WELCOME TO CHARLESTON!

Extended Coastal Cruising:Medical Preparation

and Care

Jerry Reves, MDDean College of MedicineDean College of Medicine

Larry Raney, MDDivision Chief, Emergency MedicineDivision Chief, Emergency Medicine

AGLCA Spring RendezvousCharleston

Our Presentation

General medical preparation Keeping fit and staying healthyDealing with emergencies(medical/trauma)When to call for help and how to do itQuestions and Answers

A Philosophy

A good cruise is a safe andhealthy journey.

Put PoeticallyOut of the night that covers me, Black as the Pit from pole to pole,…

In the fell clutch of circumstance I have not winced nor cried aloud. Under the bludgeonings of chance My head is bloody but unbowed…

I am the master of my fate: I am the captain of my soul.William Ernest Henley. 1849–1903

Our GoalIs not to make you a doctor, but togive you confidence with and tips on

dealing with cruising medical problems

AGLCA

Before Setting Outfrom a medical point of view

Provision the boatPlan for the routinePlan for the problem

Our bodies and our health areas much concern as the othercomplicated machine – our boat.Human maintenance!

The Basics

Carry all own medications (andprescriptions)Have brief medical profile in writing:

Medical problems, including any surgeriesMedications (large supply, prescription withyou, fill at a national chain drug store)AllergiesImmunizations (tetanus, etc)

Medical Provisioning

Marine Medicine or First Aid BookMarine Medical KitMedicines

We Recommend A Book(s)

First Aid KitFirst Aid Kit(see handout)(see handout)

We donWe don’’t recommend commercial!t recommend commercial!Build your ownBuild your ownDonDon’’t need t need ‘‘medical grademedical grade’’ stuff stuff

With a few exceptionsWith a few exceptions

See handoutSee handout

First Aid KitFirst Aid Kit

Most available at local drugstore if you doMost available at local drugstore if you dowish to buy orwish to buy orWest Marine is expensiveWest Marine is expensiveon the web:on the web:

http://http://www.buyemp.comwww.buyemp.com//

First Aid KitFirst Aid Kit

Trauma Shears ($3 - $15)Trauma Shears ($3 - $15)Tape Tape –– cloth, 1 cloth, 1”” and wide and wideHand sanitizer and antiseptic wipesHand sanitizer and antiseptic wipesAlcoholAlcohol

Rubbing or Rubbing or EverClearEverClear70%, not full strength70%, not full strength

First Aid KitFirst Aid Kit

Large bottle of eye salineLarge bottle of eye salineSeveral if have spaceSeveral if have spaceMultiple uses Multiple uses –– eyes, irrigating wounds, etc eyes, irrigating wounds, etc

Tweezers and magnificationTweezers and magnificationAs per previous photoAs per previous photo

First Aid KitFirst Aid Kit

Box of menstrual padsBox of menstrual padsBuy gauze if you wish, this much cheaperBuy gauze if you wish, this much cheaper

Non-sterile glovesNon-sterile glovesLatex free if allergicLatex free if allergic

Ace wraps (several)Ace wraps (several)

First Aid KitFirst Aid Kit

Duct tapeDuct tapeI prefer GorillaI prefer Gorilla®® - no conflict! - no conflict!

Cotton-tipped applicatorsCotton-tipped applicatorsAbout 100 sterileAbout 100 sterileHuge box non-sterileHuge box non-sterile

Big box of tongue bladesBig box of tongue blades

First Aid KitFirst Aid Kit

Dental flossDental flossIts not just for teeth anymore!Its not just for teeth anymore!

VaselineVaselineBuy antibiotic ointment if you wishBuy antibiotic ointment if you wishNo proven benefit over plain PJNo proven benefit over plain PJ

First Aid KitFirst Aid Kit

A few 18-G needles and large syringesA few 18-G needles and large syringesRx only Rx only –– get your doctor to help here get your doctor to help here

A LOT of clean white cotton - towels orA LOT of clean white cotton - towels ortee shirts.tee shirts.

Bandaging, padding, cleanup, etcBandaging, padding, cleanup, etc

Medical Kit(see handout)

Aspirin, acetaminophen,and ibuprofenImodiumAntacid of choice and/orPepto-BismolBenadrylHydrocortisone Cream1% (OTC)Zinc oxide creamSudafed

Neosporin ointmentMineral oil, milk ofmagnesiaBenzoinBetadine solutionSterile saline bottleDramamine, Phenergan*Transderm-scop patch*Zithromax* (erythromycin)Augmentin* (penicillin)Cipro*

* Raney and Reves

What about an AED?What about an AED?

