong the problem or make matters worse.
• If unavoidable take Imodium, starting with 2 capsules and then every hour 1 capsule till diarrhoea stops up to 6 capsules (total 8) a day.
• If the diarrhoea persists for more than a few days you need medical help.
Ear infection.
In the tropics diving, snorkeling and swimming can cause ear infections due to water not being expelled from the ear canal. A wet or damp ear canal can easily become infected with bacteria. Keep the canal as dry as possible with iso-propyl alcohol and the infection should clear up.
If the inflammation remains a problem use Sofradex or similar preparation but this needs to be acquired on prescription so ask your GP.
Malaria.
Malaria is present in Vanuatu, Papua New Guinea, Solomon Islands with a relatively low risk in coastal areas and no risk in cities. The disease is caused by various Malaria parasites of which the M. falciparum is the most dangerous and in the mentioned countries most prevalent.
The Anopheles mosquitoes transmitting the parasites are active during the night between dusk and dawn.
• The best defense is to avoid being bitten in the first place by using an effective insect repellent such as Deet 50% (diethyl-m-toluamide) or Autan 20 % (Icaridine). No drug gives 100% protection but that should not be an excuse not to use them.
• Stop mosquito invasion inside the yacht by using insect screens and or sleep under impregnated mosquito nets.
• Use battery-powered insecticide fans or sprays at night.
• Drugs are available for prevention against developing the disease as well as treatment once the disease has established itself. Unfortunately the parasites have developed a resistance against the most common drugs mefloquine (Lariam) and chloroquine (Nivaquine) in most areas as well against the latest front line drug Artemisinin.
• Therefore seek always the latest advice about which drugs to take.
• Different drugs have different dosage regimes and some have side effects that make them less advisable. E.g. Doxycyclin can cause severe hyper sensitivity against sunlight or mefloquine (Lariam) can cause depression or other mental problems in people with a certain susceptibility in that area.
• Whatever you choose start a test for a few days, in the case of mefloquine 3 weeks before leaving since side effects then show up before departure and not when the drugs need to be taken.
• Read the instructions carefully since treatment needs to be maintained to well after leaving the area.
• Currently a vaccine is in the latest phase of registration but won’t give much more than 30-40% protection and is unlikely soon to be available for individual use.
Treatment of malaria:
If, despite prophylaxis, you develop a fever of at least 38°C after you have been in a malaria area, are getting worse and have no access to a doctor, then you should treat yourself as if you have malaria.
Seek before you leave advice on what tablets to take with you from the a specialised tropical disease centre.
Dengue.
Dengue, also known as break bone disease is caused by viruses transmitted by infected Aedes mosquitoes who are active during daylight hours. These mosquitoes have very conspicuous black and white stripes on body and legs. There are no drugs available to treat or prevent the disease once bitten by an infected mosquito.
Prevention against being bitten is paramount. Wear during trips inland loose clothing with long sleeves and long trousers, Apply Deet with a concentration of 50% on non covered body parts especially ankles feet and neck. It remains effective for about 6 hours. Deet 50% is effective as is Autan 20%.
All other so-called repellents are not proven effective and unreliable.
Symptoms:
• High fever up to 40° C (104° F),
• A prominent skin rash like measles,
• Joint and muscle pain,
• Pain behind the eyes
• General unwell being lasting for more than a week.
Full recovery may take several weeks. Seldom the disease develops into a the more serious haemorrhagic fever that needs hospital treatment and can be lethal.
Dengue can be attracted in most tropical Pacific islands such as Micronesia, French Polynesia, New Caledonia and even in sub tropical north Queensland Australia. Most responsible governments will announce an outbreak but in the past one Caribbean Island denied all knowledge just to protect their own good name and/or the tourist industry.
Ciguatera.
Ciguatera is caused by toxins from particular marine micro algae, living on dead coral and seaweed. These toxins accumulate in reef fish feeding on the algae and sea weed without causing any harm to the fish and is passed along the food chain from small fish to bigger predator fish.
