On Board Medical - Thank You Dr. Jim

[Passages]

Passages is currently on a 3 week cruise through New England and catching a wi-fi signal here & there.

Last year in planning the trip I had a hunch that a general thread on Medical Supplies on Board might come in handy. I had no idea.

A few days ago I was at a slip when my daughter jumped on board shouting that a girl was hurt on the rock jetty. I grabbed my kit and went out to see. The parents were trying to comfort a 8 year old girl who had fallen between the rocks and was bleeding from her toe, leg, knee and arm but most worrysome was a growing bump on her head.

There was no cell service where we were so we had someone go to a gas station to dial 911. In the meantime, I pulled out a bottle of sterile saline (no antiseptics according to Dr. Jim) and began working on the head wound. Once clean, I pulled out a felt pen to outline the the size & shape of the bump for reference. Then applied a chemical cold pack. The girl became very quiet and we became concerned of shock so I had Mom keep her talking. We then began cleaning & bandage the other wounds, applying direct pressure with gause on the deepest cuts.

When the EMT's arrived, they saw what I had done and my kit and asked if I was in medicine.

I am not. I have no training other than what I read here and in a few books. I'm not going to lie, I was scared, but did the best I could. The heartfelt thanks from the parents as the child was loaded into the ambulance can not be put into words.

Again, I'd like to thank Dr. Jim Rosenthal for his great post last year and encourage everyone to have basic medical supplies on board and familarity with their use.

Now I'm going back to enjoying my cruise.

[Jaxfishgyd]

I think you passed your test to get your "honorary" Dr degree ! Great job and it just goes to remind everyone of the dangers that are always around us.

[jim rosenthal]

I was delighted to read this, as I get rather little feedback on the medical information I post. As you have found, it is very satisfying to be helpful in a situation such as the one you spoke about so clearly.

We all get scared. I get scared sometimes, too, but the important thing is to press on and do what is required, regardless of how you feel, and that is exactly what you did. Well done!

[Bob Bradley]

Great post. One question - probably for Dr Jim - Why no antiseptics?


Side note - right after reading this, I saw the post entitled "HELP with bleeding" and I thought perhaps the forum had changed its emphasis from Hatteras to MASH unit.

[Passages]

Great post. One question - probably for Dr Jim - Why no antiseptics?

Bob,
According to Dr. Jim, antiseptics damage tissue and slow the healing process.

Below is a cut & paste of Dr. Jim's most excellent post:




Medical Supplies On Board

--------------------------------------------------------------------------------

OK, here are a few suggestions, of a generic nature:

I would recommend that anyone who is interested in providing good first aid on board obtain a book first, and read it. There are two kinds of books that would be useful for this:
The first would be a book written specifically for the purpose of guiding first aid in the marine environment, and there are a few out there. They are written by doctors and as far as I know, they are just fine.
The second would be a good first-responder manual- in other words, a text or manual used by EMT-Paramedics. They actually provide more initial care than any other group of medical workers, as a class, and their textbooks and manuals are easy to read, well-illustrated, and cogent. Bear in mind that the book- any book- is only as useful as your ability to find stuff in it. You do not want to be meeting the book for the first time when someone's artery is squirting at you or your elderly guest just complained of chest pain and passed out. You will wish you had read the chapters on bleeding, chest pain, and loss of consciousness prior to those events.

I've seen reviews of various medical kits for boats. The last review I saw was in PBR, and they felt that the only one worth investing in was a modular kit that was rather expensive. The review was written by, or in consultation with, an emergency physician, and I thought was right on the money. If I were buying a kit, I would get the best one I could afford, and check its' contents regularly. For all the stuff I carry, a plastic tool box works a lot better, frankly.

