Seasickness: Few maladies are as pervasive as seasickness. Treatments still span the spectrum from witchcraft and acupressure to transdermal drug-delivery systems and electric nerve stimulation. Nothing seems to work consistently on a majority of patients, or even on a single patient at different times. The only effective treatment is what works for you today.
You're probably familiar with the usual medications: ginger, scopolamine patches, meclizine and Benedryl. There is also the combination of promethazine and ephedrine, known as the NASA cocktail. Outside of the United States, you can buy Stugeron, which is another antihistamine used for nausea.
The latest promising treatment is a transdermal electric nerve stimulator marketed under the name ReliefBand. It applies a low-level pulse of current to the nerves passing through the wrist. It is the only Food and Drug Administration-approved device for the prevention and treatment of nausea, and it seems to work. Several of our Offshore Emergency Medicine seminar graduates report excellent results using them. It is available over the counter or by prescription. The principle difference between the two is that your medical insurance is more likely to reimburse you for the prescribed device. For more information, see www.woodsidebiomedical.com.
The other new development is the re-release of Transderm Scop following a change in the formulation of the delivery system. This is the ubiquitous patch worn behind the ear from which the skin gradually absorbs the drug scopolamine. Transdermal delivery of drugs is becoming quite common. If you're also trying to quit smoking, prevent pregnancy and control your angina, you can go to sea looking like an old inflatable dinghy. A funny thought, but it's a reminder that these patches all contain real drugs, and you should check for drug interactions before combining them.
If you already have the cure for seasickness that works, good for you! If not, or if you're periodically signing on new crew, it's best to have several different treatment options available. Consider the ReliefBand, Transderm Scop patches, an over-the-counter motion-sickness medication, like meclizine (Bonine), and ginger capsules. One of these is likely to help.
Dehydration: This is the inevitable result of seasickness, and it is a dangerous condition. Dehydration is a mechanism for volume shock, which, if uncorrected, will result in circulatory collapse and death just as surely as bleeding from a ruptured spleen. The symptoms include elevated pulse rate, lightheadedness, pale skin, and reduced urine output.
While you can't do much about a ruptured internal organ, you might be able to correct dehydration. The first treatment for volume shock is to stop fluid loss. That's why you need several options for treating the nausea of seasickness. Next, you'll need to replace the fluid. Since the patient is probably still barfing, or at least nauseated and unable to take fluid by mouth, you'll need options. There are two: intravenous and rectal.
Learning to perform IV therapy under adverse conditions (aboard a boat in a storm, for example) is not easy. It takes time and lots of practice. You're not going to become competent using only a rubber arm and food coloring. And you're not going to maintain your skill unless you perform it regularly. However, it is still the most effective way to rehydrate a sick person.
If you choose to invest in this type of training, look for a program that will allow you to perform IVs on living people. Look for the opportunity to practice your skill on a number of people. This is what it takes to be truly competent. It will be a challenge for a non-medical person to find effective training, but if you're responsible for a large crew on a long voyage, it will be worth it.
Your other option is rectal rehydration. You can take advantage of the fact that the large intestine is designed to absorb fluid from feces before excretion. It doesn't care where the fluids come from. All you need is a plastic tube, a bag and some rehydration fluid.
You can buy an enema bag at a surgical supply house or pharmacy. Or you can use a Camelbak-type hydration bladder. The technique is not rocket science. Lubricate the business end of the tube with Vaseline or anything similar, and insert it in an inch or two into the rectum.
For fluid, use normal saline IV fluid, or a 50/50 dilution of a rehydration drink like Gatorade or Excel. You can also make up rehydration fluid using the World Health Organization's formula: in a liter of water dissolve 1/2 teaspoon of salt, 1/2 teaspoon of baking soda, and two to three tablespoons of sugar, honey or light corn syrup. Warm the fluid to 102° to 105° F to avoid causing hypothermia, and let it run in by gravity only. Begin with about 300 cc, and repeat this dosage as tolerated until the patient feels better and begins to produce a normal amount of urine.
