Medicine For Mariners

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Medicine For Mariners101

• Robin B. Garelick, MD, FACEP
• SV Quantum Leap

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Objectives

• Learn and Have Fun
• Common Medical Conditions
• Seasickness
• Hypothermia
• Hyperthermia
• Sunburn
• Trauma
• Marine Evenomation
• Wound Care
• Customizing a Medical Kit
• Basic First Aid Tips
• Future Topics and Workshops ?

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Mal de MerSeasickness

• AKA Motion Sickness

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Seasickness

• Throughout the world, it is the most frequent
  medical problem responsible for maritime search
  and rescue.
• Primarily during stormy weather.
• Can cause a lack of will to persevere in stormy
  weather and rough seas.
• Wet, seasick and scared - they want to go home.

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Seasickness can cause

• Mental Deterioration
• Physical Deterioration
• Progressive Dehydration
• Loss of Manual Dexterity
• Ataxia (walk like youre drunk!)
• Impaired Judgment
• After several hours of illness - loss of will to
  survive
• Fatalities due to poor seamanship complications
  during emergency evacuation

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What does seasickness look like ?
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Basic Underlying Mechanism of Seasickness

• Your body, inner ear and eyes all send different
  signals to the brain.
• A disturbance occurs in the inner ear.
• Fluid within the vestibular system shifts in
  relationship to position.
• Position sensors in our muscles and joints send
  signals to the brain based upon our movements.
• Our eyes may have a fixed position when below
  deck or trying to read.
• Neural mismatch occurs while we are in motion.

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The inner ear its 3 canals

• Semicircular Canals
• Purpose of canals is so we stay balanced and live
  in 3D world
• 3 Planes of Space
• Up-Down
• Left-Right
• Front-Back

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The anatomy of motion sensors

• Canals are lined with haircells.
• The fluid in the canals is called endolymph.
• The haircells are our motion sensors and when the
  endolymph moves - a message is sent to our brain.

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The neural mismatch

• Dopamine (neurotransmitter) is released and
  triggers a chemoreceptor zone in the brain which
  activates our vomit center.
• Initial response to the neural mismatch occurs at
  the brainstem level.
• So how do we prevent this or blunt the
  response????
• AKA How to get your sea legs.

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Getting your sea legs

• Occurs over 24 to 72 hours.
• For many - the brain learns to compensate over
  time and you accommodate.
• Medication prevents symptoms but may not
  completely reverse once they occur.
• After a prolonged period of time at sea the
  reverse occurs as you get used to being on land.

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Signs and Symptoms

• Sleepiness and excess yawning
• Nausea (stay positive and tell yourself you wont
  vomit)
• Extreme Nausea and Vomiting
• Dizziness
• Headache
• Pallor
• Cold Sweats
• Depression
• Lack of interest

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Seasickness Triggers

• Going below deck for extended periods of time
  while underway.
• Looking through binoculars for extended periods
  of time (stabilizing binoculars).
• Reading a book, focusing on compass, detailed
  work or staring at one point.
• Keep peripheral vision on the horizon and not
  staring at an object your brain will interpret as
  stable because your semicircular canals are
  screaming motion.

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Preventative Measures

• Avoid alcohol.
• Get plenty of rest before departing.
• Drink plenty of water and stay hydrated.
• Avoid heavy foods and fatty meals while underway.
• Consider seasickness aids.
• Ginger
• Homeopathics
• Accupressure/Seasickness Bands

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Medications for Seasickness

• Antihistamines
• Meclizine (Bonine, Non -drowsy Dramamine)
• Cyclizine (Marazine)
• Diphenhydramine (Benedryl)
• Cinnarizine (Stugeron)
• Anticholinergics
• Scopolamine (Transderm-Scop)
• Antiemetics
• Promethazine (Phenergan tablet or suppository)
• Prochlorperazine (Compazine)
• Metoclopramide (Reglan)
• Odansetron (Zofran)

