Dealing with medical emergencies at sea.
Part Three: Diagnoses and Treatment
By Major Henry Chandler MBChB, MRCS, DMCC
And Dr Chris Chandler FRCOG
Landlubbers say that worse things happen at sea, but that’s not quite accurate. It’s just that the bad things which happen on land are worse if they happen at sea, for obvious reasons: no doctors surgeries, ambulances or hospitals. So we need to be prepared for all medical emergencies as best we can. What follows is a concise and clear guide to recognising the symptoms and how best to deal with them when you are far out at sea.
Sepsis / Septicaemia
Sepsis is one of the biggest health concerns for a skipper and his or her crew. It is a potentially life-threatening condition whereby an infection is overwhelming the body’s own immune system and causing organ dysfunction or failure. It is a combination of the infection itself and the body’s own response in an attempt to fight it. In an austere environment, you are essentially travelling back hundreds of years (medically speaking) to a time when people could die from “a simple scratch”. This makes early recognition and decision making essential.
Recognising sepsis is not always straightforward, even in a hospital so the difficulty increases exponentially on a boat. The safest course of action is to have a very low index of suspicion, so If a crew member feels unwell, ask yourself, “could this be sepsis?”. There has to be a source of infection somewhere, so they may have a temperature (>38 degrees C) or feel hot but in some cases, the temperature may actually be low, so absence of a raised temp does not exclude it! An infected cut, abdominal pain, a productive cough, toothache, pain on passing urine, headache and neck stiffness may be your only clues.
Check the vital signs (pulse, breathing rate and blood pressure) within the limitations of your expertise and equipment. You can always assess a pulse: Place two fingers on the palm side of the forearm just up the arm from the wrist crease on the thumb side. If you can feel a pulse, check the rate against a watch. If it is racing (>100 bpm) for somebody who has been lying in their berth, this is cause for concern. Does it feel like your own pulse or does it feel weak?
A weak or absent pulse at the wrist suggests low blood pressure, another indicator of sepsis. If the signs point towards sepsis, or you strongly suspect it, it is time to start antibiotic treatment and plan your fastest route back to civilization.
It is likely that your casualty will deteriorate. Support them by strict administration of sips of fluid. With sepsis, absorption through the gut is impaired, but without intravenous medications, this is still your only hope. Large volumes taken orally will sit in the stomach and make the patient feel sick or vomit. The antibiotics usually take between 24-48hrs to make a noticeable difference, so give them early. If you are giving antibiotics, you should be making your way to higher medical care and asking for advice.
The acronym FAST will give you a very good indication if you are dealing with a stroke incident.
At sea, if somebody is unfortunate enough to have a stroke, you need expert medical assistance pronto. This is a real “pan-pan medico” situation. There may be a large vessel in the vicinity that can evacuate your casualty. The supportive measures you can provide are reassurance and warmth.
Get the victim somewhere safe and comfortable and try and keep them awake. Don’t try and force them to drink as they may choke.
Broken bones, although always painful, can be assessed as serious or less serious.
The very serious includes open fractures, where the bone is poking out through the skin, or a fracture that incapacitates a crew member vital to the safe running of the vessel. The management for both types is largely the same, but as very serious fractures are limb- threatening they require immediate decision-making to try to get the casualty to safety as soon as possible.
In the marine environment, managing fractures is about managing pain. The best way to relieve the pain of a broken bone is to put it back together and hold it there rigidly. As such, splinting the limb effectively so the fracture doesn’t move with every wave should be the aim of treatment. Immobilise the joint above and below where possible.
If the limb is visibly deformed, try to straighten it. This straightens the blood vessels and should give the foot or hand beyond the fracture the best chance of survival. This will hurt about as much as the original fracture, so if this is required, give painkillers first.
Splinting a deformed limb is very difficult and the muscle imbalance across the fracture will promote more pain and swelling, but a few seconds of agony is worth the relative comfort over the following days/weeks whilst sailing to safety. Be aware of swelling and be prepared to release any splints if the pain is getting worse, not better. Elevate the injured limb above the heart.
Open fractures should be managed in the same way, but with consideration to the wound as discussed previously. Infection is the enemy and in this scenario could rapidly become life-threatening. Wash and dress the wound as above and start antibiotics whilst planning your evacuation.
It is increasingly rare to be at risk of having a heart attack without your doctor having picked this up and started treatment. High blood pressure, increasing age, high cholesterol, being male, a family history of heart attacks and smoking all increase your risk of having a heart attack. The biggest risk comes from having previously had a heart attack, even if you’ve had a stent.
