MARINE MEDICAL KITS
Michael Jacobs, MD

This is part of Dr. Jacob’s presentation at the Wilderness Medical Society Conference (Maui, HI, 2008)

Following this presentation, participants will:
1. Appreciate the special requirements of a marine kit
2. Be able to select appropriate medical supplies for a ship’s medical kit.
3. Understand the specific use of these items.

Ask Dr. Bill Forgey, an expert in wilderness medicine, to identify the most important component of a back country snake bite kit, and he’ll quickly reply: “The car keys.” Ask Viktor Yazykov, a sailor who circumnavigated the globe in the 1998-99 Around Alone Race, what he considers the most essential items in a marine medical kit, and he’ll certainly respond:  ”A satellite telephone and computer.” Indeed, he could not have drained a potentially life-threatening abscess in his elbow without a detailed, 14 step surgical procedure e-mailed to him from physicians at WorldClinic, a medical advisory service (see Appendix) that uses phones, satellites, and the Internet to treat patients around the globe.

On land, access to definitive medical care for a critically sick or injured person involves rapid transport to a medical facility, hence Forgey’s “car keys.” At sea, direct radio consultation with the medical facility may be the only way to obtain medical expertise; evacuation of crew may be too hazardous or impossible. In the South Atlantic, a satellite phone was Yazykov’s best option.

Medical advisory service provide mariners with 24/7 access to physicians trained in the art of remote medical support. Coastal cruisers therefore require, at a minimum, a VHF radio, and offshore sailors need a single side band radio, satellite phone, or ham radio. Consider this equipment an integral component of the medical kit.

Medical Supplies: The comprehensive list of medical supplies listed below is divided into two main groups: items for the Crew Medical Kit and those for the Ship’s Medical Kit. Thoughtful selection of medical supplies involves consideration of the following factors and how they specifically relate to the crew and anticipated voyage:

• Common ailments at sea. For example: sunburn, skin infections, and seasickness.
• Common onboard traumatic injuries. Sailors frequently suffer head, rib, hand injuries, and burns.
• Number of crew and duration of trip. This determines the quantity of medications and supplies.
• Environmental extremes on the trip. Remember, suppositories melt and liquids freeze.
• Endemic diseases ashore in cruising areas (e.g. Malaria prophylaxis).
• Preexisting health, age, and risk factors of crew (e.g., ASHD)
• Availability of medical evacuation
• Medical problems associated with specific activities in the aquatic environment e.g., scuba diving, snorkeling.
• Medical expertise of crew (surgical types love to stitch and start IV’s; medical types favor glue and pills).
• Access to reliable, comprehensive, and definitive medical care.

Don’t expect to treat every medical or surgical emergency, but don’t omit items simply because you’re going on a short coastal trip. The same medical problems may occur on a weekend cruise or month long trip. Drugs and supplies useful for multiple medical problems should be selected. Above all- Bring what you know how to use.

The Crew Medical Kit
This is a conveniently accessible crew medical kit for treating a variety of simple and common medical problems. Keeping this kit separate ensures that supplies in the ship’s primary medical kit remain intact, organized and protected. Items should be grouped (by medical problem)  packaged in labeled zippered plastic freezer bags, and stored in a watertight container. The following is a list of suggested supplies and non prescription medications. Brand name drugs (in italics) can be substituted with other brands or less expensive generic preparations.

Seasickness Medication:
Bonine or Dramamine,
ginger capsules or other remedies that work for you and your crew.
Add Sudafed or No-doz to counteract drowsiness from anti-histamines;
oral rehydration packets (Emergen C, others).

Anti-inflammatory and analgesic medications:
Ibuprofen or naproxen sodium,
enteric coated aspirin;
acetaminophen for pain relief and fever.
Note: Many nonsteroidal anti-inflammatory drugs may increase sensitivity to the sun, so minimize sun exposure when using them.

Sun Protection:
Waterproof sunscreen (SPF 30) that blocks both UVA and UVB,
sunblock  lip balm,
zinc oxide for covering the nose,
100% Aloe Vera gel and
topical 1% hydrocortisone cream for painful sunburn;
spare high grade polarized sunglasses that block  UVB/UVA.

Minor wound care materials: Waterproof adhesive bandages in a variety of sizes including:
finger and knuckle strips (Band-Aid, Nexcare),
New-Skin antiseptic liquid bandage,
Benzalkonium (BZK) antiseptic wipes,
antibacterial soap (Hibiclens),
alcohol-based hand gel (placed In galley and head),
“baby wipes” in head,  and
antibiotic ointment.