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Side Effects of Medications

• Antihistamines Anticholinergics
• Sedation/Drowsiness
• Dry Mouth
• Blurred Vision
• Serotonin Receptor Antagonists
• Headache
• Fatigue/Malaise
• Antiemetics (except Odansetron/Zofran)
• Akasthesis/Dystonia
• Sedation

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HypothermiaAKA Im Cold

• Primary Secondary Hypothermia
• Primary Cold Exposure
• Secondary Medical Conditions or Medications that
  prevent response to cold or predispose to heat
  loss.
• Immersion (Man overboard!!!!)
• Acute versus Chronic

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Hypothermia Defined

• Mild Hypothermia core temperature below 95o to
  89.6o.
• Moderate Hypothermia core temperature below
  89.6o to 82.4o.
• Severe Hypothermia core temperature less than
  82.4o.
• We set 86o as the CRITICAL Temperature.
• Mild and early moderate hypothermia are treatable
  without emergency medical intervention rescue.

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Acute vs.Chronic Hypothermia

• Thermal Conductivity of water 25 times greater
  than air.
• Acute Hypothermia develops in minutes to hours
  after sudden immersion in cold water.
• Chronic Hypothermia develops over hours to days
  when inadequate protection from cold wind and wet
  spray.

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Predictable Rate of Cooling

• Based on water temperature
• Body shape (short round bodies cool slower than
  tall thin bodies).
• Insulating fat layers (finally an advantage to
  having more sub-q fat).
• If immersed - activity during immersion (less is
  better).
• Amount of body immersed.
• Protective clothing being worn.

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How do we preserve heat ?

• Divert warm blood from the surface to our core.
• skin and muscles to the brain, heart, lungs,
  kidney and liver.
• The decrease in surface blood flow improves
  insulation
• Shivering occurs to produce heat by increasing
  metabolic activity. Max shivering at 89.6o to
  91.6o.
• Hypothermia develops when heat loss exceeds heat
  conservation.
• Muscle rigidity occurs at 86o.Voluntary shivering
  stops with we are unable to rewarm ourself.

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Signs and Symptoms

• Clumsiness in activity.
• Difficulty walking (especially with heavy gear or
  clothing).
• Subtle changes in mental status which impair
  judgment (confusion and disorientation).
• Decreased responsiveness to verbal and painful
  stimuli.
• Coma and unconscious state in severe hypothermia.

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Treatment of Hypothermia

• Initial treatment in mild hypothermia
• Take shelter from wind and water.
• Replace wet clothing with multiple layers of dry
  insulated garments that make the skin feel dry.
• If no dry clothing then add an extra layer of
  foul weather gear.
• Wrap in blankets, sleeping bag, sail or sailbags.
• Feed simple carbs and light sweet beverages (warm
  preferred)
• Allow shivering to continue for self rewarming.
• In moderate to severe hypothermia - evacuation is
  required for emergency medical intervention.

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Treatment of Hypothermia

• In moderate to severe hypothermia
• Heart can be stunned into ventricular
  fibrillation - therefore handle the victim
  gently.
• Lay victim flat.
• External hot packs to the armpits, groin, chest
  wall and neck to stabilize body temperature.
• Cuddle to help stabilize their body temperature.
• Cough and gag reflexes are diminished - do not
  try to give hot liquids or food.

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• Remember to keep them bundled and protected from
  cold.
• Helicopter rescue may incur winds of 100 mph from
  prop downwash and increase wind-chill for the
  hypothermic victim.

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Survival Gear
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HyperthermiaAKA Im hot

• Definition
• A medical condition arising when the bodys
  capacity to lose heat does not match the total
  body heat load.
• Occurs when a normal physiologic response becomes
  pathophysiologic (body temperature gt than the
  brain set point).

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Types of Heat Illness

• Heat Rash rash caused by plugged sweat glands
  and we get a secondary inflammatory reaction.
• Heat Edema self limited swelling of the hands
  and feet seen early in heat exposure.
• Heat Cramps muscle cramps associated with
  exercise and secondary to loss of sodium.
• Heat Syncope fainting from dilatation of the
  surface blood vessels from high temperature.
• Heat Exhaustion Loss of circulating volume in
  the face of heat stress.

