MEDICAL NOTES FOR OCEAN CRUISERS

Dr Michael Sandberg

Chant de Mai returned to Chichester last July after a one year Atlantic circuit to the Caribbean. During this time we treated many fellow sailors. The intention of this article is to assist blue water cruisers to prepare medically, outlining the care of common or important conditions and highlighting some items to have in the medical bag. It is not meant to be a comprehensive guide.

Self-help and reliance on ones own abilities is the key to long distance cruising. It was our experience, however, that while extensive engine spares and the electrical multimeter were routine, a thermometer and basic antibiotics had often been forgotten. While the human body has an advantage in being designed to undertake many of its own repairs, one can go too far in trusting this property!

There is no substitute for seeing a trained doctor -- the advice given here is for when you are unable to contact one. It is essential that on making a landfall you consult a doctor and discuss any symptoms, or treatments you have self-prescribed. It may well have been the wrong diagnosis, or a symptom may need follow-up and tests despite in itself having resolved. It goes without saying that with SSB radio you should usually be able to obtain medical advice.

Contrary to one's natural impression, the risk of succumbing to an exotic tropical disease is relatively small. The main dangers are accidents and the type of infections that one might get at home.

PREVENTION IS THE PLOY

Accidents

The risk of accidents increases dramatically with overtiredness. Try and avoid, or at least realise, its potential.

Winches -- finger, hand and wrist injuries occur all too easily, as do rope burns. Pedantic attention to safe technique is essential.

Sharp objects -- knives, fish hooks. Beware that unexpected wave.

The boom -- use a preventer (vang) or boom brake.

Keep the boat tidy -- inside and out. While Chant de Mai was out of the water in Trinidad I had created an impossible tangle of tools in the cockpit, with the consequence that Sarah tripped and spent six weeks on crutches.

Close hatches/companionway -- when working on foredeck or coachroof.

Bare feet -- discourage for deck work, particularly anchor handling.

Gas explosion -- meticulous discipline / gas alarms / cut off / flame failure devices.

Burns in the galley -- half fill mugs if rough and always fill only when in sink.

Skin sores -- wash sweaty areas regularly (need I say more!). Otherwise a crew can be a haven for fungal infections in the tropics -- expose (when appropriate) but beware sunburn.

Sunburn -- have a bimini at sea and an awning in port. Cover up well with clothing and use high protection factor creams and sunglasses. Non-acclimatised guests are particularly at risk. (There is plenty of information in the general press about damaging effects and melanoma risk -- beware).

Dehydration -- in hot climates do not forget to increase your fluid intake as enormous amounts of salt and water may be lost through sweat. Kidney stones are much more frequent in the tropics.

DIARRHOEA

Prevention

* Do not drink unboiled water -- locals may well have natural immunity to its bugs.

* Fruit and vegetables -- peel or cook freshly.

* Only eat fresh, well-cooked meat (NB: Salmonella).

* Beware shellfish allergies -- also food poisoning is common as they concentrate sewage. Don't eat them the night before you head off across the ocean, anyway!

Treatment

If a crew member develops diarrhoea don't let it spread! The patient should not be involved with any food preparation, use separate towels and not share drinking bottles.

So long as there is no blood in the diarrhoea, the vast majority of episodes are viral and best not treated with antibiotics, which can make diarrhoea worse. Most episodes should settle within two to three days.

Don't use anti-diarrhoeals -- `bung you uppos' -- as they can in certain infections be dangerous and will stop the clearance of the bug from the gut.

If blood is present you need medical advice -- start a course of Ciprofloxacin, see end of section.

Adequate hydration and salt balance are the key to treatment -- large amounts of water and salts are lost in diarrhoea and in the tropics this can rapidly become serious. Glucose and electrolyte sachets such as Diarolyte or Rehydrat (available from chemists without prescription) reconstituted with boiled water are the mainstay of treatment. The glucose helps the intestine to absorb salts and water. Depletion of potassium and sodium in diarrhoea can cause weakness. If losing large amounts of fluid it may be necessary to drink up to 4 or 5 litres (8 Imp pints, 10 US pints) of water per day. Roughly half the fluid should be combined with glucose and electrolyte sachets.