Head injury: Vessels at sea offer unlimited opportunities for personal injury. The head seems to be a popular target. You'd think we'd all be wearing helmets. Being able to distinguish a serious head injury from one that's not serious is a valuable skill to have.
To a medical professional, the term "head injury" means brain injury (aka concussion), and that's potentially dangerous. Damage to the head that does not involve the brain is called a scalp wound, contusion, facial abrasion or laceration, and that's less serious. So, when your helmsman is clobbered by a flying jib, part of your assessment is looking for evidence of concussion. Anyone with a concussion can go on to develop brain swelling, and that can be life-threatening.
A concussion is diagnosed by a change in brain function at the time of injury. Being knocked out for several minutes is an obvious example. Or a patient may not remember what happened to them or how they got where they are. They may feel confused or disoriented. All of these represent the symptoms of a concussion.
The more lengthy or profound the change in brain function, the more serious the concussion is. A patient who was unconscious for more than a minute or so is more likely to develop brain swelling later. So is one who remains disoriented or forgetful for a period of time after the accident. And the longer the memory loss is, the worse the prognosis. On the other hand, a concussed person who does not remember the few seconds surrounding the injury — but remembers everything before and after — has a mild concussion, and that is not particularly worrisome.
The best part of knowing how to diagnose a concussion is recognizing when your patient doesn't have one. This is the person who remembers everything that's happened. They may have an ugly scalp laceration, or a big lump and a headache, but they don't have a concussion. No concussion means no brain swelling and no life-threatening problem.
The ideal treatment for a moderate or severe concussion is observation and evacuation to medical care. If your patient develops significant brain swelling, they're going to need a neurosurgeon. Be prepared for vomiting, which is the most reliable early sign of brain swelling. Keep the patient lying on their side or stomach to prevent aspiration of secretions or vomit into the lungs. In long evacuations or situations where evacuation is impossible, be sure to keep the patient warm and well hydrated. Most people will recover if the swelling is not too severe.
Wound infection: It is normal for any wound to be painful, red and a little swollen right after injury. Within 48 hours, it should improve dramatically. If it gets infected, it will get worse instead. An increase in swelling, redness and pain are the symptoms of wound infection.
To deal with this, you will need warm water, antibiotics and maybe a scalpel. Heat applications are very effective for initial treatment. You can use warm soaks on an extremity or place a towel soaked with hot water on the infected area. This increases the circulation, helping your body fight the infection. It may cause a superficial infection to "point," offering you an opportunity to drain it.
An abscess is the result of your body closing off the infected tissue from the rest of your system. It will contain pus under pressure, which will be painful and possibly dangerous. If the abscess is near the surface (pointing), you can go a long way toward a cure by draining it. Clean the skin over the abscess with soap and water or povidone iodine (Betadine), and nick it with a sterile blade. Gently express the pus and irrigate the abscess with clean water or sterile saline. Continue warm soaks and, if you're remote from medical care, begin antibiotics.
A voyaging boat's medical kit should stock several broad-spectrum antibiotics. This can get expensive, but it is necessary. Talk to your medical practitioner about drugs to cover the spectrum of infections you might encounter. Examples include: Cephalexin, Azithromycin and Ciprofloxacin.
Be sure to carry enough. Two full courses of each type are not excessive. You are more likely to use antibiotics while voyaging than ashore, where a wait-and-see attitude is more appropriate. At sea, you must be more aggressive with your treatment of a wound infection. The worry here is that the infection will extend into a joint or tendon sheath, or become systemic. When the bacteria begin to colonize deep structures or grow in the lymph system and bloodstream, the patient is in serious trouble. In the offshore environment, early and aggressive treatment is the rule.
Burns: Burns are among the most difficult wounds to manage, particularly the large ones. Your immediate reaction is to cool the burn with water, which is exactly the right thing to do. Unfortunately, in the process, you contaminate a sterile wound. It can't be helped.
