Creating a Culture of Safety and Health on Board: Transparency and communication are the cornerstones of optimal crew safety and health. There should be a designated medical officer. This can be the skipper or another crewmember. The crew should be strongly encouraged to report to the medical officer any medical issues that evolve during the voyage, ranging from seasickness to injuries to illness. A problem-oriented, non-judgmental, non-stigmatizing culture must be established and maintained. Pre-existing, chronic medical problems and relevant prescription medications should be discussed with the medical officer. If there are confidentiality concerns, an alternative could be to have each crewmember place their medical history and medication list in a sealed envelope to be opened by the medical officer only if needed for medical decision making. Either way, knowledge is safety. A sailing crew is a highly interdependent team that depends on communication for proper functioning. The approach to safety and health on board needs to be consistent with this fact. The Medical Kit:
This is a topic that has at its core varying interpretations of risk and probability of a given medical problem occurring. You cannot be prepared for everything. Different medical personnel and different crews will have honest differences on the relative value of various supplies and medications. The supplies you carry on board will reflect your medical training and experience, your knowledge of your crew’s known medical issues, and your itinerary and duration of the voyage away from possible medical support or resupply. That said, this is what I would carry on board for coastal cruising. What I would add for offshore racing or an extended passage is in italics: tools: --iris scissors (pointed fine tips) --bandage (“EMT”) scissors--blunt tip --forceps (tweezers) --automated BP cuff --thermometer --LED head lamp (Petzl, Black Diamond) --hot water bottles (3) --magnifying glass --suture materials (only if prior training and experience) --scalpel blades #11& #15 (2 each) --duct tape --1 1/2” #16 sterile needle--2 (draining hematomas under nails, emergency tracheostomy). --Foley catheter (16F) kit (sterile)
orthopedic: --SAM splint material
--ACE bandage 3”,4”,6” --dressing tape --elastic, self adhering wrap (Coban) --triangular sling wound care: --bar of plain soap --Zip-Lock bags for irrigation --soft bristle toothbrush (in unopened package) for wound cleaning --non-sterile gloves (nitrile if latex allergic) --cotton swabs --Steristrips 1/4” and 1/2” --tincture of benzoin (skin adhesive for wound closure strips) --cyanoacrylate glue (Dermabond ~$24/ 0.5ml, VetBond ~$14/3ml, or Superglue for $2.99). bandage materials: --8” x 10” sterile pads (6) --4” x 4” sterile gauze pads (24) --non-adherent dressing (Telfa,etc) --stretch bandaids in various widths and finger shapes. --porous adhesive tape (multiple rolls) --transparent,waterproof, breathable bandages (Tegoderm, Opsite, etc) -for burns and cuts that will get wet. --moleskin --protect blisters and abrasions. --Spenco Second Skin--blisters and burns. --Coban (see ortho above). OTC Medications: --acetaminophen (Tylenol,etc) for headaches, minor bumps. --ibuprofen for sprains, strains, headache and general pain. --aspirin 325mg--one only in event of suspected heart attack. --aluminum hydroxide antacid ( Maalox, Mylanta,etc) --ranitadine (Zantac,etc)--heartburn; --diphenhydramine (Benadryl,etc). Allergic reactions, sleep aid. --hydrocortisone 1%--mild allergic skin rashes and itch. --loperamide (Imodium)--effective for diarrhea --terbinafine ointment--for fungal rashes --meclizine--seasickness prevention Prescriptions Meds: (use in consultation with medical professional if possible) • anti-infectives: --mupirocin (Bactroban)--very effective topical antibiotic for small, local infections. --amoxicillin/clavulenic acid (Augmentin,etc)--skin infections, resp. infections). --cephalexin--skin infections if penicillin allergic.
--trimethoprim/sulfa--UTI, skin infections if known history of MRSA. --ciprofloxacin (Cipro)--UTI, bacterial enteritis (salmonella,shigella,etc) --metronidazole (Flagyl)--giardia, abdominal infections like diverticulitis, appendicitis distant from surgical care). --erythromycin eye ointment --for eye infections. --cortisporin ear drops --for swimmer’s ear anti-allergy: --prednisone--potent anti-allergy/anti-inflammatory,especially asthma. --triamcinolone 0.1% ointment--stronger than hydrocortisone topically. especially with dressing --Epi-Pen--for severe anaphylaxis (bee stings,etc). Expensive, expiration date rapid. • anti-nausea: --promethazine--suppositories (for established vomiting) and tablets for nausea. --ondansatron--dissolvable sublingual wafers for nausea. Not shown effective for seasickness, but great for other forms of nausea --scopolamine TSS patch--for seasickness prevention in responsive patients. --scopolamine tabs (Scopace)--for seasickness prevention. • pain: (must be kept under lock and key--high diversion/abuse potential). --codeine 30mg without acetaminophen. --injectable morphine (subcutaneous, IM)--for severe pain (broken bones,etc) Dental: ---oil of clove. Can relieve pain. ---Cavit, temporary filling material. In Addition:
All crew members should have their personal medical supples, individual OTC meds and any prescription medications readily accessible. Ideally, these should be discussed with the designated medical officer before and during use. * * * * * * * * * * * * * * * * * * * * The kit detailed above is by no means all-inclusive and may not contain specific equipment or medications that would be recommended by other professionals or will be needed by some sailors or crews--especially those with special or pre-existing medical problems. A consultation with a medical provider to better tailor the kit to specific needs is strongly advised. Case Studies
