WHAT’S IN YOUR FIRST AID KIT AND HOW TO USE IT?1

Betsy Plotkin, MD

Presented at Bay Fest 2006, April 20, 2006

The outline is organized by problems with medicines or other equipment mentioned as needed. There is a suggested first aid kit also attached. Note that, in Mexico, almost all medicines are over the counter with no prescription needed. Where I write (Rx), it refers to the medicine requiring a prescription in the U.S. Whenever possible, know the generic name of the medicine you want as these names are usually consistent even if the brand names are different. What requires a prescription in Mexico is sedatives (Valium, Xanax, most sleeping medicines) and narcotic pain medicines (codeine, oxycodone, morphine, etc.) Injectable antibiotics are available without a prescription, but are not widely stocked by most pharmacies. Except in emergencies, prevention and non-medicinal treatment are preferable to drugs.


Disclaimers: My training is as a general internist thus I have generally not included pediatric doses or specifics. Illness presents in very individual ways and nothing substitutes for in-person medical evaluation. If you have any doubts about your situation, contact a medical professional for specific personal advice. Allergies must be considered before taking any medicines suggested herein.

Far a suggestion of an Offshore Medical Kit - Click Here

THE BASICS—prevention of illness


Food—Carry all food groups, including canned or dried fruits and vegetables.

Consider a multivitamin. Carbohydrates give quick energy, protein gives more lasting energy. Treat fresh produce with either bleach or iodine solution if not peeled or cooked and, if eating out, don’t eat unless peeled or cooked. Meat should be thoroughly cooked. Alcohol intake should be monitored and avoided while driving (car or boat).


Water—

Depending on the source, your water may need to be treated (filter, then bleach or iodine). When eating out, avoid water, ice unless known safe source.

Watermakers remove all minerals as well as contaminants, (thus the need for a vitamin).

Avoid dehydration above all. More water needed in dry and hot climates. No absolute amount can be stated. Drink enough to urinate a few times/day.


Rest—get sleep, arrange watches to correlate with biological rhythms


Conditioning—stay fit. Easier said than done. Walk, swim, do yoga, row.


Vision—carry extra contact lenses and 2 pairs prescription glasses


Hearing—carry extra hearing aid batteries


Dental—have teeth evaluated and needed work done before cruising

Take care of your teeth while cruising (brush and floss)


Psychological—know yourself, know your crew, recognize fatigue, recognize “hypoglycemia” (low blood sugar), acknowledge the need for alone time, acknowledge your limit of knowledge, acknowledge FEAR and how best to handle a “crisis situation”, be willing to ask for help if needed, understand your reaction to these feelings.



SPECIFICS


Sun Exposure-- Protect yourself with clothing/hat, sun screen (know your skin reaction), wear sun glasses (protects your eyes and vision). Sunscreen interacts with your skin chemically so takes about 30 minutes to take effect and needs to be reapplied every couple hours. It also requires a fairly generous application to work optimally. Combination UVA and UVB protection is optimal. UVB causes sunburn but UVA may be associated with skin cancers and other sun related skin damage.

Treatment of overexposure--

First degree burns (usual sunburn)—cover up, cool compresses, analgesics

Second degree burns (blistering)—leave blisters in place until they break,

Once open, apply antibiotic ointment such as Bacitracin, watch for infection


Dehydration—Dangerous because, if unable to sweat, can lead to heat stroke. Drink enough that your urine is light yellow. Watch for dizziness when standing, headache, weakness, all signs of possible dehydration.


Sea Sickness

  1. Anyone can get seasick and it can recur after adjusting if conditions are extreme. It can also recur on return to land!