DependsDependsHowHow’’s your wallet?s your wallet?

$1250 - $3000 (or more!)$1250 - $3000 (or more!)

WhatWhat’’s your risk?s your risk?Litmus testLitmus test……

What about an AED?What about an AED?

If you own one of theseIf you own one of these……

Practice Preventive Medicine

DietExerciseDressAlcoholRules of roadJudgment

Diet as Preventive Medicine (see handout)

Eat healthy balanced dietProvision with fresh food at each portObserve all physician diet instructionsDaily vitamin supplement (with calciumadded)Keep well hydrated (wt./2 = oz. per day)Weigh every day (have scales on board)

Ignore this Sign

Exercise as Preventive Medicine(see handout and

http://www.nia.nih.gov/HealthInformation/Publications/ExerciseGuide/)

Strength (arms and back especially)EnduranceBalanceFlexibility

Benefits of Exercises

exercise = less likely to suffer from fractures orbone injuries –and ailments such asosteoporosis and reduced back pain. Weightbearing exercises can improve calciumdeposition in the bones.Helps prevent many diseases (heart & cancerImproves overall strength – useful on anycruise

Dress as Preventive Medicine (see handout)

According to weatherFor the sunShoesGlovesPFD’s

Dress as Preventive MedicineHot Weather

Synthetic fabrics

Dress as Preventive MedicineCold Weather

Wool

Cold water immersion

Eat Drink and Be MerryIn MODERATION !

Rules of the Roadand attentiveness

Judgment, Rules Do not intentionally get in harm’s way

Docking and locking

Some Common Medical Problems

SunburnSea sicknessGastro Intestinal (Diarrhea, Nausea andvomiting)InsomniaWeather related (Heat stress andHypothermia)

GI Problems

Nausea and VomitingMany causes

Sea sicknessGI virusSerious conditions

RxClear liquids½ conc. GatoradePhenergan (25mg)Enema with Gatorade

DiarrheaMany causes

Food reactionViruses and BacteriaAnxietyInflammatory bowel disease

RxReplace fluids, ½ conc. GatoradePepto-Bismol

Serious Causes of N&V

Heart attackIntestinal obstructionConcussionBleeding gastric ulcerPersistent over 24 hoursFever over 101 F

Dehydration

Mild (loss of 3-5% body weight) – darkurine, thirsty, normal pulseModerate (5 to 10 % body weight) – smallvolume very dark urine, rapid pulseSevere (> 10% body weight) – no urine,sunken eyes, imperceptible pulse, shock

SunburnSunburn

Best treatment (again) is avoid!Best treatment (again) is avoid!Best sunscreen is appropriate clothingBest sunscreen is appropriate clothing

Ibuprofen or naproxen for discomfortIbuprofen or naproxen for discomfortOintments may helpOintments may help

Sea Sickness“mal de mer”

Mild symptoms consist of tiredness, mildqueasiness, weakness and cold sweats.Nausea, lethargy and pallor occur as thecondition progresses.Vomiting, retching, sleepiness and a desireto withdraw from surroundings follow asadvanced signs.

“At first you are afraid you’ll die, then you’re afraid you won’t.”

Sea Sicknessprevention & treatment

Rest well on the night before.Eat a light, low fat meal the evening before.Party prudently. Limit alcohol before and during the trip.Consult with your physician about the best medicinal or herbalremedy for you. Take or apply it at least three hours before youset out. Consider need for treatment of upper respiratoryconditions or allergies. (Scopolamine patch, bendaryl,dramamine, ginger)Stay hydrated. Drink water or juices, particularly if in direct sun.Avoid alcohol.Ask the captain to position you near the center of the boat whererocking motions are less.Assume a job on board that involves keeping your eyes on thehorizon and away from tasks requiring reading or close focus.

Insomnia

Establish a regular schedule every day.Make sure the bunk (cabin) is dark and quiet.Keep bunk dry, cleanAvoid stimulants before bed (caffeine and alcohol – somemedications).A light snack of protein (milk, cheese etc) prior to going to sleepcan be helpful.Visit the head before turning in .Keep ambient temperature comfortable (cool rather than warm).If sleep doesn’t come in 20 – 30 minutes get up return to thebunk later.Benadryl 25-50mg

Extremes of Temperature

*Remember that water is all importantevaporation (lowers skin temp)

conduction (warms or cools > air)

Hypothermia

Mild – shivering, normal mentationStop exposure (below decks, wet clothing off)Dry clothes and blanketsWarm liquids (sugar) and foodNo alcohol!