“My coronary arteries are like a 25 year old’s! I’ve been told”. As mentioned previously, ensure a good supply of all prescribed medications are brought and stowed by the individual. If somebody suffers from angina (chest pain caused by the heart not getting enough blood/oxygen) you should seriously consider the implications of travelling to remote environments.
In the event of somebody experiencing chest pain on exertion that then radiates into the neck/jaw and/or left arm, along with looking pale and clammy, insist that they stop what they are doing and rest. Give them 300mg Aspirin, as well as any medications they have been advised to take for the onset of symptoms, if they have a history of heart disease (eg Glyceryl trinitrate spray, isosorbide mononitrate).
The aim is to reduce how much work the heart is having to do thereby reducing how much blood the heart muscle requires from the dangerously narrowed blood vessels supplying it. Seek urgent medical help and continue 300mg Aspirin twice daily.
A new productive cough, pain on breathing, increased effort to breathe, in combination with fever, may indicate a chest infection. These symptoms tend to come on over a few days. In severe cases can lead to sepsis. Start antibiotics if a chest infection is suspected. It is hopeful that the patient will recover and the trip can continue, but reassess regularly. People prone to chest infections may well have rescue medications with them including steroids and inhalers and will hopefully have told you beforehand!
Prevention is key. Prepare your food properly and wash your hands regularly. The body is pretty good at ridding itself of anything harmful that is ingested, by vomiting it out early on. Occasionally, the effects are not noticed until the food has passed the stomach, this will lead to a more systemic illness associated with diarrhoea. Sip fluids and oral rehydration salts until symptoms settle.
There are many causes of abdominal pain, from trapped wind, to intestines that have strangled their blood supply and died.
In hospitals, trying to differentiate between them is difficult and often requires blood tests and CT scans to aid the diagnosis.
At sea, all you will have is what’s onboard and perhaps medical advice via sat phone.
Abdominal pain is more likely to be due to last night’s meal or constipation. Dehydration can easily occur at sea, especially in warm climates and one consequence may be constipation. Dried fruit or over the counter remedies will usually suffice, but constipation can lead to straining and bleeding external haemorrhoids (generally painless but an alarming sight). Constipation in severe cases can cause a mechanical blockage of the bowel leading to severe abdominal pain and vomiting.
If something inside the abdomen has ruptured, burst, or perforated the noxious contents irritate the lining of the abdomen which will do everything in its power to wall off the offending organ. This will make the tummy hard and board-like. The patient will likely want to remain perfectly still, their pulse rate will climb and they will look unwell. Start painkillers and antibiotics remembering that they will struggle to absorb oral medications, so use alternatives (intravenous/intramuscular) if that is an option.
If your casualty is suffering inflammation of an internal organ (such as appendicitis as opposed to a burst appendix), they may well get better with time, painkillers and antibiotics, but this should only be found out whilst executing your escape.
Burns & Scalds
Hardened ocean sailors take care to avoid sunburn with liberal coatings of sunblock and a wide-brimmed hat. However, even old salts can get caught out. I have spent many summers sailing in the Mediterranean and have never been burnt, but a couple of years ago we chartered in the Caribbean in February. I followed my usual early holiday Med routine, but the next day I was like a lobster fresh from the pot.
Treatment involves keeping the area cool, (fresh or saltwater will suffice) and application of a soothing moisturiser, ideally one containing Aloe Vera. Taking an anti-inflammatory agent such as Ibuprofen may help but it is also very important to keep well hydrated. Thereafter, keep the area covered with a “rash vest” or similar appropriate clothing. If blisters occur don’t be tempted to burst them as they form an effective barrier against infection.
For other burns and scalds, as ever, assess first. In the event of fire make the boat safe first. Fight the fire, if safe to do so, and ensure ignition sources, (gas etc) are switched off. Actually it is far more likely that this type of injury will be a simple contact burn from a hot pan, or a scald from boiling water.
Run the injured area under cold water to reduce the immediate heat and prevent secondary burns. Seawater is absolutely fine for this and in far more plentiful supply than your freshwater. If the skin is intact, keep it that way. When the blisters burst naturally, keep the area clean. Again, copious amounts of seawater is fine for this, and then pat dry. Protect with dressings. Non-adherent dressings will be far less painful to change. Change the dressings when they become saturated. Use each dressing change as an opportunity to clean the wounds. Over time they will dry out and unless very deep, burns will heal with new skin fairly quickly.