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Types of Heat Illness

• Heat Stroke complex clinical condition
  characterized by
• Core temperature of 104o to 106o.
• Neurologic Changes (aka change in mental status)
• Multiorgan dysfunction can occur - breakdown in
  ability of kidneys and heart to function within
  normal limits.

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How do we lose heat ?

• Radiation 65 of heat loss
• Conduction lt 2 of heat loss (increases when
  immersed in water)
• Convection 10 of heat loss
• Respiration/Breathing 5 of heat loss
• Evaporation 35 at rest and up to 75 of heat
  loss with activity.
• Most effective means of heat loss BUT at 95
  humidity, evaporation no longer occurs.

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Factors that Predispose us to Hyperthermia

• Prolonged exertion
• Poor muscle conditioning
• Inability to acclimate to the temperature
• Sleep deprivation
• Disease states
• Cardiac, dehydration, endocrine disorders, skin
  disorders, infections, seizures, etc.

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Factors that Predispose to Hyperthermia

• Rapid change in humidity or temperature
• Heavy and/or constrictive clothing
• Extremes of age - the very young and the very
  old
• Medications Drugs
• Anticholinergics TCAs and Phenothiazines
• Amphetamines Cocaine
• Diuretics (water pills)
• Alcohol
• Beta Blockers (drugs that end in -ol)
• Alpha agonists

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Signs and Symptoms of Heat Exhaustion

• Malaise
• Weakness (low blood pressure)
• Headache
• Decreased Appetite
• Nausea/Vomiting
• Increased heart rate
• Profuse sweating

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Heat Stroke

• True Medical Emergency that requires rapid
  cooling measures
• While awaiting assistance - remove excess
  clothing.
• Try cooling methods such as body misting, fan,
  cool wet sheets r ice packs to the groin, axilla,
  neck and chest area.
• Rapid cooling improves survival.

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Treatment of Hyperthermia

• Hydration, hydration, hydration!!!
• If you can read the newspaper through your urine
  - youre well hydrated.
• Electrolyte drinks like Gatorade or Powerade
  (avoid salt tablets).
• Avoiding excess heat with medication/medical
  conditions that predispose to heat illness.
• Decrease alcohol consumption.
• Minimize sun exposure.
• Avoid sleep deprivation.
• Decrease outdoor activity/exercise routines and
  shift to an indoor environment.

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Treatment of Hyperthermia

• Avoid sleep deprivation.
• Decrease outdoor activity/exercise routine and
  shift to indoor environment.
• Cold showers/transom shower/anchor washdown.
• If going to a hot climate - acclimate slowly over
  a period of 1 to 2 weeks.

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Sunburn and Solar Injury

• Sunburn is classified as a thermal injury.
• Red, hot painful 1st degree burns show up 2 to 6
  hours after exposure.
• 2nd degree burns occur when there is swelling,
  blisters and subsequent peeling.

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Sunburn Prevention

• Schedule water activities (when possible) in
  early morning or late afternoon hours.
• Chemical sunscreens (PABA) absorb UV rays and
  require application at least 30 to 60 minutes
  prior to sun exposure so they can penetrate the
  deep layers of the skin.
• Physical sunscreen (zinc oxide) act as physical
  shields and reflect or scatter light. They are
  effective immediately.
• Use on high exposure areas lips. ears, facial
  areas.

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Sunburn Prevention

• Reapply liberally every 2 to 3 hours and more
  frequently if in and out of the water or excess
  perspiration.
• Waterproof formulations last 2X longer than water
  resistant formulations.
• Consider UV block clothing and hats that cover
  sensitive areas (face/ears/neck/scalp)

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Sun Related Eye Injuries

• Excess UV Radiation can lead to cataracts and
  damage to the retina.
• Photokeratitis is a sunburn type injury to the
  cornea
• Intense eye pain
• Increased tearing redness
• Spasm of the eye itself as well as the lid

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Sun Related Eye Injuries

• Pain temporary loss of vision starts in 4 to 12
  hours.
• Treatment is with antibiotic ointment or
  solution.
• Bacitracin Ophthalmic Ointment
• Polytrim Eye Drops
• Cipro Eye Drops (Contact lens wearer)
• Avoid bright light after a photosensitivity
  injury (24 hours).
• Pain medication
• Sunglasses that block UVA UVB with a wide
  brimmed hat.