HypothermiaHow Hypothermia Affects Most Adults

Expected Time of Survival Under 15 - 45 Mins30 - 90 Mins1 - 3 Hrs1 - 6 Hrs2 to 40 Hrs3 Hrs- Indefinite

Exhaustion orUnconsciousness

Under 15 Mins15 - 30 Mins30 - 60 Mins1 - 2 Hrs2 - 7 Hrs2 - 12 HrsIndefinite

Water Temperature(Degrees Fahrenheit)

32.532.5 - 40.040.0 0 50.050.0 - 60.060.0 - 70.070.0 - 80.0Over 80.0

Hypothermia

Severe – no shivering, altered mentationStop exposure (below decks, wet clothing off)Dry clothes and blanketsHeat packs to groin, arm pits, neckNothing by mouth!Be gentleEvacuate

HEATTwo KeyFactors1. Temperature2. Humidity

Hyperthermia

Heat exhaustionWeakness, nausea, dizziness, malaise, HANormal mentationSweating or lack thereof not useful

Heat strokeAbove, but altered mentationTemperature typically higher

Differential Diagnosis

Hyperthermia - Treatment

Heat exhaustionRemove from heat sourceCool patient (more later)Cool fluids orallyWatch urine (pale yellow, not concentrated)

Does not usually require evacuation visit

Hyperthermia - Treatment

Heat strokeMedical emergency, 80% mortalityCool patient (more later) as fast as possibleNothing by mouthEvacuate

Hyperthermia - TreatmentCooling the victim

Ice/cold packs to neck, groin, arm pitsSpray with tepid(not cold) water andfanGive cool liquids(if conscious)Immerse in cool water

Try not to bring < 100°Will overshoot

Uncommon: But BIG Problems

Heart attack

Stroke

Heart Attack

Heart Attack

SymptomsChest and or L arm painUpper body pressureAnxiety – ”impending doom”Cool, clammy, nauseaRapid pulse, low BPShortness of breathFeinting

TreatmentLie downObserve- breathing &pulse, BPTake a full aspirin andnitroglycerin, if consciousCPR if not breathing orpulseless + defibrillateAnalgesic, if availableEvacuate (time is critical)

Stroke

Types:• Transient Ischemic Attack• Internal bleed• Ischemic

S * Ask the individual to SMILE .T * Ask the person to TALK to SPEAK A SIMPLESENTENCE (Coherently) (e.g. "It is sunny out today").R * Ask to RAISE BOTH ARMS .

Stroke

SymptomsSpeech problems, slurredspeech, or difficultyspeakingParalysis and weakness, legor arm or in the face,usually on one side of thebodyVision problemsBalance problems losingcoordinationHeadache, severe and withno known cause

TreatmentLie downObserve- consciousness,breathing & pulse, BPCPR if not breathing orpulseless Evacuate (time iscritical)

Some Common TraumaSome Common Traumafirst aidfirst aid

Accidents happen!

“This is your last chance, no it’s yours”

BasicsBasics

Basic Life Support courseBasic Life Support courseKnow where 911 wonKnow where 911 won’’t work (any timet work (any timeunderway)underway)Poison Control Poison Control –– excellent advice 24/7 excellent advice 24/7

800-222-1222 (entire US)800-222-1222 (entire US)

Falls and General AccidentsFalls and General Accidents

Sprains/strainsSprains/strainsFracturesFracturesDislocationsDislocationsConcussion/AMSConcussion/AMS

CutsCutsNosebleedsNosebleedsKnocked out teethKnocked out teethPenetrating injuryPenetrating injury

Sprains/StrainsSprains/Strains

RICERICERestRestIceIceCompression (ACECompression (ACE®®))ElevationElevation

Acetaminophen (TylenolAcetaminophen (Tylenol®®) or ibuprofen) or ibuprofen

Sprains/StrainsSprains/Strains

Rest and elevation x 24-48 hrs onlyRest and elevation x 24-48 hrs onlyThen get back activityThen get back activityNormal activity promotes faster healingNormal activity promotes faster healing

Fractures and DislocationsFractures and Dislocations

Is it broken?Is it broken?Obvious deformity (not always so obvious!)Obvious deformity (not always so obvious!)Crunching/grindingCrunching/grindingBone sticking outBone sticking out

In doubt In doubt –– assume broken assume broken

Fractures and DislocationsFractures and Dislocations

Get to hospital!Get to hospital!If that is not a quick optionIf that is not a quick option……

Straighten fractures?Straighten fractures?Only for loss of pulses or bone sticking outOnly for loss of pulses or bone sticking out

Relocate?Relocate?If you can If you can –– immediately following fall immediately following fall

Fractures and DislocationsFractures and Dislocations

Splint (as it lies, or after straightening)Splint (as it lies, or after straightening)With what?With what?