The classic example is the cook of the day who catches the boiling spaghetti water thrown off the stove by an unexpected wave. You will need clean water or sterile saline to flush the wound, and forceps and scissors to remove any peeled and dead skin. Once the wound is cleaned, you will need a large dressing to protect the burn from contamination and air.
Dressings come in the form of ointments or fabric. Burn creams are generally antibiotic and anesthetic, offering protection from bacteria and pain relief. The effects are usually short-lived, so they must be irrigated off and reapplied at least daily. A small tube of the stuff is not enough. Try to buy it by the pint.
An inexpensive bandage for a large burn is a clean cotton T-shirt. Next time you do laundry, pull one right from the dryer into a stout plastic bag and seal it up. Even if you never need it for a burn, you'll always have at least one clean shirt onboard. A cotton sheet or commercial "burn sheet" will work, too.
A more sophisticated dressing useful for smaller burns is a product called Xeroform. This is iodine-impregnated Vaseline-type gauze, which will protect the fresh burn from the air and provide antibacterial action for about five days. This can be covered with something like Bioclusive (Johnson & Johnson), which is a Gortex-like membrane providing further protection from the environment. A partial-thickness burn should be well on its way to healing by the first dressing change. For access to these products, try www.boundtree.com, or www.mooremedical.com.
Seafood poisoning: Ciguatera, scombroid and paralytic shellfish poisoning are the occasional side effects of the wonderful fresh seafood available to sailors. Bacterial or dinoflagellate toxins absorbed by the gut, not direct bacterial infection, cause the symptoms. The goal of initial treatment for all three is to minimize the absorption of toxin and enhance its excretion. Activated charcoal is the tool for the job.
Charcoal is available for medicinal use in the form of a liquid slurry, which is a real mess, or tablets or capsules. At the first sign of food poisoning, take the recommended dose of charcoal with lots of water. Charcoal binds toxin, and prevents more from being absorbed by the gut. Some formulations of activated charcoal are combined with a cathartic, like sorbitol, to speed its passage through your gastrointestinal tract. You are not likely to need this, since diarrhea is one of the presenting symptoms.
Ciguatera poisoning is caused by the toxin excreted by a reef-dwelling dinoflagellate. It is concentrated in the flesh of larger fish and is not destroyed by cooking. The best way to avoid ciguatera is to eat only small fish. Four three-pound groupers are a lot safer than one 12-pounder.
Symptoms include gastroenteritis with cramps, vomiting and diarrhea. The dreaded neurological component comes with tingling and sensory deficit, like reversed hot and cold sensations, and can last for months. Beyond the generic use of activated charcoal, long-term treatment is variable and controversial. If you experience the neurological symptoms of ciguatera exposure, seek medical care and advice.
Scombroid is what can happen when your 'fridge is a little too warm. Bacteria grow on the surface of the fish, releasing a histamine-like toxin. Symptoms include hives and itching, swelling, diarrhea and vomiting. These resemble the symptoms of anaphylaxis. The treatment is activated charcoal and an antihistamine like diphenhydramine (Benedryl).
Paralytic shellfish poisoning is found most frequently in mussels and scallops. Symptoms include the usual vomiting and diarrhea, and sometimes neurological symptoms up to and including respiratory paralysis. Mild cases can be managed with charcoal, hydration and time. Cases showing signs of neurological involvement need evacuation to medical care.
One marine bacterium that will infect the gut is vibrio. This organism will cause fever, chills and bloody diarrhea. These are the signs of active infection, which might benefit from antibiotics. Try using ciprofloxacin in the dose prescribed for traveler's diarrhea.
Anaphylaxis: A local allergic reaction is annoying but not life-threatening. It can produce a bit of localized itching, localized rash and swelling, or maybe a stuffy nose as in hay fever. The chemical mediator is histamine, released by white blood cells. The treatment is usually an antihistamine, like diphenhydramine.