Deeper burns heal with granulation and scar tissue, but in the remote ocean environment, should be treated in the same way. Deep burns across joints could cause permanent restriction to the movement of the joint and should be managed by a plastic surgeon.
Burns around the airway or inhalational scorching can cause airway swelling and obstruction. Without skilled medical intervention this type of injury can be quickly fatal. Mild airway burns can lead to a hoarse voice and difficulty breathing or swallowing. Support the patient with sips of fluid and anti-inflammatory medication.
Wounds and Bleeding
Sailing vessels are festooned with contraptions seemingly designed to inflict pain on the user. Steel cleats to kick, metal winches at shin height and huge amounts of potential energy stored in ropes under tension. Bumps and scrapes are commonplace and should not cause any additional problems. As previously stated, the box of sticky plasters will be far more useful than the vast majority of the first aid kit. Deeper wounds, away from medical care, may require additional input. Infection is the enemy, so ensure all wounds are thoroughly irrigated with copious amounts of water, seawater is fine.
The next decision is about closure. If the skin edges are healthy looking – not too ragged or thin and they can be pushed together without too much tension – holding the skin edges together by any means will allow the wound to heal in time.
Steristrips are often adequate for this. They should not be cut as the length of the Steristrip is intended to give maximum adhesion and therefore hold the wound edge best. Any tape will do in an emergency. Tissue glue can be used in the same way and applied over a closed wound, not squirted into an open wound. All adhesives stick best to dry skin, so you need to stop the bleeding first. With sufficient pressure and elevation above the heart where possible, all bleeding stops eventually. Pressure should be applied directly to the bleeding point, so one finger is better than two, which is better than a palm, which is better than a bandage. Do not be tempted to check before five minutes. The first clot is the strongest. In cold weather with cold extremities double this to 10 minutes as the blood’s ability to clot is impaired. Once your wound is closed, maintain pressure with an elasticated bandage and elevation. Avoid ‘checking the wound’ too regularly. Once every couple of days is fine. If your bandage becomes saturated with blood, start again.
Whilst the above describes a relatively simple wound, the principles are the same for much larger wounds.
Clean, stop the bleeding and close the wound. If wound closure is not possible due to skin or tissue loss, keep the area clean, apply non-adherent dressings with something adsorbent secured in place with elasticated bandages. This will allow a stable clot to form and with time, the wound bed will granulate, the edges contract and scar tissue will form.
Major wounds to the chest, head or abdomen will likely require surgical management and should be managed as above whilst planning the shortest route to medical care.
Urinary Infection / Retention
Cystitis/urinary tract infection is another common problem which may be more likely if dehydrated. Pain on passing urine, passing urine more frequently or even blood in the urine will all usually respond to increasing fluid intake and a course of antibiotics as above.
Many (male) seafarers are now of an age where prostate problems are common. Ultimately, the prostate gland can become so enlarged that it presses on the urethra (pipe carrying urine from the bladder) and prevents the normal flow of urine (retention). This extreme situation is unlikely to occur without some warning. The individual will almost certainly have noticed needing to pass urine more frequently and having to get up more than once at night. Don’t ignore these symptoms, get them checked before you set off on a long passage. You really don’t want to suffer fluid retention away from medical help.
Staying ashore will not protect you from the slings and arrows of the human condition. Going offshore requires the skipper to take time and think about and plan for certain emergency situations. In many respects, you will be better prepared than the landlubber who falls back on the emergency services and will go a long way to mitigating the risks. Nothing can truly eliminate fate, whether you remain in your back garden or set off across the blue beyond, but if you’re thinking about it, and have good medical supplies onboard, you can improve you and your crew’s chances of avoiding real medical difficulties.
“I would like to thank Henry and Chris Chandler for this valuable and incisive guide for blue water sailors. It’s clear that they have committed considerable time and thought putting this three part series together. In my years sailing I have experienced, albeit on very rare occasions, some of the incidents they catalogue here. I wish I’d had the benefit of their sound advice and guidance with me at the time. I’m sure the information they have given will make a difference to, and be greatly appreciated by, Ocean Sailor readers. Can I suggest that anyone who is contemplating voyaging across oceans, where they must rely on their own resources, download or print these three invaluable articles off and keep them in the first aid locker.”
– Dick Beaumont, Chairman of Kraken Yachts