Ciguatera toxin accumulates in humans in fatty tissue as well when they consume the bigger fish. At a certain level it will cause nausea, vomiting, abdominal pain and diarrhoea, starting between one and six hours (maybe more) after eating the one too many fish. This can get worse, with tingling of the lips, hands and feet, and can progress to paralysis and death.
It is unclear if the toxin ever gets metabolised and or excreted.
Treatment.
There is no treatment. If symptoms start shortly after eating reef fish make the sufferer vomit to empty the stomach from the residual toxic fish.
Ciguatera is best avoided by asking locally if fish caught over reefs are safe and by not eating too much fish, especially if it is large one.
Although one cannot trust the locals as the following story highlights. “Friends had spent a good deal of time on one island and were invited to the chief’s daughter’s wedding. The centre piece of a lavish feast was a beautiful fresh fish. Our friend’s wife ate only fish and developed ciguatera. To this day she cannot eat fish without having a reaction.”
Pelagic fish caught away from land are safe to eat.
Stingers in and under water.
Jellyfish of which the box jelly fish are the most painful are widespread in the Pacific. A specific anti-venom is made in Australia. The pain of an extensive sting is excruciating.
Stingrays are common and can be buried in sand. Their sting is very seldom fatal. The barb in a stingray tail can cause lacerations that easily become infected and broad spectrum antibiotics should be started right away. .Ciprofloxacin 500 mg twice daily for 5-7 days.
Stingrays will be chased away by making plenty of movement when entering the water.
Sea urchin spines inject a venom that causes much pain, but they are very easy to see. The spines should be removed from the skin if possible, although they often fragment. Many corals sting, such as the fire coral, a branching variety looking like a red tree. Do not touch live coral.
Some cone shells such as the geographic and the textile cone shell harbour highly venomous snails. The sting will be delivered from the sharp-pointed end, penetrating clothing and can be fatal within hours. The sting is painless since the venom has pain killing properties.
Lionfish (zebra fish), scorpion fish and stonefish are widespread in the Pacific, and have poisonous spines on their backs. Stone fish is very difficult to notice since it looks like a stone with algae growth on it.
It is important to wear shoes when walking in the water.
All these poisons cause intense pain and inflammation.
Spines should be removed which is very difficult to do since they disintegrate easily.
Prevention of stings should be to wear protective clothing when snorkeling or swimming such as 0,5 mm thick wet suit even in tropical waters.
Treatment should be removal of all stingers from the skin by washing with seawater. Not fresh water since that will provoke release of the toxins still inside the stingers. Followed by soaking the area with vinegar and or applying baking soda paste or toothpaste on the affected area. Cinnipirin or Claritin tablets will diminish itching.
Heat stroke.
Not simply a matter of being too hot when the body temperature rises to 40° C or 104° F or higher in hot and humid weather.
One needs immediate treatment to prevent damage to the brain, heart, kidneys and muscles ultimately resulting in death.
In airless cabins in yachts without air conditioning not only small children but also elderly people particularly when on blood pressure medication are at risk of overheating.
symptoms:
• High body temperature of 40°C (104° F) or above.
• Change in sweating. In the tropics and without exercise most likely a dry skin.
• Disorientation
• Flushed skin.
• Nausea and vomiting.
• Rapid breathing
• Rapid heart beat.
Treatment:
• Take patient away from heat source be it the sun or out of an airless bunk.
• Cool the body with whatever means such as shower, wet towel in the wind or a fan.
• Drink plenty not too cold water to replenish lost fluid through sweating.
Vaginitis.
Not uncommon in the less than sterile and moist conditions on board a yacht.