For most people it lasts about 3 days, then the inner ear and brain adjust

Rare people never adjust and should question whether cruising is appropriate


For the first 3 days:

Stay on deck if possible or close to midship if below

Use a bucket on deck for a head if symptoms are very severe

Take the helm

Stay active—lying down feels better but may delay adjustment

  1. Keep food preparation to a minimum and eat simple foods, small amounts often, prepare foods before a passage to minimize galley time

  2. Medication may delay adjustment, but if unable to keep anything down, try taking for one day full dose and then tapering (side effects of almost all the medicines include sedation, dry mouth, irritability and constipation):

Oral: Dramamine—sedating but effective

Meclizine (Rx)—(Bonine without prescription) also sedating

Phenergan (Rx)—25 mg every 6 hours

Phenergan plus Ephedrine (Rx) 25 mg—less sedating

Stugeron--30 mg initially then 15 mg every 6-8 hrs. (not available in U.S.; very effective and less sedating; available in the UK at 15 mg and in Mexico OTC Stugeron Forte at 75 mg)

Other: Scopolamine patch (Rx)—one every 3 days

Phenergan suppositories (Rx)—one every 6 hours if vomiting


Female Issues

  1. Contraception—think about it unless pregnancy is welcome and remember, birth control pills may not work if too seasick to keep down

  2. Menopause—occasionally heavy bleeding in peri-menopause, discuss with medical provider before leaving; hormones can be taken to avoid bleeding.

  3. Yeast infections and other vaginitis very common in hot climates. Initial treatment includes rinsing perineum often, wearing cotton or breathable underclothes (or none). If not responding can use Nystatin (Mycostatin) or Clotrimazole cream or suppository or a single pill orally of Fluconazole (brand name is Diflucan (Rx))

  4. UTI—prevention includes drinking lots of fluids. Also bring antibiotics if prone (Macrodantin, Trimethoprim-Sulfa or Cipro are all effective in a 3 day course for uncomplicated bladder infections, see below for signs of kidney infection)


Male Issues

  1. Urinary retention—more common after age 60 with prostate problems, exacerbated by antihistamine type medicine which include cold and allergy remedies and seasickness medicine. Symptoms are inability to urinate despite full bladder. Suggest carrying a urinary catheter if known prostate problems.

  2. Urinary infection—treatment for men is 10 days unlike for women, Trimet-Sulf or Cipro appropriate.

  3. Physical injury—especially hernia or back injury due to awkward positions for performing lifting tasks. Keeping fit helps, attention to body position to avoid strain also important


Minor infections and other medical problems

  1. Skin—Use antibiotic cream on open sores (Neosporin, Bacitracin) For scrapes that occur in the water especially on coral, suggest Bactroban (Rx and hard to find in Mexico). Burns should be kept clean and dry, blistered skin treated with Silvadene cream to avoid infection or other antibiotic ointment. If more redness, swelling, red streak develop, would recommend oral antibiotics (Cephalexin 500 mg 3-4 times/day).

  2. Ear— keep dry with solution of vinegar and alcohol after swimming/diving. Swimmers ear is an outer ear infection with swelling of the ear canal and pain when tugging on the ear. Treatment is ear drops (cortisporin otic solution (Rx)). Inner ear infection is more painful, usually hearing is muffled, pain not worse with tugging on ear, may have fever. Treat with oral antibiotics (Amoxicillin (Rx), Cephalexin (Rx) or Augmentin especially if recurrent (Rx))

  3. Diver’s ear—pain after difficulty clearing the ears diving; treat with anti-inflammatories, or, if not improving, antibiotics (same as above); decongestant nasal spray and/or Sudafed to help clear ears.

  4. Cold or flu—treat with usual rest, fluids, Tylenol or Ibuprofen for fever.

  5. Eye infection—if eye is red, itchy/irritated and has goopy discharge, probably have conjunctivitis. Treat with antibiotic eye drops such as Gentamycin (Rx), Tobramycin (Rx) ophthalmic solutions. Do not use solutions containing cortisone. If eye is red, painful and NOT GOOPY, get professional help.