Any long hard objectAny long hard objectPaddle, boat hook, wooden spoon, umbrellaPaddle, boat hook, wooden spoon, umbrellaThink of cardboard, newspaper, PFDThink of cardboard, newspaper, PFDSAM splint or SAM splint or ensoliteensolite pad pad

Lots of padding and duct tapeLots of padding and duct tape

Fractures and DislocationsFractures and Dislocations

SplintingSplintingFingers and legs Fingers and legs –– tape together! tape together!

Injured splinted by goodInjured splinted by good

Fractures and DislocationsFractures and Dislocations

Makeshift splintingMakeshift splinting

Fractures and DislocationsFractures and Dislocations

Makeshift splinting Makeshift splinting –– cardboard or cardboard or ensoliteensolite

Fractures and DislocationsFractures and Dislocations

How?How?Joint above and joint belowJoint above and joint belowLeave tips/toes exposed if possibleLeave tips/toes exposed if possible

Detect lack of circulation/sensationDetect lack of circulation/sensation

Falls – Back/Spine

Suspect with any ‘hard’ fallWith midline back or neck painWith any numbness/tingling/weaknessWith intoxication (can’t evaluate)

Immobilize back/neck best possibleEvacuate

Falls - ConcussionFalls - Concussion

Blow to head + Blow to head + ““ainain’’tt right right”” = concussion = concussionOr brief loss of consciousnessOr brief loss of consciousness

Should be evaluated by physicianShould be evaluated by physicianWhat to do meanwhile?What to do meanwhile?

ConcussionConcussion

Not much, unfortunatelyNot much, unfortunatelyKeep comfortable and safeKeep comfortable and safeDo NOT need to keep awake!Do NOT need to keep awake!

But check periodically (every 4-6 hrs)But check periodically (every 4-6 hrs)DonDon’’t give anything by moutht give anything by mouth

Cuts

Apply direct pressure to stop bleedingNever attempt to clamp!Consider pressure-point for major bleedingTourniquet only as last resort

Can result in limb loss!Release every hour (with direct pressure)

Cuts

Once bleeding controlledClean with soap and waterSmall? Approximate edges with tape

Doesn’t need to be fancy – get job doneDuct tape works (poke multiple holes 1st)

Can use Superglue® [trade secret! –medical grade is SurgiSeal®]

Cuts

Large?Cover with menstrual pad(s)Bulk on more pads or cottonWrap with ACEElevateGet to hospital

Nosebleeds

Rarely a major problemCan be a real pain…Trivia – most common cause?

Epistaxis digitorum

Nosebleeds

Most of the time (>90%) anteriorTreat with pinchingFirst clear any clots by gently blowingGrab fleshy part of nose in front of boneHold tight for 20-30 minutes

Nosebleeds

Resist temptation to ‘check’Pushing nose causes rebleed

Homemade Holder:

Nosebleeds

Persistent bleeding down throat?May mean posterior – more seriousStay upright, get to hospital

Feeling lightheaded – evacuate

Displaced Teeth

Handle minimally and by crown only!Gently wash to remove gross debris

Patient’s own saliva or milk. Saline OK

Displaced Teeth

Gently irrigate socket with saline/waterUsing other teeth as guide, replace toothBite gently onto tissue or cloth

To hold in place

Get to hospital

Displaced Teeth

Can’t replace?Place under patient’s tonguePlace in room temperature milkLeast good – place in salineTime is of the essence to save tooth!

Every minute out, decrease 1%

Penetrating Injuries

Do basics of life supportDo not remove – more damage, bleedingDirect pressure for bleedingStabilize object (prevent movement)Evacuate

Foreign BodiesForeign Bodies

FishhooksFishhooksStings/bitesStings/bitesSplintersSplinters

FishhooksFishhooks

Unless you have training, donUnless you have training, don’’t tryt tryGet to ERGet to ER

Bulky padding to immobilizeBulky padding to immobilize

Stings and BitesStings and Bites

Very few of major concernVery few of major concern……but they can hurt like heck!but they can hurt like heck!Need to go to ED for any more than minorNeed to go to ED for any more than minor

Tetanus update if >5 yearsTetanus update if >5 years

Stings and BitesStings and Bites

For severe pain:For severe pain:Try immersion in very hot water - 110Try immersion in very hot water - 110°°Most marine toxins are heat labileMost marine toxins are heat labileMay take 45-60 minutesMay take 45-60 minutesBenadryl and aspirin or ibuprofen may beBenadryl and aspirin or ibuprofen may behelpfulhelpfulGo to ER if not responsiveGo to ER if not responsive

SplintersSplinters

Very common in boatingVery common in boatingUsually easy first aidUsually easy first aidBest tools?Best tools?

