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Medical issues while cruising.

9K views 91 replies 26 participants last post by  wavestimulus 
#1 ·
I am a retired physician and full-time cruiser who is in the process of writing a new 'Medicine for Cruisers' book that will be available in both hard copy and web-based format. The book will be basically practical and cover pre-cruising medicals, cruising with pre-existing conditions, obtaining medications in foreign locations, possible insurance strategies, first aid, treatment of basic medical problems and emergencies, obtaining medical help in foreign countries, medical repatriation and the level of first aid and drug kits that can be sensibly carried.

Since medical texts are an excellent cure for insomnia I plan to illustrate the book with actual experiences of cruisers. In order to do this, I am asking for members to share, with me, their medical and insurance experiences, good, bad and informative, an example would be cruising with type I diabetes. I plan to write a definitive but practical book that will be of significant value to cruisers. Suggestions about the ideal format are also welcome.

I will maintain patient anonymity and medical confidentiality throughout the process. I will, with permission, contact anybody who contributes to verify the details of their experience.

Contributions can be on the forum, direct pm's or to my e-mail which I will provide if requested.


Phil Kellett MD.
 
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#2 ·
These slides describe a medical evacuation in 2012. It might be worthwhile knowing that AMVER volunteer ships are available for this purpose.

Click on the Rescue Me link



Jack
 
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#3 ·
Dr Phil,

These notes are from my circumnavigation partially with a girlfriend and part solo.

First, it's a very rare event something goes wrong with do the illness or injury. It's a very healthy lifestyle.

I did "Remote Area First Aid" and the instructors continually said 'get medical advice/help' but its REMOTE LOCATIONS! Their ain't nothing but the cruisers own abilities and the books they have with them and medical equipment. I would be pleased if you yell people how to do something than just 'seek medical advice' :)

I won't stitch a wound but I can do similar with elastic tape, can't I? I could make a cast from fibreglass and epoxy, couldn't I? How? Or is it better to just splint for 1 week?

Fear tactics mean many cruisers have $1,000s worth of drugs, kit incl defibrillators on board. A reasonable risk analysis of this expensive equip would be good... for example does a 50 year old healthy, slim male need a defibrillator, or is it just higher risk cruisers? And how do we calculate individual risk?

In my 40,000nms my first aid kit has only been opens to grab asprin and BandAids - I think most cruisers are similar.

I think it's a great idea to get a cruiser specific medical book ... would be a great help wether on the Kindle, Laptop or hard copy (but these days mostly eletronic publishing is the go).


Good luck with it! :)


Mark
 
#4 ·
I'm a cruiser and a retired neurologist with boards in stroke, sleep and neuroepidemiology. Inspite of this training and trauma training I am woefully deficit in tropical medicine, dermatology and infectious disease.
What I think is with advances in telemedicine and availability of satellite services a real time consulting service made available to cruisers at reasonable cost would be a great development. Perhaps billed as a base access cost. Then additional bill if used.
One could see a rotation of skilled pcps with a bank of specialists on call could meet this need. No books to thumb through in a high stress setting. No hours wasted on learning ( and forgotten) about dealing with events of low probability.

Would be interested in discussing further off line. If of interest PM me.
 
#10 ·
What I think is with advances in telemedicine and availability of satellite services a real time consulting service made available to cruisers at reasonable cost would be a great development.
There are a couple of services that provide this:


I recall reading about one cruising family who subscribed to a remote medical assist service where the service included a portable patient monitoring device. This device monitored vital signs and uploaded the data to the onshore medical assist team.
 
#5 ·
Some precautionary things would be nice, like I didn't know about how you can get sick from eating reef fish. I was down I the Caribbean in 13 and 14 and pretty much lived on snapper and barracuda and just recently learned that can make you sick.
You know local knowledge chapters would be real useful, like don't eat this step in that and what to do if you did.
 
#6 ·
I will think more about specifics from our circumnav. For now, one thing that comes to mind is that an app would be much more useful than a web site. I imagine that the two could be structured in the same way using a Q and A approach.
 