  6. Sinusitis—can occur due to colds, frequent swimming with inadequate drainage or allergies; treat with nasal irrigation (if familiar) and antibiotics (Amoxicillin, Cephalexin, Augmentin, Cipro (second line)—all Rx)



  1. Intestinal—diarrheal illnesses may be common due to unfamiliar foods or contaminated water. Constipation may also occur

  2. Bring Imodium for mild diarrhea symptoms (one every 6 hours)

  3. PeptoBismol for prevention of diarrhea in tropics (2 tablets 3-4 times/day)

  4. Antibiotics for severe symptoms (Cipro plus Imodium once may be curative, if not, twice/day for 3 days. In Thailand, need Zithromax due to resistance)

  5. Constipation—carry some kind of laxative, eat fiber (veggies, fruit, legumes, grains) and drink water.


Allergic reactions

    1. Skin rashes are very common; treatment:

  1. Rinse with fresh water after swimming for prevention

  2. Hydrocortisone 1% cream (0.5% for kids) for mild rashes, insect bites

  3. Stronger cortisone cream (Lidex, Temovate) for stubborn rashes

  4. Rashes in “folds” of skin (armpits, groin) or not responding to cortisone, try antifungal cream (Lotrimin 2-3 times/day)

    1. General allergic reactions

  5. Anti-histamines (Benadryl,Vistaril or Claritin) for mild reactions or hives

  6. Prednisone or other cortisone for extreme allergic reactions (review with medical provider)

  7. Epinephrine injection for life threatening reactions (including insect sting); Epipen is not available in Mexico, is Rx in U.S. In Mexico they will give you a bottle and syringe for Epinephrine. If possible, bring Epipen from U.S. Unfortunately, also expires yearly so needs to be replaced.

  8. Asthma inhaler aboard if anyone has ever had asthma or wheezing (Albuterol Rx)


Major infections and other major medical problems

(note: boiling water for 20 min. sterilizes it if needed)

Most SSB radio nets have a medical emergency section. There are frequently doctors cruising who can give advice. Major infections are characterized by high fevers (until very advanced when temperature may become lower than normal), severe weakness, possible delirium, shaking chills and then the characteristic other symptoms depending on the site. Whenever possible, get medical help before self-treatment as even a single dose of an antibiotic will nullify any attempts to culture the infection source.

  1. Pneumonia

    1. Symptoms: fever, cough, chest pain, severe fatigue, shaking chills.

    2. Treatment: oral antibiotics for milder (Zithromax 500 mg day 1 then 250 mg daily for 4 more days or Biaxin 500 mg twice/day for 10 days are recommended, Augmentin 875 mg twice/day likely would work, Cipro is a less good choice) or injectable antibiotics for more serious illness (Ceftriaxone 1 gram injection daily)

  2. Appendicitis

    1. Symptoms: mid-abdominal pain that migrates to the right lower abdomen, loss of appetite, possibly nausea, fever

    2. Treatment: no food by mouth, contact medical authority. If on passage may be temporarily managed with injectable antibiotics (Ceftriaxone) until surgical care available.

  3. Kidney Infection

  4. Symptoms: possible pain with urination, cloudy urine possibly with blood, fever, shaking chills, nausea and vomiting and back pain on either side just below the ribcage when tapped on

  5. Treatment: Cipro 500mg twice/day for 10 days, drink lots of fluids.

    1. Intestinal obstructions

  6. Symptoms: abdominal pain, nausea, constipation, severely tender abdomen and no bowel sounds

  7. Treatment: nothing by mouth, contact medical person

    1. Cardiac problems

  8. Symptoms: chest pain (dull, pressure, constant) radiating to the back, upper abdomen or arms particularly the left arm, breathlessness, sudden fainting can be a sign of cardiac disease

  9. Treatment: nitroglycerin, other heart medications if appropriate given personal medical history, aspirin. Contact medical person immediately.

  10. Stroke

  11. Symptoms: loss of function on one side of the body, loss of speech ability, sometimes loss of consciousness, usually no pain, sometimes headache (hemorrhage stroke)

  12. Treatment: contact medical person

  13. Severe dehydration

  14. Symptoms: weakness, dizziness, nausea, headache, cessation of urination, dehydrated skin, sunken eyes

  15. Treatment: sip water every 5 minutes. If unable to take liquids orally, start IV fluids.

  16. Hypothermia and near drowning—review treatment**, know CPR.


Injuries (minor)

  1. Cuts—stop the bleeding, use antibiotic ointment in tropics especially (Bactroban for reef scrapes, Bacitracin for other)

  2. Sprains—(RICE) Rest, Ice, Compression (ace wrap), Elevation. Anti-inflammatories for pain if needed (e.g., Ibuprofen).