Case 1 A 45 yo man, Bill, and his sailing buddy, Mike, had dropped anchor on a beautiful, warm, sunny afternoon in the San Juans. They had a few beers in the unshaded cockpit and prepared to cook some kebabs on the barbeque. This they washed down with several bottles of good Washington State merlot. They noticed some sunburn and put on some sunscreen, even as the heat of the day abated. After the sun went down, they decided to retire. Mike awoke during the night with considerable thirst. He downed 500ml of bottled water. Bill did not. The following morning neither sailor felt too much the worse for wear. They had a light breakfast and 2 cups of coffee each. Bill remembered to take his blood pressure medicine which consisted of a mild diuretic, hydrochlorothiazide, and an ACE inhibitor called lisinopril. A few minutes later, Bill and Mike boarded the dinghy to go ashore. Bill became quiet. As they tied up at the public dock and climbed out of the dinghy, Bill slumped down, became unresponsive and was noted to have seizure-like activity which lasted approximately one minute. --Why did Bill experience a change in his neurological status? --What would you do? --What is the underlying process that ultimately caused this? Case 2 The 46 foot sloop, Malatet, was entering the Pacific ITCZ after several days of broad reaching in a steady 20Kt breeze. The wind died down to 12 Kts and veered to dead astern. The water was calm with a moderate swell. The main was eased to port and the 130 genoa was poled out to starboard. Both sails were full and pulling. A preventer was tied in to the main. As the swell increased and the wind died, the skipper started the engine and ordered the sails struck. The preventer was removed but before the mainsheet could be retrieved to bring the boom to the midline, a large swell caused the boom to come across to starboard. Crew members immediately called out a warning, but one crewmember who was wearing a broad brimmed sunhat, was struck a glancing blow on the forehead and forward scalp by the mainsheet block that attached to the boom bail, resulting in a 5cm (2") laceration. There was profuse bleeding but no loss of consciousness. The crew member became agitated at the sight of all the blood. How would you proceed to prioritize addressing the needs of your injured crewmember?
What would you do? Case 3: Sam has been sailing on Puget Sound for several years without difficulty. An opportunity to crew on a delivery from Port Townsend to San Francisco came up and he took it. The send-off party was great and he was careful to moderate his beer and wine intake. He got to his berth at midnight after drinking 500ml of water. Departure was planned for 5 AM with the ebb. Sam applied his Transderm Scop patch and took some Bonine (meclizine) before retiring. He was tired but excited in the morning. For breakfast he drank 2 cups of coffee and ate a bagel. Despite a prediction of a 10kt westerly wind, within a hour of departure the wind had increased to 20Kt against the ebb, resulting in a significant chop and correspondingly active boat motion. When Sam was asked to enter waypoints into the chartplotter he began to feel unwell. He continued to try to perform his assigned job and did not ask to take the helm because he was uncomfortable revealing his situation to the skipper. Ten minutes later, he began vomiting. What did Sam do right? What could he have done differently? What would you advise him to do now? Case 4: Alain joined your crew in the Bay of Islands, New Zealand, just prior to a planned departure for New Caledonia. He replaced another crewmember who had had a family emergency. His sailing resume was impressive, with multiple long passages and he reported navigation and culinary skills, in addition to fluency in French. After a brief interview, the captain was satisfied that he was competent to join the crew. Several hours after departure Alain seemed to become quieter and more withdrawn, although conditions were quite benign. He made several of visits to the head and there were concerns that he was getting seasick. But when he emerged from the head, he acted more upbeat, even energetic, for a some time. He stood his watch during which he seemed somewhat jittery and distractible. After completion of his watch he became withdrawn and moody. This pattern persisted for several days. The captain then had a frank discussion with Alain. --What could account for Alain’s behavior?
--What options might you have? --How could this have been prevented? Case 5 Frank, a seasoned cruiser and USCG licensed retired tug captain, was cruising with his family in Mexico aboard their 46 foot sloop No Malo. Over the course of several days, he began feeling increasingly fatigued. Within a day, the fatigue had progressed to the point of profound muscle weakness despite aggressive fluid and electrolyte administration. His wife, Alice, consulted the nearby cruising community, which included a chiropractor and a nurse. The consensus was that Frank needed more fluids and rest due to fatigue and excessive sun exposure. The next day, Frank was, if anything, weaker. He had trouble walking. Increasingly concerned, Alice took Frank to a local doctor, who kept him overnight in the clinico with a diagnosis of “dysentery”. Her fellow cruisers reassured her that Frank would be alright, but late that night she used a borrowed satellite phone to contact a physician friend in the US for further consultation. What do you think might have been going on? Was Alice over-reacting? What do think the physician recommended?
Turner Syndrome Management Guidelines Australasian Paediatric Endocrine Group – November 2003 by George Werther, with advice from Margaret Zacharin Introduction Turner syndrome affects around one in 2500 female live births, the majority of which carry mosaicism in at least some tissues. Thus, the phenotypic features vary significantly among affected individuals. Consequently, w
Seit jeher versuchen die Menschen dem natürlichen Alterungsprozeß Einhalt zu gebieten - mitmehr oder weniger Erfolg. In der Ayurveda Medizin wurden therapeutische Maßnahmen zurRegeneration schon vor über dreieinhalbtausend Jahren zur medizinischen Fachrichtung„Rasayana“ erklärt. Ein Auszug aus dem ältesten Werk der Inneren Medizin zeigt, was füreinen wichtigen Platz die verjüngenden Ma