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#7 ·
Great idea... One of the many aspects my wife and I talk about is her current medical history and any foreseeable risks if we consider going cruising away from home for a considerable time

I've come across this great source and would consider both of us getting certified so either of us can perform the medical emergencies as they arrive not only for us but for other cruisers, etc.

https://www.wildmed.com/wilderness-medical-courses/first-aid/offshore-emergency-medicine/
 
#39 ·
...some English friends took a similar UK course and the kit came with a body bag that contained full instruction!

Phil
Hmmm, great, another piece of equipment I have to put on my cruising list. This brings up so many other questions. How many body bags do you need, one for everyone on board? (I'm thinking that it's actually one bag less than the number of your crew because the last person to die probably isn't going to be able to zip themselves in their bag).
Then there is the question of storage. Do the body bags come with a shipboard embalming kit? Where are you advised to store the deceased crew members, in the v-birth or in a cockpit locker? Without the embalming kit I would lean toward towing them behind in the tender.

All Things Considered, I think I will just leave instructions to bury me at sea.
 
#9 ·
Before we set sail from Frisco in 1970 on our circumnavigation, I asked my father (an orthopedist) to put together a med kit for us.
He did not include sutures as he felt that they were not something an amateur should do under the cleanliness conditions available on a small craft at sea. Lots and lots of butterfly bandages and topical antibiotics.
He also included a very old Merck Manual which proved to be a brilliant idea, as very few places we went had the modern medications readily available in the states.
We were able to enter the unmanned clinics on several islands and find medications (Sulfonamide antibiotics) noted in that old book and we quite possibly saved a few lives.
Of course prevention is by far best. I have a hard and fast rule aboard any vessel I operate; do not get hurt. So far nobody has felt the need to break it.
 
#12 ·
Phil,

I'll share some of my wife's condition and see if it's pertinent to your research. When my son was born during the epidural his blood mixed with my wife's blood (how?) either way her blood started coagulating badly and she was hospitalized for over a week while the heparin thinned her coagulated blood... Weeks later she was on Warfarin, now on Coumadin... she needs bi-weekly to monthly PT's (Prothrombin Time) tests... because they found out she now has a Protein-K deficiency she cannot digest any green vegetables or other foods which interfere with the Protein -K as this will raise her PT... it's a horror when she either bleeds almost to death or the blood begins to coagulate because the Coumadin levels are low... nightmare... So she being an epileptic since 2 years of age (German Measles) she's been taking Phenylbarbital and Dilantin to control seizures... this in turn over the years has caused her to have osteoporosis and now has to take Calcium supplements and shots... again horror stories... so all of this takes it's tolls on her body... namely her legs suffer swelling and must take great pains to reduce it... Now what does this has to do with cruising emergencies? You guessed it... we must be within earshot of some medical facility, have the proper medications at hand (some locations we've visited do not stock these medications) and must be capable of securing emergency protocols to administer emergency treatment... all this while on a boat travelling god knows where.

How can this help you and how would I proceed with a decent level of cruising later although we've been good so far on land.
 
#13 ·
The world has become much smaller and basic medical services are available in most places. We have had minor medical services in Mexico, French Polynesia, New Zealand, Australia, Malaysia and Thailand.

A good first aid kit, a course or two in basic first aid should do fine for most cruisers. Think prevention is the best remedy.

My gal had a hatch slam on her middle toe just a few days ago, blood spurting on my teak...cleaned and bandaged the wound from our medical kit. Anchored near a local village, went in to the clinic. X-ray, wound cleaning, bandaging and a splint, some antibiotics as well. Cost was 400 baht or about 11.00 bucks.

North Americans will be shocked on how little it costs for medical services in the rest of the world.

I have several other medical type service stories if you want more information. PM me.
 