  3. Tendonitis—analyze cause and alter use of affected part; splint area if not resolving in 10 days. Anti-inflammatories for pain.

  4. Bruises—unavoidable, ice if lots of swelling in first 2 days.

  5. Crush injuries (often hands)—ice, elevate, assess as best possible for fractures.

Injuries (major) (Note: make sure you are not at risk for a similar injury!)

  1. Broken bones—have splints aboard (SAM splint) and know how to immobilize or even set bones if in very remote cruising area. Compound fractures with exposed bone need special treatment including antibiotics. Contact medical person

  2. Head injuries—know how to assess severity *

  3. Major lacerations—edges need to be put back together for best healing but will heal whether or not they are, use stitches, steri-strips or Dermabond (same as Superglue). Repair within 6 hours or leave open. Assess function of injured part. Watch for infection. Learn to suture?

*Head injuries

Assess skull for bone indentation indicating fracture (expect more serious symptoms)

If any chance of neck injury, place in neck collar or backboard

Clear fluid running from nose or ear suggestive of spinal fluid leak, indicates very severe injury.

Severe nausea or vomiting can be a sign of more severe injury and brain swelling

Assess level of consciousness: can the person carry on a normal conversation? Are they confused? amnesic? irritable? irrational? sleepy? Anything other than normal warrants close watching.

Check the pupils for equal size and constriction with light. Watch this every 1-2 hours and if any change, and/or level of consciousness declines, suggest emergency evacuation.


If the above show none of the more serious signs, the person may have a mild to more severe concussion which can be watched aboard safely. The other more serious signs above suggest brain hemorrhage, skull fracture, and/or increased brain pressure which should be managed professionally if possible. Arrange medical evacuation.

Concussions are a brain bruise. They are managed as follows:

Watch pupils and level of consciousness for 24 hours every 1-2 hours

Give no aspirin or sedatives during this time (aspirin thins the blood and could exacerbate hemorrhage and sedatives make it harder to assess level of consciousness)

Expect resolution over days to a few weeks with common symptoms including headache, vertigo, confusion, “foggy” headed feeling. These symptoms should gradually improve after the first 48 hours. If not, reassess the severity, and, if symptoms worsen dramatically after the first 48 hours, contact medical person immediately (could be a sign of slow bleeding in the skull).


**Hypothermia

This is one of the most common hazards of Pacific Northwest boating due to cold year-round water temperatures (46-56 degrees F). Survival without special clothing in cold water areas is unlikely beyond 1 hour and significant incapacitation begins very quickly but is certain within 20 minutes. As always, prevention is the best treatment. Dress warmly, wear a lifejacket, use a harness. Children and thin people succumb more quickly to hypothermia. If body temperature drops below 90 degrees F, significant medical instability makes survival more difficult. Even in tropical waters, as long as the water temperature is below body temperature, hypothermia can occur, although it is usually milder and only after long exposure.

Early signs:

Blurred vision

Lack of coordination (loss of fine manual dexterity happens very quickly)

Uncontrolled shivering (shivering stops when body temperature goes too low)

Despondency

Incoherence or slurred speech

Treatment of early hypothermia:

Get out of wet clothes and get on warmer dry clothes

Moving around is OK at this phase (exercise to generate warmth), but NOT if hypothermia is more severe.

Drink warm liquids (lots of them, often dehydration is part of hypothermia)

Get in a warmer place if possible (in the cabin, out of the cockpit)


Severe hypothermia:

Diminished level of consciousness to coma

Dilated, unresponsive pupils in severe cases (call for med-evac while starting treatment)

Abnormal heart rhythms or cardiac arrest.

Treatment of moderate to severe hypothermia:

Active rewarming (classically, remove clothes, have two other naked people surround the person in a sleeping bag or very warm blankets)

Hot packs (like those chemical ones) or hot water bottle (warm water on the stove and put in a bottle) in the armpits, groin and around the head or a warm hat for the head. (Do not put the person in a warm bath if you should have the kind of boat that has one—this takes warmth from critical organs out to the extremities and can lower core body temperature and be fatal!)