Medical instruments: e.g., blood sugar monitor if crew with diabetes (with extra batteries).

Non-prescription pharmaceuticals for common minor medical problems:
isotonic buffered eye wash for sun irritated eyes,
antacids and Zantac for indigestion (H-2 blockers also used in allergic reactions, and  scombroid poisoning ),
Metamucil or Colace for constipation,
Imodium and Pepto-Bismol for diarrhea,
Tinactin powder and Lamisil cream or gel for fungal skin irritations in the groin and feet (jock itch, athletes foot),
Monistat vaginal cream or suppositories for yeast infections,
Sudafed decongestant for sinus, inner ear and nasal congestion,
guaifenesin cough syrup,
diphenhydramine antihistamine for allergies and insomnia,
Preparation H or Anusol HC cream and Tucks witch hazel pads for hemorrhoids,
Eucerin for dry skin,
Otic Domeboro for treating swimmer’s ear, and a drying solution the external ear canal.

Insect repellent: Sawyer Controlled Release DEET Formula; a 24-hour protection for adults and children formulated for minimal absorption of DEET.

Rubbing alcohol (40%-70%)  and white vinegar (5% acetic acid) for inactivating the stings of jellyfish, man-of-war, anemones, and other sea creatures.

Personal medications for existing medical problems and anticipated complications.

The Ship’s Medical Kit
There are two categories of ship’s medical kits: coastal and offshore. The coastal medical kit is appropriate for cruising within the 20-mile range of a VHF radio, a distance within which shore-based assistance will likely be able to evacuate the patient within 24 hours.

The coastal medical kit must have supplies to treat  both common problems and stabilize a more severely ill patient in the event that transfer to a hospital is delayed. The Crew kits supplements the supplies in the Ship’s kit.

The offshore kit, with SSB (single-sideband) radio or satellite phone should be stocked to permit  more comprehensive and prolonged treatment. Extended medical care and definitive treatment may be required.

An asterisk * denotes drugs or items that are optional for the coastal kit but necessary in the offshore kit.

The prescription medications have been selected because they are easy to administer, have convenient dose schedules, (12-24 hr. dosing means less bulk!) and have a low  incidence of sun-sensitivity reactions. Note the useful shelf life of these drugs and replace accordingly.

Antibiotics:
Cephalexin, Cefadroxil  (Keflex Duricef,) for infections involving teeth, ears, sinuses, skin, wounds, respiratory, and urinary tract
Levofloxacin (Levaquin) for infections in the bowel, gallbladder, female pelvic organs, prostate, and urinary tract; excellent for skin, ear, sinus, and respiratory infections; (slight risk of photosensitivity reactions, so cover up!)
*Metronidazole (Flagyl) Added to Levofloxacin for severe intra-abdominal infections e.g. peritonitis, appendicitis, diverticulitis, uterine and fallopian tube infections; also dental infections.
*Imipenem-cilastin sodium (Primaxin) Administered intramuscularly for urgent treatment of appendicitis or bowel perforation while awaiting evacuation.
Azithromycin (Zithromax- Z Pack)) for all infections in the upper and lower respiratory tract including tonsillitis, ear infections, sinusitis, bronchitis, and pneumonia.
Ciprofloxacin (Ciloxan) topical ophthalmic drops for eye and external ear canal infections.
Erythromycin ophthalmic ointment (Ilotycin) for eye infections and corneal abrasions.
*Denavir cream for oral herpes
*Valacylovir HCL (Valtrex) for Herpes Zoster (shingles) and Herpes Simplex  (genital Herpes)
*Fluconazole (Diflucan) for vaginal yeast
*Doxycycline for tick illness, tropical FUO- Beware photosensitivity

Seasickness:
Transdermal Scopolamine (Transderm-Scop) patches
Promethazine HCL (Phenergan) pills and suppositories for both seasickness and and vomiting
Ondansetron ODT (Zofran)for intractable vomiting.