#14 ·
M- helpful links but from brief review neither seems aimed at the mom and pop cruiser but rather mega yachts and aircraft. Resources on most vessels is satphone, ssb and laptop. Envisioned conversation and possibly uploads of a reasonable amount of pixels to allow some not very detailed pictures.
Once more data laden communication feasible additional support becomes available. Also critique and healthcare resources available in your region and routing/directions to them.
Example - vessel at sea. Description of symptoms given to remote support. Differential,diagnoses generated and further questions asked. Differential diagnosis improved and course of immediate therapy suggested. If acute intervention required remote support walks caregiver through it. Aftercare arranged by remote support and vessel directed to that place.
Before voyage standard health kit provided so remote support can direct care knowing in advance appropriate meds/supplies are in place and limitations of same. Revisions and renewing expired supplies done automatically. Reminders routinely communicated to registered end user. Memory stick given as well with care explainations. Remote service can say things like " go to page 57. Does the rash look like that or like what's on page 58?". Or "go to page 103 and follow directions there shown in pictures" Or "go to this video. It shows what you need to do".
Payment by subscription service with superimposed fee for service billing. Hope is this would place this service within financial reach of cruisers. Cruisers themselves would critique locale health care providers to aid in establishing good aftercare. Crowd sourcing. Independently service would review credentials of providers and facilities.
 
#15 ·
G- just wonder if your loved one is under a neurologist's care? Was struck by the use of Dilantin and phenobarbital as there are a host of newer anti epileptic drugs which are not associated with osteoporosis and are quite effective. Not knowing the details cannot offer medical advice but just that general statement. Would note due to side effect spectrum those two agents are used less frequently than in the past.
Best to you and yours
 
#18 ·
Out... Thanks... Yes she has been under neurologist care since I've known her. Yes she has been put on other epileptic trial drugs since the current medications prescribed will eventually be taken off the market. The results during the new trial drugs were that the new drugs have caused many seizures and consequently she was hospitalized. Not sure if the doses were adjusted correctly during initial use but definitely she needed to be taken off immediately and back to the former drugs. Eventually a new trial drug will be forthcoming that will allow her to be taken off Dilantin. I would like the Phenylbarbital to be taken off as this one drug is what limits her the most and causes much tiredness after a full day and nothing will boost her up except sleep.

So back on the tried and true... not sure what else the neurologist can prescribed due to the reluctance of her going through episodes again. She is fine nonetheless and I have yet in the 32 years I'm married to her to witness a gran mal seizure. Lucky for me as I would think it was a blood clot to the brain or other trauma and I would panic... Yes unfortunately one of the side effects to the Dilantin is the bone loss but fortunately it is counteracted with calcium supplements and she's good there along with her orthopedic specialist it is under control.

As much as it sounds doom and gloom for her she's all there... Special Ed. teacher, Middle/High School Swim Coach, Lifeguard, USA Swim Official, she was Junior Hunter Champion in Equestrian events at UF, and much more. The epilepsy/blood conditions did not deter her from having a full life including raising two children, home, etc. Much to learn regarding these conditions and why my son has devoted himself to medical school and taking up neuro-genetics at Mercer Univ.
 
#17 ·
I was an ex islotated duty medic in the air force and back county emt in Idaho (vol basis) - so when we left 8 years ago at age 62 I put together my own first aid kits. We have been out now 8 years and carry no insurance as we did not worry about it for the first 3 years as we were in and out of the USA. Then we really headed out and tried to get insurance but at age 65 no one wanted to insure us.
When we got to Colombia the Admiral had a congenitial problem with her hand where the fingers curl in. We saw an ortho guy who knew a hand surgeon who performed hand surgery at a cost that was very very low and with really good pt she is better than new. I have been having some issue with skin growth and see a dermatologist every 6 months. In Trinidad had a growth on my nose that just got worse and had 1/2 of my nose replace at again a very low cost. I still see a dermatologist every 6 months and carry my records and they are not hesitant of sapping things that are suspect. In Tunisia I ripped a shoulder tendon and had surgery and 2 screws inserted at a low cost and the Admiral had her other hand repaired.
While traveling inland in Romania I got pneumonia and was self treating until we got back on the boat in Albania and finally had to see a doc. He said yep pneumonia and treated me. The chest xray showed something that he did not like but not serious and told when when I make the next long stop I needed to get it looked at with a scan. I eventually did and it was nothing but they did find a stone in my gall bladder and took it out. Now that was a bit more expensive but a lot less than the USA.
At age 70 now we can not find insurance.
 
#21 ·
Good info... Since my wife is a teacher she gets the State Health Plan by Blue Cross/Blue Shield... covers her, myself, and my son till he is 26 years of age (currently 24). The real blow was Obamacare took our personal deductible from $500 person to $2000 per person and it was $2000 max family deductible (before) to $4000 max deductible (now) and we're fuming at this point! I'm sure everyone's insurance has done similar.