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Photosensitivity Reactions

• Exagerrated sunburn or rashes triggered by sun
  exposure after taking a particular medication or
  applying a chemicla or plant extract to the skin.
• Burn appears immediately and lasts up to 2 to 4
  days.
• May get hives or poison ivy type rash.

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Treatment of Photosensitivity Reactions

• Mild treat like you would a sunburn.
• Moderate to Severe
• May require prednisone (steroids).
• Pain medication
• Remove offending agent (if not a required
  medication)
• Stay out of the sun
• Use sunblock frequently and generously.
• Read the label on all medications and check
  manufacturer websites.

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Sun Poisoning

• Severe reaction after intense sun exposure.
• Fever Chills
• Headache
• Nausea Vomiting
• Dehydration and may experience altered mental
  status if the blood pressure falls
• Treatment is the same as heat exhaustion with the
  addition of prednisone for the most severe
  reactions.

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Drugs that Cause Photosensitivity Reactions

• Antibiotics
• Cyclines
• Flouroquinolones (Cipro, Levaquin, Avelox)
• Bactrim/Sulfonamides
• Nalidixic Acid

• Antihistamines
• Antiparasitics
• Antihypertensives
• Captopril
• Diltiazem
• Nifedipine

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Drugs that Cause Photosensitivity Reactions

• Anti-Inflammatory
• Motrin/Ibuprophen
• Indocin
• Naprosyn
• Piroxicanm (Feldene)
• Diuretics
• Diamox
• HCTZ
• Lasix/Furosemide
• Trimaterene (Maxzide)

• Miscellaneous
• Benzocine
• Benzoyl Peroxide
• OCP
• Topical Cortisone
• Amiodarone
• Xanax
• Retin-A/Accutane
• Hypoglycemics
• Glipizide
• Glyburide
• Tolbutamide (Orinase)

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Sunscreens that Cause Photosensitivity

• Preps containing the following
• Aminobenzoic Acid
• Avobenzone
• Benzophenones
• Cinnamates
• Homosalate
• Methyl Anthranilate
• PABA Esters

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Treatment of Sunburn

• Cool wet compresses for 15 to 20 minutes every
  hour.
• Frequent cool showers or duse with cold sea
  water.
• Pain medication (Ibuprophen, narcotic
  analgesics).
• Topical aloe vera gel for comfort and healing.
• Antibacterial Ointment
• Lidocaine jelly or anesthetic sunburn spray.
• Leave blisters intact as your own body fluid
  skin are a natural barrier and promote healing.

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Perfumes, Lotions and Cosmetics that Cause
Photosensitivity

• Bergamot Oil
• Oil of Citron, Lavendar, Cedar, Lime, Sandalwood,
  Citrus Rind Oils and 6-methylcoumarin
• Hexachlorophene (Phisohex, etc.)

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Trauma 101

• Sprains, strains, fractures, contusions,
  dislocations..
• All bets are off out to sea!
• Chest and head trauma are the most common
  injuries for recreational boaters.
• Head Injuries include both blunt and penetrating
  trauma.
• Chest injuries include both blunt and penetrating
  trauma

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Head Injuries

• Falls, hit in the head with flying objects and
  naturally the boom .
• Cuts to the face and scalp.
• Blunt trauma to facial bones.
• Nose bleeds secondary to facial trauma.

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What to look for with a head injury

• Was there a loss of consciousness (LOC)?
• Is amnesia present?
• Do they have normal speech, mentation and are
  they moving all extrmities?
• Is there a complaint of numbness or tingling in
  an arm or leg?
• Is there nausea/vomiting?
• Is there a complaint of blurry vision?