Narcotic Analgesics:
Acetaminophen
Oxycodone 5mg capsules
*Hydromorphone (Dilaudid) suppository

CNS Medications:
*Lorazepam (Ativan) for severe anxiety, insomnia
*Modafinil (Provigil), Urgent need for wakefulness
*Respiradone (Risperdal), for transient psychosis

Cardiovascular Medications (depending on crew age and risk factors):
Aspirin, nitroglycerine SL and paste, metoprolol, clopidogrel (Plavix)

Trauma supplies:
Full size and finger size SAM® Splints (2 of each)
High compression elastic bandages 4″
Instant cold pack (if no ice aboard)
14 G Angiocath for emergency thoracotomy, tracheotomy
Eye pad for corneal abrasions and injuries

Surgical Supplies:
Bandage scissors
Unsterile nitrile gloves
Cotton-tipped sterile applicators and tongue blades
Tweezers and magnifier for foreign body removal
Topical anesthetic LET gel or 10% topical lidocaine
No. 11 Scalpel blade and handle for drainage of an abscess
Nu-Gauze iodoform packing strips for draining wounds
*Disposable Skin Stapler (15 Shot Precise, 3M)
*Staple remover
*Sterile paper drapes and disposable sterile gloves
*Suture kit -prepackaged kit with optimum assortment of equipment, supplies, anesthetic, and sutures (If experienced suturing wounds)

Wound Care Materials:
New-Skin Liquid bandage dressing
Silver sulfadiazine (Silvadene) cream for burns
20cc. syringe with 18-Guage plastic catheter for high- pressure wound irrigation
Povidone Iodine solution 10% (Betadine )-Use 1:10 dilution with water for wound irrigation solution
Chlorhexidine (Hibiclens) germicide to clean superficial wounds
Skin-closure strips (Steri-strip))
Benzoin swabs to increase adhesiveness of tape and skin closure strips
4″ Kling or Conform roll gauze bandage
Self Adherent elastic wrap (Coban, Vet Wrap)
Waterproof adhesive tape
Tegaderm- transparent, semi-permeable dressing for wounds
Adaptic 3″x3″ non-adhering wound dressing
Xeroform dressing- iodine-petrolatum impregnated gauze
Hydrogel Occlusive dressing (Spenco Second Skin, Duoderm) to absorb fluids from weeping burns and open wounds
Sterile gauze dressing pads 2″x2″, 3″x3″, and 4″x4″
Trauma Pads- 8″x10″ and 5″x9″

Allergic Reactions:
Epinephrine auto-injector (Epi E •Z Pen, Twinject) for anaphylaxis (2)
Prednisone for severe envenomation and allergic reactions
Betamethasone Valerate (Valisone).1% topical cream for contact dermatitis
*Cetirizine/psudoephrine (Zyrtec-D) a non sedating 24 hour antihistamine

Airway Supplies:
Albuterol (Proventil) metered inhaler
Oral airway kit with assorted adult and child sizes
Laerdal CPR Pocket-Mask™
*Stethoscope

Dental Kit:
Super-Dent or Cavit dental mixture for temporary filling,loose crowns and broken teeth
Oil of Cloves (Eugenol ) for topical dental analgesia
*More extensive dental kit (with instructions)

Gynecological Supplies:
*Urine pregnancy HCG kit
Norgestrel/Ethinyl Estradiol (Ovral ) for dysfunctional uterine bleeding and emergency contraception

Miscellaneous: Tetracaine anesthetic eye drops, large safety pins, duct tape (many uses),  Urine Chemstrips, l6 French Foley Catheter with sterile lubricant, bag, clamp, and plug for urinary retention (catheter also useful as improvised chest tube, and posterior nasal pack), enema bag for rectal hydration, *3cc syringes and assorted needles, *hyper/hypothermia thermometer

Optional Medical Equipment and supplies-
Blood pressure cuff, stethoscope. otoscope, digital thermometer, reusable hot water bottle, skin super glue (Dermabond ) for topical closure of easily approximated lacerations on face, trunk, and limbs, and wound closure forceps for use with tissue adhesive

Nonprescription pharmaceuticals for children: Oral rehydration salts for treatment of dehydration, Desitin diaper cream, activated charcoal-for accidental poison ingestion, pediatric strength decongestant and antipyretic, antiseptic pads with added 2.5% lidocaine (a kinder way to clean wounds, especially abrasions), Auralgan otic solution for ear pain, Chloraseptic throat spray, Benadryl chewable tablets for allergic reactions, E.N.T. pocket waterproof otoscope for oral, nasal, and ear exams.