None of us are taking Medicare and not ready till I'm 66-3/4 years of age... got a ways to go.
 
#22 ·
Dear Dr. Kellett,

I have a number of stories from my delivery experiences. I am happy to share them with you and if any are of sufficient interest for you to want primary sources I can ask the crew member to contact you for more detail. I don't follow PMs so if you would like to connect please email me at dave@auspiciousworks.com.

Your initiative sounds interesting and worth supporting. There are a number of people (outbound among them) I would recommend you consult with. I can give you a list.

best, dave
 
#23 ·
MC (both parts), gap, D and evacuation. Through AMA good rates and includes offshore Rx. Evacuation insurance includes network to achieve local stabilization.
My Boston colleagues believe your brain stops working effectively if you are outside 128. This is rubbish. As stated above you get can get excellent medical care outstanding the US. But due to family support systems as well as specialized care still feel most have best outcome on US soil for major illness or trauma.
See major issue as patient having difficulty assessing if provider is compentent and facility top notch with no local knowledge and language/cultural barriers. Even in the US having had a only referral practice it was evident patients had difficulty assessing skill set of their PCPs. Demeanor often a confounder.
 
#24 ·
One of the best things I ever did was to take an EMT class at a local hospital, through a local community college. I needed an advanced first aid cert at the time, though a buddy and I decided to go all in and do EMT. It took about 6 months of a couple of evenings per week and some weekend rotations. It's been 25 years since, but I retain much of it to this day. Most of the procedures were to stabilize and transport, the later of which is not applicable to offshore. Nevertheless, the diagnostic, wound treatment and lifesaving skills are indispensable.

Anecdotally, most in the class were there to become professional EMTs and work for an ambulance company, or volunteer for a local fire department. Some were such num nums that I often thought, if I fell unconscious, required an ambulance and awoke to find one of them hovering over me, I would die of fright. I'm just hoping those few didn't find jobs. :)
 
#25 ·
Anecdotally, most in the class were there to become professional EMTs and work for an ambulance company, or volunteer for a local fire department. Some were such num nums that I often thought, if I fell unconscious, required an ambulance and awoke to find one of them hovering over me, I would die of fright. I'm just hoping those few didn't find jobs. :)
At present and since about ~1995, EMTs, etc. etc. and other medical practitioners involved in 'pre-hospital medicine' are subject to intensive and continual formal 'quality assurance' oversight (per each patient contact), required continual continuing education and periodic 'update' training as the 'national scope of practice changes', and with periodic recertification to the 'current EMS national scope of practice' .... by state (and umbrella national) authority. All those engaged in 'prehospital medicine' are under strict 'medical control'.
One simply cannot be a lone wolf EMT, etc., nor practice the prehospital arts in complete isolation of the 'EMS SYSTEM'. In the current national scope of practice and for a long time in the past, All EMS personnel - for all levels of certification - are formal 'physician extenders' within a well regulated, exceptionally high quality and controlled 'system'; and this includes' volunteers' as well as 'pros'.
 
#27 ·
Well, I've been running with a rural volunteer fire and rescue squad for about ten years now. When I meet somebody in that role, they are generally pretty glad to see me and my associates. Pouring rain,freezing snow, 3 am, we'll get you to the er and you won't be worrying about anyone's test score.
 
#28 ·
I would think that ways to manage common simple traumatic injuries would be a biggie for your book. Best ways to clean and dress a wound. If you can't or won't suture a bad one perhaps it could be steri-stripped and/or glued ("Dermabond" that is commonly used to close simple surgical wounds is the same kind of cyanoacrylate as found in Superglue or Krazy Glue). Ways to splint a fracture if it occurred (obviously much simpler if it's a finger or toe compared with a major long bone). These are things that could happen even to healthy crew and can respond well to simple interventions.

Nutritional issues and health consequences related to storage of food and fresh water would be good.