But, when the allergic reaction begins to affect the whole body (systemic reaction), you should be worried. The term is "anaphylaxis," and it can present in a spectrum of severity from mildly annoying to rapidly fatal. Histamine release is the culprit here, too.
Mild anaphylaxis, with nothing more than generalized hives, will often respond nicely to oral antihistamines. A typical dose is 50 mg of Benadryl every six hours. Hives and itching will subside, and the patient will feel better.
Severe anaphylaxis may present with hives, airway swelling, chest tightness and shortness of breath. The treatment still includes the immediate administration of antihistamines, but these sometimes take too long to have an effect. We must be able to give a fast-acting drug to save the patient's life right now.
Epinephrine, also known as adrenaline, is the drug that immediately reverses the airway constriction and soft-tissue swelling caused by histamines. Its effects are short-lived, maybe 10 minutes, but one or two injections will buy time until the antihistamine can take effect.
The most common delivery system for patient use is the EpiPen Auto-injector. It's expensive and requires a prescription, but it's nearly idiot proof. You should stock at least two of these life-saving devices in your medical kit, along with an oral antihistamine. Take the time to review the signs, symptoms and treatment for anaphylaxis, as well as the instructions for the use of the EpiPen. This is a medical emergency that won't wait for fumbling, on-the-job training.
Pain: "Doc, whenever I drink tea, my right eye hurts!" The doctor replies, "Take the spoon out of the cup." This timeworn joke is a good reminder that the best way treat pain is to treat the problem. The treatment for a dehydration headache is water, not aspirin.
However, when you do have to treat pain as a problem, there are two basic classes of drugs to turn to: nonsteroidal anti-inflammatory drugs (NSAIDs) and narcotics. Unless your patient has an allergy or other contraindication, NSAIDs should be the mainstay of your pain treatment. Since they inhibit the chemical mediators of pain at the site of injury, they leave your brain fully alert and functional.
Because NSAIDs like ibuprofen (Advil) and naproxen sodium (Aleve) are available without prescription, people tend to think they are not strong medicine. But taken in its full therapeutic dose of 600 to 800 mg every six to eight hours, ibuprofen is a very effective pain reliever. Your doctor may recommend a prescription NSAID, such as Celebrex, which has the disadvantage of being very expensive, but the considerable advantage of once-a-day dosing.
Acetaminophen (Tylenol) is also a good pain reliever, and it is easy on the stomach. You should carry Tylenol capsules or tablets as an alternative to ibuprofen or naproxen sodium for the treatment of mild to moderate pain in people who are experiencing seasickness or gastric irritation. A good trick for relieving moderately severe pain with NSAIDs is to leapfrog the full dose of Tylenol with that of ibuprofen. For example, give 600 mg of ibuprofen at 1200, 500 mg of Tylenol at 1500, 600 mg of ibuprofen again at 1800, 500 mg of Tylenol at 2100, etc. This can get you through a few days without causing significant side effects.
The next step up is the use of narcotics, which relieve pain by dulling your brain's ability to perceive it. Unfortunately, narcotics dull everything else about your brain in the process. Judgment is impaired, reaction time is slowed, and you become less alert. If that's not enough, narcotics also make you constipated … a less-than-desirable side-effects profile for a boat at sea.
A good NSAID and narcotic combination for moderate to severe pain is hydrocodone bitartrate/acetaminophen (Vicodin), or oxycodone hcl/acetaminophen (Percocet). Hydrocodone and oxycodone are much less likely to cause stomach upset than codeine. An offshore voyager should also consider carrying indictable morphine for patients in severe pain who cannot tolerate medications by mouth. For all of these narcotics, you will need a prescription and training from your practitioner.
Note: A magazine article is no substitute for comprehensive training, or the advice and instruction of your medical practitioner. Being prepared to render medical care in a remote or extreme environment is serious business and deserves to be a significant part of your preparation for voyaging.
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Jeff Isaac is a sailor and physician's assistant. He teaches medical seminars for the Ocean Navigator School of Seamanship.