Prescription medicine for children: antibiotics may need to be in a liquid suspension or chewable tablet for ease of administration and dosage adjustment based on child’s weight.
Amoxacillin Clavulinate (Augmentin) for ear, sinus, pharyngeal, respiratory, and urinary infections
Americaine - potent topical anesthetic for otitis
Mupirocin (Bactroban) cream for wounds and impetigo
*Cefprozil (Cefzil) for severe infections

Several items are not routinely recommended for the offshore kit for the following reasons:
1. Intravenous solutions, tubing, and IV needles for IV rehydration may be the choice of medical professionals, but experience for all others Is required. The same applies to suture sets.
2. Automatic external defibrillators are life saving only if expert intensive care together with a full complement of drugs and equipment is immediately available In the context of ACLS, and hospital coronary care unity. Non fatal heart attacks can be treated with aspirin, oral and topical nitrates, beta- blockers, and anti-platelet drugs.

Question:

I am 73 and solo sail. I have sailed from Oakland, CA to Mexico, to Hawaii, and am now heading out into the south pacific.I am not sure what medical kit to order.
Thanks, Susan M.

Dr. Jacob’s Answer:

I commend you for solo sailing at your young and vigorous age of 73- Probably the most important element in maintaining your health at sea is a good physical exam, female exam, blood work, possibly an exercise stress test, and a review with your physician of any possible medical problems that might arise during your trip. You need to review your medical history in detail.

For a solo sailor on an extended trip, the  Marine 1000 would be ideal, supplemented with medications (antibiotics etc) necessary for a prolonged cruise.

You may want to read a paper I wrote on marine medical kits (view in browser or download Word Document), which might be helpful in expanding your basic supplies.

Good luck and safe sailing,

Michael Jacobs, M.D.

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Question: Do you think i could fit a sleeping bag inside your emergency bivy?

AMK Answer:

Ian,

Thanks for your question.

It depends on how big your bag is. Most bags will, however extra long or below zero bags might be a tight fit.

The Heatsheets Emergency Bivvy is non-breathable so if you put a sleeping bag inside of it you would create a bit of condensation and perhaps get the outside of the bag and insulation wet. It would get you out of the weather however, so a little condensation would be a small price to pay. If your bag has a water resistant outer shell this would help kepp your insulation from getting wet.

I have used the Thermo-lite 2.0 Bivvy with a sleeping bag inside and although I did get some condensation, it was not of significant consequence. The Thermo-lite 2.0 Bivvy has a foot vent and side opening so there is more air flow helping to keep condensation down.

Let me know if you have any more questions.

Thanks,

Frank Meyer

Marketing Director/Co-Founder

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BACKCOUNTRY GRUB: WHAT’S SAFE TO EAT AND DRINK?

Christopher Van Tilburg, M.D.

In October, a solo climber on Washington’s 12,276-foot Mount Adams fell on Suksdorf Ridge, and broke his ankle. It’s just what every climber fears: being alone on a high mountain with a disastrous injury. Unable to walk, he dragged himself down the snowfields. After five days and nights, he was found at 6,200 feet suffering from frostbite and dehydration. He survived on creek water and an eclectic mix of creepy crawlers: ants, centipedes, spiders, mushrooms, and berries.

Sooner or later, if you spend time outdoors, you may find yourself without food or water on a wilderness outing; hopefully it’s just a short distance to your car and you are uninjured. But in survival mode, if you are lost and injured, you may need to eat and drink from the wilds.

You can live several weeks without food. But you won’t last much past five to seven days without water, even fewer if you are in the desert or at high altitude. Finding water is a paramount priority.

Drinking from creeks, like the Mount Adams climber, is probably a risk worth taking in prolonged survival situations. Yes, you can get protozoa infections like Giardia and Cryptosporidium, as well as bacteria and viruses. However, it takes just one day for you to begin to become incapacitated from dehydration.

When you find a source, ideally you should have a means to purify water before drinking. That means boiling, filtering, or chemical treatment. I carry water purification tablets for emergencies: they are compact, light, and easy to use.

Remember, when in the mountains, eating snow can cause hypothermia, because you need to use vital calories to melt it in your mouth first. So you should carry a lightweight backpacking stove to melt water. When in the desert, locating water can be extremely difficult, so if you find a source, consider staying put until you are rescued. If you do get a gastrointestinal infection from drinking backcountry water, see your doctor A.S.A.P.

As for food, if you can’t identify it, don’t eat it. You can get seriously ill from toxins and infections. My friend Greg Davenport, a survival expert, said critters with eight or more legs like centipedes and millipedes are often toxic. He recommends sticking to insects, which have some nutrition, but not much. A typical 100 gm (3.5 ounce) serving of fish, for example, yields 22 g protein, 1g fat and 0g carbos. The same weight of crickets yields 13 g protein, 6 g fat, and 5 g carbos. But that’s a big pile of crickets to scrounge for.