18 gauge needle18 gauge needleQuality tweezersQuality tweezersGood magnificationGood magnification

Watch for infection (puss, red streaks)Watch for infection (puss, red streaks)

One Setup

EyesEyes

Foreign bodiesForeign bodiesSplattersSplattersTraumaTrauma

Eyes Eyes –– Foreign Bodies Foreign Bodies

Be very careful!Be very careful!Q-tip or dry tissue, careful wipeQ-tip or dry tissue, careful wipeConsider under the lids (see below)Consider under the lids (see below)Try irrigationTry irrigation

Eyes - SpattersEyes - Spatters

The solution to pollution is dilution!The solution to pollution is dilution!Move quicklyMove quicklyIrrigate, irrigate, irrigateIrrigate, irrigate, irrigate……

And then irrigate some more!And then irrigate some more!

Sterile saline best, but tap OKSterile saline best, but tap OKDonDon’’t make your own, buyt make your own, buy

Eyes - TraumaEyes - Trauma

Best treatment Best treatment –– don don’’t let happen!t let happen!Goggles Goggles –– won won’’t use if you dont use if you don’’t havet haveNot much can be done in the fieldNot much can be done in the fieldGet to hospitalGet to hospital

Eyes

For FB that can’t be removed or eyetrauma:

Patch BOTH eyes. non-compressive patchCommercial products available

Bottom of paper or foam cups, taped in placeOr gogglesTape/cloth to block light entering eyes

BurnsBurns

MinorMinor

MajorMajor

Minor BurnsMinor Burns

Again, avoid!Again, avoid!OTC pain relieversOTC pain relieversIce ok, but limit total timeIce ok, but limit total timeClean dressing. +/- antibiotic ointmentClean dressing. +/- antibiotic ointment

Major BurnsMajor Burns

Get help!Get help!Remove burned clothingRemove burned clothingApply dry clean dressingApply dry clean dressingDonDon’’t use ice!t use ice!DonDon’’t give anything by moutht give anything by mouthEvacuateEvacuate

Other Emergencies

Drowning

Electrical injuries

Drowning

CautionsThink hypothermiaPatient that seems to get better

Still needs to be seen by physician!

Think secondary injuryEspecially to spine (diving, fall)

Drowning

Any submersion & respiratory symptomsBasics of life support

Mouth to mouth is keyBeware ‘secondary drowning’

Any drowning should be evaluated in ERIf resuscitation needed, evacuate

Electrical Injuries

Too much to cover thoroughlyMostly burns, major and minor

All should be evaluated in ER

Key fact: ‘dead’ people after electrocutionFrequently not – in ventricular fibrillationCPR until able to deliver shock

Electrical

Lightening – reverse normal triageResuscitate the dead (V-fib)Anyone making noise, moving, OK for nowAll should be checked in ER

Is it an emergency?Warning signs and symptoms:-- Difficulty breathing, shortness of breath-- Chest or upper abdominal pain or pressure lasting two

minutes or more-- Fainting, sudden dizziness, weakness-- Changes in vision-- Difficulty speaking-- Confusion or changes in mental status, unusual behavior,

difficulty waking-- Sudden or severe pain-- Uncontrolled bleeding, severe bone fractures & burns-- Severe or persistent vomiting or diarrhea-- Coughing or vomiting blood-- Drowning or near drowning--Suicidal or homicidal feelings

Am. Col. Of Emergency Physician

Who to Call for Help

At Port – call 911Underway – call Coast Guard on VHF 16

Place call ASAPRemember range ~20 miles

Coast GuardCheck vessel location (from GPS –other identifiers –e.g.marker number___)Use HIGH transmit powerGive Appropriate alert, boat name:

“Mayday” – immediate, life threatening“Pan-Pan” – non-life threatening, but evacuation needed

Give position – have CG repeat to confirmSpeak slowly and distinctly – keep short and simpleUse CHANNEL 16 switch when advised

Questions?Questions?