Inflammation of the vagina can be classified as:
• Bacterial vaginosis. Caused by bacterial overgrowth of normally present anaerobic bacteria when the balance of aerobe and anaerobe bacteria is distorted,
• Yeast infection with the natural occurring Candida albicans
• Trichomoniasis caused by the parasite Trichomonas vaginalis commonly transmitted by sexual intercourse with a sometimes symptom-less carrier.
Symptoms in general:
• Change in discharge
• Vaginal itching and irritation
• Pain during intercourse and urinating
• Bleeding and spotting.
Symptoms specific for:
• Bacterial vaginitis: grey-ish white discharge with a fish-like odour.
• Yeast infection: white thicker sometimes clotted discharge
• Trichomonas vaginalis: yellow greenish discharge.
Treatment :
• Bacterial vaginitis: one dose of 4 tablets of Metronidazole 500 mg. Not for the partner unless with symptoms
• Trichomoniasis also for the partner even without symptoms: one dose of 4 tablets of Metronidazole 500 mg.
• Yeast infection: 1 vaginal tablet Clotrimazol 500 mg.
Appendicitis.
Feared but rarely encountered.
The appendix is a pouch of no particular use sticking as a finger out of the colon.
A blockage in the lining of the appendix causes a bacterial infection in this pouch resulting in inflammation, swelling and pus forming.
The risk is in a rupture thereby releasing the bacterial growth into the abdomen with possibly life threatening consequences.
Signs and symptoms:
• Sudden pain of lower right side of abdomen sometimes starting near the navel and moving to the lower right side.
• Pain increases with pressure by hand or after coughing, walking etc.
• Nausea and or vomiting not caused by sea-sickness.
• Constipation or diarrhoea.
Treatment:
• When far away from hospital start a wide spectrum antibiotic course until hospital treatment can be accessed.
• Surgical removal of the inflamed appendix and drainage of the possible abscess that may have formed.
Kidney stones.
Small hard deposits of Ca-oxalate, Ca-phosphate or Urine acid can form in the kidneys when the urine becomes too concentrated for these substances to stay dissolved. When these stones move they cause sometimes unbearable pain.
They need to be flushed out or in case of bigger stones surgically removed.
Luckily with little damage in the end.
Symptoms.
• Severe pain under the ribs spreading to the lower abdomen and the groin.
• Pain on urinating.
• Red or dark cloudy and smelly urine.
• Difficulty urinating.
Treatment.
• Pain medication by mouth or if necessary per injection. (Diclophenac)
• Drink extra water to flush the stones out of the system. 2-3 L per day.
• Large stones need surgical removal.
Heart attack.
A blockage in the arteries feeding the heart results in damage or part destruction of the heart muscle through loss of oxygen. This is a very serious condition and needs direct hospital care.
Anybody who suspects to be prone to a heart attack needs, before embarking on a voyage, to consult a specialist and have a supply of drugs such as aspirin or nitroglycerine just in case.
Symptoms.
• Pain or just pressure in the chest sometimes spreading to the shoulder and neck.
• Nausea, indigestion, heart burn or abdominal pain.
• Cold sweat.
• Shortness of breath.
• Tiredness, dizziness.
Treatment.
• Restore blood flow through the heart through heart massage on an unconscious person. Comfort a conscious person in a half sitting position with well supported head and shoulders and bent knees to ease the strain on the heart.
• Immediately contact the emergency services when available.
Considerations:
No yacht is big enough to carry a complete A&E department or a Pharmacy.
Talk to a medic and a pharmacist who have ocean sailing and cruising experience for advice and suggestions specific to your crew and cruise
Emergencies do happen but are not frequent. The big difference is that an ambulance is not likely to get to you so some preparation is necessary.
First Aid Kit
Suggested contents and quantities according to the number of crew members and/or the duration of the trip:
Wound care materials and skin disinfectants.