Look for other injuries such as a head injury

If consciousness not improving with rewarming, consider other medical conditions such as alcohol intoxication, history of diabetes, possible medicine ingestion.

If the patient loses their pulse, perform CPR and continue rewarming techniques. Hypothermia can preserve brain and organ function because of decreased metabolism, so that the person can recover completely even if they have a cardiac arrest. (The classic ER teaching is: the person isn’t really dead unless they are warm and dead—in typical sensitive ER talk.)

SPECIFIC SEAFOOD, SEALIFE AND TROPICAL HAZARDS

  1. Food Related

  2. Paralytic Shellfish Poisoning—a special Northwest hazard caused by microorganisms filtered by bivalves (clams, mussels, oysters, scallops). Occurs seasonally (late spring, summer). Cooking does not eliminate the risk. Eating contaminated shellfish can be fatal since respiratory muscles can be paralyzed (mouth to mouth resuscitation until medical evacuation with a ventilator could be life-saving). Early symptoms include numbness/tingling around the mouth, spreading to the face/neck. Induce vomiting if suspected case and call for medical help.

  3. Ciguatera—another paralytic toxin obtained from eating affected tropical reef fish (e.g., groupers, barracudas, snappers, jacks). Pelagic (open ocean) fish are not affected. Larger (older) fish are more likely to have more toxin. Commercial test for toxin now available. Symptoms occur 2 to 6 hours after eating, starting with numbness around the mouth, spread to limbs, nausea, vomiting, diarrhea, weakness. Symptoms can last for weeks. When in doubt, don’t eat reef fish or ask local fishermen.

    1. Sea Creatures

  4. Swimmer’s Itch—Rash due to exposure to seawater from microbes, jellyfish larvae or other. Best prevented by rinsing with fresh water each time after swimming. If rash develops, itching may respond to cortisone cream and antihistamines.

  5. Stings (jellyfish)—Recommend book for reference. Vinegar, alcohol or meat tenderizer neutralize nematocysts. If tentacles attached to skin, cover with shaving cream and after a couple minutes, scrape with edge of credit card or other dull surface to remove. Continue to apply vinegar up to 30 minutes to relieve pain. Do not rinse with fresh water initially as this activates stinging cells on skin!

  6. Sting Rays—Generally stung on leg or foot after stepping on ray, rarely fatal but pain is extreme and wound may take a long time to heal or may become infected. Initial treatment is to rinse with seawater, let wound bleed freely, remove any visible debris, wash with fresh water then apply heat (either soak or heating pad) as hot as can be tolerated without scalding for at least 30 minutes.


    1. Tropical Diseases--See CDC website: www.cdc.gov/travel for more information on the following diseases and their prevention. Note: Any high fever during or even weeks to months after travel to tropical countries warrants evaluation unless clearly caused by a known infection. Malaria can show symptoms up to 5 years after initial infection for instance.


  1. Malaria—Caused by a blood parasite which is acquired from a mosquito bite. The carrier mosquito is active in the early AM and around sunset. Protect from mosquito bites (protective clothing, DEET containing bug repellant, mosquito screens). Avoid being out during evening and early AM when malaria containing mosquito most likely to bite. Take preventive medicine when in endemic areas. Most of southern Mexico and Central America require the first line medicine Chloroquine except the San Blas islands in Panama which have resistant malaria. Symptoms are intermittent high fever, chills, headache.

  2. Dengue fever—a viral infection transmitted by mosquitoes (reported in French Polynesia, rare cases in Hawaii, reportedly has been in Sea of Cortez as well). It can be fatal but in healthy people just makes them sick as dogs for several weeks. Symptoms include bad headache, high fever, rash and severe joint pains. Any sign of internal hemorrhage warrants medical evacuation. There is no treatment except supportive. The mosquitoes carrying dengue bite during the day so preventive measures are appropriate at all times (see above).