As far as things to carry in addition to the kit, some suggestions:
-lots of wound dressing materials in various sizes. Often several people get injured at once. I would carry enough wound dressing materials to take care of six large wounds. What I have found useful are lots of four-inch square sponges, Kerlix to wrap them on, and ACE wraps to hold everything on. Keep in mind that medical professionals tend to put on very large dressings. You aren't going to have to care for six large wounds at once, but you won't run out of supplies.
-lots of clean water and soap to wash wounds with. The water in your FW system is NOT clean enough for this purpose. No one has ever shown that antiseptics such as alcohol, iodine, etc get wounds any cleaner than soap and water, but antiseptics DO kill tissue and make it harder for wounds to heal. The best agent for wound cleaning is bottled sterile saline with a SMALL amount of betadine mixed in. This will help kill bacteria and doesn't kill tissue. The amount of volume you use to wash a wound is as important as anything else, the more the better.
-splinting materials are important. The one maneuver that relieves the pain of an injured limb more than anything else is splinting it, applying an ice pack, and elevating it. The splinting materials we use are fiberglass sheets and strips vacuum-sealed in metal foil envelopes- you dip them in water and apply them and they cure. Splinting is enough for any injured part. You should not try to cast anything unless you know exactly what you are doing. Essentially any rigid material that is not heavy and can be padded and molded a bit can function as a splint. Padding is important to avoid pressure points and consequent skin damage- we use cast padding called Webril, but it should be widely available. Ace wraps go over that- not too tight. All this stuff comes in rolls and you should have several of all those. Clean rags can also be used to pad splints, and large clean rags can be used to make slings.
-if you are faced with the necessity of getting a badly injured or unconscious person off a boat, a litter may be invaluable. This is basically two poles and a cloth sling between them. Note that much of the equipment carried by EMS providers has to do with very basic tasks such as picking people up, moving them, immobilizing injured parts, and covering people up if they are hypothermic or in shock. Space blankets, which reflect heat back in, are useful to have.
-duct tape, several rolls, should be available. This is not a medical item. It is so useful that to describe it as a medical item only would demean its' utility. However, for example, I think a manageable litter could be made of poles, cloth and duct tape, if you needed to do it.
-you should have a list and supplies of everyone's prescription meds on board. Bear in mind that physicians are licensed by state, so, for example, I am not licensed to write a scrip in any states other than Virginia and Maryland. Likewise, if your doctor wrote a scrip with refills, and he is licensed in Florida, you may very well not be able to refill the scrip in any other state, even if you have the bottle, his phone number, etc. This problem is virtually guaranteed for any controlled drugs such as pain medicines and some seizure medicines. The lesson here is: bring as much of your own medicines with you as you will need for all the day you expect to be away, plus a few weeks to spare. Some drugs- notably insulin- must be kept cold. Plan for this. You do not want to run out of this drug especially, far away from home.
-specific meds I would carry are: Bacitracin ointment, aspirin, Tylenol, Motrin, lots of heavy sunblock, steroid ointment such as 1% HC, which is OTC, Benadryl, and, if you can get it, Silvadine, which is a burn cream that is very useful. I think it is available only by RX but it is worth the trouble to have. It can be used in anyone who is not allergic to sulfa drugs. I agree with your choice on the EpiPen- you should have at least one. Two would be better.
You asked about the most common on-board ailments: my feeling is that the most common ones would be burns (sun and otherwise), scrapes, contusions, lacerations, sprains, fractures, jellyfish and nettle stings, ray tails- minor trauma. Far less common is major trauma: head, neck, chest and abdomen injuries. Essentially for these you will have to provide field care as best you can while calling 911 (see below). The most common illnesses would probably be things like heat exhaustion and heat stroke, food poisoning, hangovers (not funny if you've had a bad one ever), and then the usual gamut of acute illnesses people can get anywhere, made worse by the fact that they are far from home. Also bear in mind that travel, although generally enjoyable, is stressful, and that the illness any person is most likely to suffer from is a worsening of the one they already have. So, for example, a patient with chronic well-controlled epilepsy who does fine at home may, in a travel situation where they haven't had enough sleep or have had too much alcohol, have a seizure. Frightening enough if they seize but stay on the boat- much worse if they fall overboard.
-certain illnesses and injuries are peculiar to the marine environment; most notably drowning or near-drowning. You should read the book on this. In ERs we tend to view this kind of injury as a composite of an airway problem, possible cardiac arrest, hypothermia, electrolyte disorder, and aspiration of foregin material into the lungs. We do not have a "drowning protocol"- this is an instance where the first-responder test is more useful to you than knowing what I as an ER doctor would do. The circumstances are somewhat different because of the field situation.
-seasickness is a topic that entire books have been written on. There are a variety of cures or preventatives. I don't know enough to comment on them authoritatively, but the wrist bands are reputed to work, ginger is reputed to work, and fresh air and being able to see the horizon is reputed to help. (in other words, being up and on deck at the exact moment that you crave nothing quite as much as lying in your bunk wishing you were dead). If you carry enough people in enough kinds of weather, it will happen. Prolonged vomiting, especially in the very yound and very old, can cause dehydration and electrolyte imbalances that are serious. The only option at that point is to get the patient off the boat and to an emergency room, unless you have the ability to intravenously rehydrate someone on board, and few of us do.
A few words about getting help: the process of getting first responders (EMS personnel) to a marine casualty is much more complex than that process is on land. It involves more steps and more people, is technically more difficult, and more dangerous to all concerned, not just the patient. Most inshore areas and coastal ones as well will have the ability to connect with land-based 911 services, but I don't know enough details on how this is done to advise you- plus there may be regional differences. In our area, I am fairly certain that if you can get cell service you can get a 911 call through. You also have the option of a radio call to the Coast Guard or local marine police or DNR. This is not something I am at all expert on. One of my colleagues who visits this forum is also a licensed captain and a police officer and may wish to comment on this.
Next: the first thing to do in any kind of emergency is take your own pulse. In other words, don't lose your cool. If you can keep your head while everyone else is losing theirs, you will either be viewed as a highly mature stable individual upon whom everyone else can depend in a crisis, OR an unsympathetic iceberg who could watch his pet cat expire without batting an eye. Kidding aside, approaching the sick and injured person calmly and methodically to do what you can to make them better or at least more comfortable while not doing any more harm is the best any of us can hope for, regardless of what we do for a living.
A few things I have found to be useful in my own work:
-I assume all injuries sustained in the marine environment are infected no matter how benign they may look. This generally means meticulous would cleaning, tetanus updates, antibiotics, splinting, elevation, and VERY close followup- no more than 24 hrs. And those are the patients that I don't admit to hospital.
-people on vacation tend to minimize their illnesses because they don't want to lose vacation time, upset their families, screw up plans, etc. Someone you know who does not look good- in other words different- is someone to be concerned about. I have found it pays for me to take family members seriously if they say their relative looks poorly, especially if that person has risk factors such as old age, diabetes, high blood pressure, etc etc. Your travel plans may be upset by having to put someone in the hospital. That, however, is better than losing them. It is essential, if you have ailing family or crew, not to stick to a schedule in defiance of their medical condition. Plans may need to be altered.
The basics of emergency care begins with "airway, breathing, and circulation". These are the fundamental and axiomatic truths on which rest all medical care given to terrestrial life forms. You should take a CPR course- not because you are likely to have to resuscitate someone on your boat, but because it will familiarize you with a few key concepts that you need to know.
And, if you are unfortunate to have someone arrest on your boat, if you have taken the course, you will have done everything you can reasonably do, which is all that can be expected of anyone. Regardless of the outcome.