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Ouch!!!!!
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Treatment of Head Injuries

• If there is neurological abnormality - immediate
  evacuation with emergency medical attention.
• Prolonged loss of consciousness
• Numb/Tingle in extremities or an inabilty to use
  an extremity without signs of a broken bone
• Remember to try and immobilize the neck

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Treatment of Head Injuries

• If there is a brief LOC then it may be safe to
  remain onboard and observe carefully for the next
  24 hours.
• Signs of a more severe injury include
• Nausea/Vomiting
• Vision Changes
• Dizziness
• Change in speech
• Change in mentation

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Chest Injuries

• Most are from blunt force
• Can cause rib fractures.
• If ribs are fractured then make sure the injured
  person can breath comfortably as they are at risk
  of puncturing their lung from a broken rib.

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What does the rib cage look like ?
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Examination of the Chest Wall

• Expose the area to look for any open wounds.
• Feel along the chest wall front and back to see
  if there are rice crispies.
• Feel the breast bone for tenderness.
• Look for any deformity of the collar bones.
• Watch the breathing pattern - is it regular or
  short and gasping?

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Treatment of Chest Injuries

• Pain medication.
• Ice bruised areas found when you examine the
  chest.
• Duck tape???
• Monitor for any changes in breathing and pain
  increase with inspiration (taking a breath).

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Sprains, Strains, Fractures Dislocations

• RICE rest, ice, compression and elevation.
• Pain Medication
• If a bone appears deformed - splint in
  anatomically and place in a position of comfort.
• If severe deformity then medical attention is
  required.
• Blood loss can happen with long bone fractures.
• Nerve injuries can occur with dislocations and
  fractures - if not treated in a timely manner.
• Not sure then summon help.

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Sam Splint - My Personal Favorite
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Sam Body
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Sam User Guide
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Other SAM Products
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Marine EvenomationThe Jellyfish Sting

• Reactions vary b the type of jelly fish, venom
  potency and the amount injected.
• Symptoms vary from burning to itching to
  excruciating pain.
• Anaphylaxis with difficulty breathing, drop in
  blood pressure and shock.

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Treatment of Jellyfish Sting

• Apply vinegar (Acetic Acid 5) immediately to
  inactivate the venom.
• If vinegar is not available use sea water.
• NEVER rinse with fresh water or apply ice
  directly to the skin as it will activate stinging
  cells and increase pain/reaction.
• If eyes are involved irrigate immediately with
  saline or sea water.

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Treatment of Jellyfish Sting

• Rubbing alcohol and vinegar can help with pain
  over the first hour.
• Baking soda paste provides relief.
• 1/4 strength household ammonia may help.
• Limited usefulness of meat tenderizer.
• Remove embedded particles or tentacles with a
  tweezer. Wear protective gloves. You can also
  apply shave cream and shave the skin gently.
• Hydrocortisone Cream
• Prednisone and Benedryl
• If stung on the mouth - watch for swelling.

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Wound Care

• All bleeding stops with pressure.
• Apply direct pressure over the wound for 15
  minutes and elevate the affected body part.
• Neck wounds - pinch the area instead of pressure.

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Wound Care

• Clean wounds with saline or fresh water kept
  onboard specifically for wound care (boiled and
  stored).
• Alcohol and Hydrogen Peroxide applied full
  strength can be toxic to tissues.
• If you cant put it in your eye then dont put
  it in your wounds.
• Other wound care information

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Methods of Wound Closure

• Bandaid
• Butterfly Bandaid
• Steristrips
• Occlusive Dressing
• Skin Glue
• Staples (surgical staples)
• Sutures

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Checking the Wound

• Monitor carefully for signs of infection and age
  appropriate healing.
• Pus draining from wound
• Pain, redness and swelling
• Fever and Chills
• Swollen tender lymph nodes
• Red streaking in the affected area

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Choosing Your Medical Kit

• Based on how far you will travel and your health
  history.
• Easy to stow and easily accessible to all
  onboard.
• Basic supplies versus advanced medical kit

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Adventure Kits
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Adventure Kits
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Other First Aid Kits
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Godspeed