I'd think that major catastrophes like a cardiac arrest due to a heart attack would likely be a lethal event even if you had a defibrillator on board if you were a thousand miles offshore when it happened but simple items like aspirin and nitroglycerin would be good if crew were in that age cohort that are easy to carry and could have positive impact. There's probably a "sweet spot" for a one or two week course of some broad spectrum antibiotic like ciprofloxacin that would be effective against a number of illnesses including bacterial pneumonia or traveler's diarrhea. I suppose anbiotics like this might even keep a crew member alive from a abdominal misadventure like a ruptured appendix or diverticulum while awaiting or headed towards rescue.
 
#31 ·
I'd think that major catastrophes like a cardiac arrest due to a heart attack would likely be a lethal event even if you had a defibrillator on board if you were a thousand miles offshore when it happened but simple items like aspirin and nitroglycerin would be good if crew were in that age cohort that are easy to carry and could have positive impact. There's probably a "sweet spot" for a one or two week course of some broad spectrum antibiotic like ciprofloxacin that would be effective against a number of illnesses including bacterial pneumonia or traveler's diarrhea. I suppose anbiotics like this might even keep a crew member alive from a abdominal misadventure like a ruptured appendix or diverticulum while awaiting or headed towards rescue.
Couple of comments about these. When you go cruising you face a set of risks that may kill you. At home, you face a different set of issues that could be fatal. In neither case can one be completely safe. In either situation you need to decide how much risk you are willing to accept. We are all pretty comfortable with (or accepting of) the land risks. When we head off sailing the risks are novel so we may, in my opinion, over-react and try too hard to reduce risks.

We had cipro on board when we crossed the Pacific. I had a staph infection that produced boils on one leg. The cipro proved ineffective. Had treatment in both Mangareva and Papeete in FP with only some success. Smaller boils remained until we got to Fiji. A doctor there prescribed an antibiotic designed for skin infections - forget the name of the drug. It worked (or the infection died out naturally). For the last part of the trip we had four antibiotics on board - for different kinds of infections including dental, digestive, respiratory, and skin. BTW, the doctor in Fiji was at the 'private' hospital. The visit cost $12 and two courses of the antibiotic cost $12 (we wanted a spare of the first aid kit). I imagine the public hospital was free. Healthcare in the rest of the world is just so much cheaper than in the US - takes some getting used to for Americans.

A doctor friend gave us a skin stapler in lieu of suturing. He said the only downside was worse scarring but that it was a very quick and easy way to handle a bad cut.
 
#29 ·
There are multitudes of apps for Ipads that can be downloaded for reasonable cost. I have several downloaded and have never needed them but worth having them especially when cruising and you can't reach shore quickly.

GotoAID First Aid ($4.99)

The Merck Manual - Home Edition ($9.99)

iTriage (free)

Dr. Phil... Something on the order of combining all three above and more regarding specifics to injuries while cruising would be of benefit to many. An app would be best... In the aerospace field the manufacturing engineers came up with task books on the specific tasks to perform an activity... step-by-step procedures that performed an assembly, etc. whereby any person with minimum skill could perform a complex task. Such a task procedure in a simple step-by step, concise method anyone can follow to perform splints, sutures, first aid, poisonings, etc. would be most beneficial for many who would shun performing these procedures.
 
#30 ·
G makes a good point that much info is already out there- downloadable and searchable. Hence if you are going to invest the time and and energy an interactive service would seem attractive. As you know for a decade plus when you buy a medical text it virtually always comes with digital and mechanism for updates.
When you are involved in pt. care and are uncertain about something you get out your phone or pad and go to "Uptodate" or like service rarely a text. If time permits next step is a literature search and download. If not done immediately you still do it afterward as soon as time permits.
Problem here is for most of the lay public is they " don't know what they don't know". The same problem as with mid level ( NPs, PAs etc.) practitioners. Some are very bright and skilled within their knowledge/experience base but have difficulty conceptualizing outside those parameters. The good ones know this potential problem and often deliver the highest quality care knowing when to get help. The bit about uncommon presentation of common disease v.common presentation of uncommon disease is an example.
Both to be able to read what's important and what's not as well as having the full panoply of current knowledge and protocols an interactive service would be an advance. Furthermore as you know often the single hardest thing is to get an accurate history. How often have you experienced someone relating details of little import but brushing over key pieces of history. Here another person not emotionally distraught can be a huge help. Similarly when walking some through an intervention a cool head and calming voice can be a great help.
This would be real value added. Something the non professional would appreciate.
 
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