• Compress bandage rolls
• Waterproof plaster strips of various sizes, never enough
• Non adherent wound dressings various sizes
• Fatty gauze (Tulle Gras)
• Disinfectant impregnated fatty gauze (Savlon or Povidon-iodine)
• Surgical or plaster tape rolls
• Steristrips
• Tubigrip bandages
• Scalpels
• Scissor and tweezers and tick remover.
• Anaesthetic cream or gel: (Solarcaine gel or Nestosyl cream)
• Disinfectant liquid (Savlon or Chlorhexidine liquid)
• Disinfectant cream (Savlon or Chlorhexidine )
• Anti septic towelettes (Savlon)
• Antibiotic cream: (Flammazine or Bactroban)
• Anti fungal cream for the skin(Lamisil or Canesten or Daktarin)
• Latex or vinyl gloves a few pairs
• Thermometer, unbreakable non mercury or disposable
Common otc drugs and painkillers:
• Paracetamol 500 mg tablets
• Paracetamol-Codeine 500/20 mg tablets
• Diclofenac 25 mg tab.
• Anti sea-sickness: Cinnarizin tablets and Scopoderm plasters (on prescription.
• Anti-diarrhoea capsules (Imodium)
• Anti-acid tablets (Omeprazol 10 or 20 mg)
• Anti-histamine tablets (Claritin or Zirtec)
• Dioralite
• Insecticide cream or lotion (Malathion lotion, Permethrine lotion or cream)
• Insect repellant (Deet >50%)
• Sunscreen lotion waterproof (P20) as well as 100 ml iso-propyl alcohol.
Second Aid Kit.
most items are only available on prescription. Consult your G.P.
Antibiotics
• Flucloxacillin 500 mg for skin infections (dose 2x 1 caps for 7 days)
• Ciprofloxacin 500 mg wide spectrum (dose 2×1 tab for 7 days)
• Doxycyclin 100 mg wide spectrum. (start with 2 then 1 tab daily for 7 days)
• Metronidazol 500 mg tablets for vaginitis (one dose of 4 tabs)
• Clotrimazol 500 mg vaginal tablet (one dose of 4 tab
• Ear drops (Sofradex)
• Eye drops and ointment (Chloramphenicol or Fucithalmic)-
Malaria prophylaxis (depending on destination and according to latest advice)
Malaria treatment according to latest advice.
Pain medication:
• Strong painkillers by mouth (Tramadol or Voltaren 25 mg)
• Painkillers per injection: Diclofenac 75 mg (Voltaren 25 mg/ml a 3 ml)
• Syringes 2 ml and 5 ml with attached needles. sterile. (also for use by local doctors)
• Sterile disposable Suture needles with thread.
• Plaster cast tape
Expiry dates on drugs
All drugs carry an expiry date which is a legal requirement. Not to be confused with shelf life. It means that the manufacturer guarantees the potency of the drug in its original container and if stored appropriately up to that date.
Solid formulations of drugs such as tablets and capsules have mostly a shelf life much beyond their stated expiry date. They remain potent and do not become harmful. Antibiotics as Flucloxacillin, Ciprofloxacin, sea sickness medication as antihistamines or scopolamine do not lose their potency for many years after their respective expiry date.
Exceptions are Nitro glycerine tablets and Aspirin tablets. Nitro glycerine, being an oily liquid, evaporates from the tablet depending on the particular formulation, on how well the container is kept closed and the ambient temperature of the storage. It does not mean it becomes harmful but could become ineffective in a serious situation. Some formulations of Nitro glycerine tablets are less prone to deterioration than others so ask your pharmacist. Aspirin has a tendency to decompose under humid conditions. This is noticeable as a vinegar smell.
Liquid formulations of drugs are more susceptible to degradation. Adrenaline (Epipen) injections lose their potency as do insulin injections. Injections should not be used when an originally clear solution shows any cloudiness.
Compulsory book on board: First Aid Manual of St John Ambulance, St Andrew Ambulance Association and British Red Cross.
recommended websites:
http://www.mayoclinic.org/patient-care-and-health-information