Wild plants—leaves, roots, bark, nuts, seeds, and berries— can be energizing or deadly. Use caution: even a small bite can cause stomach pain, nausea, vomiting, diarrhea, and rashes. Mushrooms can kill you. Davenport said aggregate berries, like thimbleberries, raspberries, and blackberries, are generally safe to eat. Purple, blue and black berries, such as wild huckleberries and cranberries, are 90% edible. Red berries are about 50% edible, so it’s probably best to avoid those, as well as any berry white, green or yellow, which are not edible.

Remember: always take enough water and food (an extra bottle of water and a few extra energy bars) to spend at least one unexpected night in the wilderness. And stash some water purification tablets in your survival kit.

Christopher Van Tilburg, MD, is the editor of Wilderness Medicine and author of Mountain Rescue Doctor: Wilderness Medicine in the Extremes of Nature now available in paperback.

Question:

I just need to make sure the moleskins do not have latex. It doesn’t say it anywhere on the package. Can you confirm that they don’t?

Answer:

Hi Lois- Thanks for your interest in our Blister Care products. Our Moleskin is made from cotton fabric coated with a latex-free zinc oxide adhesive.

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Question:

I noticed your comment on this service and you referenced an article in Sail magazine. Could you give me that info. to find this coverage for an upcoming long distance sailing trip. Thanks

Answer:

Here are the resources:

Telemedicine Organizations World Clinic 276 Newport Road New London, NH 03257 (1-800-636-9186) www.worldclinic.com

Maritime Medical Access George Washington University Medical Center Department of Emergency Medicine 2150 Pennsylvania Ave., N.W., Washington, DC 20037 Phone: (202)-741-2919/2918 Fax: (202)-741-2921 www.gwemed.edu/maritime.htm

MedAire/MedLink 80 East Rio Salado Pkwy. Suite 610 Tempe, AZ 85281 480-333-3700 Fax 480-333-3592 www.medaire.com

Question:

I live in N.E. Ohio and every Oct. I check and update all of my kits (first aid, winter truck pack and home kit). I have been looking at your two bivvy sleeping blankets for my truck kit. Can you tell me which one works the best in very very cold weather?

Answer:

Cassie, They both work well. The main differences are that the Thermo-Lite bivvy will breathe better - meaning less moisture condensation inside - due to the foot vent opening and Velcro side closures. If you are inside your truck, out of the wind, this would be my choice. The Thermo-Lite bivvy is also made of a stronger material. On the other hand, I like the Heatsheets bivvy because of its weight, size and the waterproof taped seams. Either bivvy will help you spend the unexpected night out in your truck.

Thanks for the question.

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Question:

1) I am a field member on our county Search & Rescue team. 2) I will be finishing with my Wilderness First responder certification in a few weeks. 3) I spend tons of time in the back country of colorado year round. From ice climbing to mountain biking. I have always carried a small field first aid kit, have have added more and more items over the years. Can you recommend a kit (for personal use) that I could use while hiking, biking, climbing, etc… in very reomte areas that can deal with everything from allergies to major trauma. thanks Nathan T., Secretary Garfield County Search & Rescue

Answer:

Nathan, I would carry the Ultralight & Watertight .9 kit and add QuikClot, an Epi-pen and a small CPR shield. You can find the Quicklot and CPR mask in our refill your kit section. The Epi-Pen you will need a prescription and go to your local pharmacy. Thanks

Q:
Hi there, My husband and I are preparing for cruising in our sailboat - expecting to leaven in April 2008. We have been planning our medical kit / supplies for the last 3 years, and both have some basic medical training. (We also have your Marine Medical 3000 as a good base) What we are looking for now is a good 24/7 medical contact service - are you aware of any? If an emgency situation does arise that we feel we can’t manage/ don’t understand - it would be most reassuring to know (in advance) we can contact an expert and always expect an answer (we have a Satallite phone, and email) Many thanks Maryanne Webb

A:
HI Maryanne- you question was forwarded to me- enclosed is an article I wrote for SAIL magazine last summer- the contacts should be correct- You’ll need to decide which company is both afordable and gives you the service you need- You also should make sure your sat phone has full coverage for your cruising area- If it is Iridium, it should do fine- let me know directly if you have any questions, good luck and fair breezes - Michael

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Q:
I am a river guide during the summer, I usually do class 3-5 rapids, and do multi day trips with up to 12 people. I have my WFR and EMT certifications. I also do a lot of backpacking, I do back country skiing in the winter. And I enjoy mountain biking on days off during the summer and was wondering which would be the best kit for me.

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