No doubt this will generate other questions, some of which I may be able to answer. And probably differing opinions as well, which is good too.

[nor'easter]

That is a most excellent post.

The comments about antiseptics are right on. I am a Navy Orthopaedic Surgeon, and when referred a patient with an open wound, I am happy when only a moist saline dressing is covering the wound. Betadine works by dessicating and will harm the tissue as well as the bacteria. This is probably not all important at all for small and superficial wounds, but for larger wounds with more tissue damage, it can be a big deal. I would suggest using saline (not FW tank water) to rinse the wound surface, and placing a moist saline guaze over the wound and covering as described above.
For splinting, you can use almost anything....pillows, sticks, rolled newspaper, etc with torn cloth garments to hold it in place. It is extremely important to make sure dressings and splints are not too tight, as swelling ALWAYS occurs, and circulation to the affected limb can be impaired.
I personaly enjoy taking care of complex trauma patients at my medical center, but I am sure that it would not be so much fun offshore in a rolling boat, in the sun/rain/wind/dark etc. It does pay to be prepared for as much as possible, and do the best you can for your crew and other boaters.

Thanks Jim for bringing attention to this, and well done Passages!

[jim rosenthal]

The last is very much appreciated. I should have made something clear which I neglected to do: running water in a hospital ED is not the same as FW tank water in a boat, far from it, which is why I recommended bottled sterile saline. I am glad you made that clear. I would not drink tank water let alone wash an open wound with it.

Liquids that are often used to "decontaminate" wounds, such as betadine or peroxide, kill tissue and do not promote healing. In the OR they use very large volumes of saline, sometimes with inert soaps or biologically inactive cleaning agents, and irrigation devices etc. The idea is to remove the contaminants without damaging the tissue that must be healthy for the wound to heal.

Questions and contributions are always welcomed.