  3. Cholera, Typhoid fever, Hepatitis A—obtained from contaminated water. Observe safe water precautions unless water known to be safe. Treat with hydration (drink lots of fluids) and bland foods, obtain medical advice if prolonged symptoms. Hepatitis A and typhoid vaccines are available.


ANALYZING YOUR MEDICAL PROBLEM

Unless someone is unconscious, not breathing, or bleeding to death in front of you, you have time to think and analyze. This can be a very important step before talking to someone on the radio about your situation so you have your facts straight. Medical diagnosis is much like detective work and depends on observed data. Here are the questions to ask yourself or your sick crew member about the symptoms:

How did it start?

How long has it gone on?

Have you ever had this before?

What makes it worse, and what makes it better?

Does it change with body position, time of day, eating, moving your bowels?

Have you tried some kind of medicine already and how did it work?

Is there any sign of bleeding anywhere (urine, stool, vomit, bruising under the skin)?

Be prepared with past medical history (surgeries, major illnesses, and current medicines, especially if reporting on someone else in your crew).

Also very helpful are some vital signs: temperature, pulse, blood pressure and general appearance. Be prepared to know how to do these tests and report them on the radio

MICELLANEOUS

  1. Carry a list of crew members medical problems, allergies and medications with boat documents

  2. Stock your medical kit appropriately for you and your crew

  3. Address Living Will and Durable Power of Attorney issues before leaving

  4. List emergency contacts, crew member medical provider names and numbers

  5. Review your own medical problems with your provider. Arrange an extended visit time with your provider (request this, do not get a usual “follow-up” appointment or they will be rushed) to discuss the “what ifs” of your particular medical problems, your medications, medications you want to get for your first aid kit and how your medications interact with them.

  6. Update immunizations including tetanus, pneumococcal vaccine if appropriate.

  7. Review destinations and possible medicines to prevent malaria with a travel clinic

  8. Consider getting the Hepatitis A vaccine series (2 shots 6 months apart)

  9. Review other specialized vaccinations required for entry into certain countries.

If possible, everyone aboard should have at least basic first aid training. Someone should have more advanced training if extended cruising or remote places.

COMMERCIAL MEDICAL KITS

The following are some websites where I have found commercial first aid kits. The most complete ones are very expensive but are organized well with separate packs for various problems and a first aid book included.

www.adventuremedicalkits.com

www.marmed.com/kits

www.firstaidpak.com

www.chinookmed.com

References and Resources

CDC

Health Information for International Travel (#CDC 95-8280)

Malaria Hotline (404) 488-4046

Disease Hotline (404) 332-4555

www.cdc.gov/travel is a great website summarizing health recommendations by travel destination

International Association of Medical Assistance to Travelers (IAMAT)

(English speaking doctors of all nationalities)

417 Center St.

Lewiston, NY 14092

(716) 754-4883

www.iamat.org


Ocean Voyages (Medical training programs onboard on the West Coast)

(415) 332-4681


Medical Advisory Services (24 hr. consultation and marine medical training)

Box 193

Pennsylvania Avenue Extension

Owings, MD 20736

(410) 257-9505

www.masta.org


Maritime Health Services (Medical training course “SALTS-Save a Life at Sea”)

2701 First Avenue, Suite 105

Seattle, WA 98121

(206) 781-8770

www.globalMD.net

shipmd@globalmd.net


Travel Medicine Clinics


AMA Guide to Your Family’s Symptoms, 1992

Complete Guide to Symptoms, Illnesses and Surgery; H Winter Griffith, MD, 1995

Where There is No Doctor; David Warner, Carol Thuman and Jane Maxwell, 1992

First Aid Handbook; National Safety Council

Advanced First Aid Afloat (4th Edition); Peter F. Eastman, MD 1995

The Healthy Cruisers Handbook; Janette Loomis, RN, BS and James H. Bryan, MD, PhD, 2002

On Board Medical Handbook; Paul G Gill, Jr, MD

Dangerous Marine Animals, Bruce W. Halstead, MD, 1995

The Voyager’s Handbook; Beth A. Leonard, 1998

The Cruising Woman’s Advisor; Diana Jessie, 1997