If you run out of electrolyte sachets, a do-it-yourself alternative is 8 level teaspoons of sugar with 1/2 teaspoons of salt mixed with one litre of water (bottled or boiled).

Continue on fluids and sachets alone until diarrhoea has settled, and then gradually introduce bland foods. If diarrhoea is not settling in five days or so, try to obtain medical advice but continue with water and glucose and electrolyte mixture which can support a person for a long time. If no medical advice is available start a course of Ciprofloxacin as this is effective in Camplylobacter, Salmonella, Shigella and typhoid fever. Dose: 500mg twice daily for seven days. (Ciprofloxacin should not be used if there is a history of epilepsy).

If amoebic dysentry is suspected treat with Metronidazole 800mg three times daily for five days. (Do not drink any alcohol with Metronidazole -- dangerous).

PLANNING -- THE CREW

There are two aspects to sorting out the medical kit. One is to have a good weaponry to attack problems that may befall the crew. The other is to have medicines available to treat flare-ups of any conditions crew members may already have.

Past medical details -- either the skipper or another designated crew member should take details of the general health and past medical problems of all crew. It is most important to enquire about any medicines being taken and specifically to ask about drug allergies and in particular allergies to Penicillin.

Immunisation of the crew needs to be sorted out well in advance via their doctors. Start a good three months before you leave. This includes checking that Tetanus immunisation is up to date. (It is beyond the scope of this article to go into all immunisation details as these need to be specific to the areas which you are visiting).

Consider medical insurance. If cruising in Europe, obtain an E111 form (included in the Department of Health's leaflet T4 Health Advice for Travellers, obtainable from travel agents) and get it stamped by the post office.

Lastly, do not forget a dental check-up before you leave.

Chronic conditions -- Chronic means a long-term illness. Many conditions such as asthma, diabetes and inflammatory bowel disease, so long as reasonably controlled, are not usually a contra-indication to ocean cruising. It is necessary, however, that a crew member should have considerably more knowledge of his or her illness than at home when the action would normally be to pop down the road to the doctor. When away cruising it may be very difficult to find a doctor who speaks the same language and it is important that such a crew member should know how to monitor their disease control, picking up exacerbations early and carrying drugs for these flares. Such issues would require taking some extra time to go through with ones doctor. I emphasise this, as during our year we came across several people in such dilemmas.

INFECTIONS

The guide on pages 00/00 should allow you to choose a small number of antibiotics to take with you on a cruise, which will cover a wide spectrum of potential infections, so that you may choose the right antibiotic for the particular infection. Antibiotics mean anti-bacterial and are therefore not of help in viral infections, which are usually self-limiting. Different types of bacteria cause infection in specific parts of the body, and one therefore needs to choose an antibiotic which will kill the type of bacteria involved at the site of infection concerned.

Which antibiotics to take

The choice of antibiotic in this guide has deliberately been made simple and practical, and is limited to a few antibiotics which are relatively cheap. A boat would be reasonably covered carrying courses of Amoxycillin, Flucloxacillin, Cephalexin, Metronidazole and also some treatments for fungal infections -- namely Canesten cream for the skin and pessaries for vaginal infections -- plus Fucithalmic ointment for eye infections. If your budget will allow, a course of Ciprofloxacin could be useful.

I have not included specific advice on appendicitis or cholecystitis (gall bladder infection) as both conditions would need `radio medical' expertise to diagnose. However the range of antibiotics suggested above includes appropriate options for their treatment.

For a longer cruise you might wish to take more than one week's supply of each antibiotic.

Penicillin Allergy

If a crew member is allergic to Penicillin you would need Erythromycin and a course of Trimethoprim or Ciprofloxacin. Amoxycillin and Flucloxacillin are Penicillins. Cephalexin is not, but 10 percent of patients allergic to Penicillin have a reaction with it and it is therefore worth having an alternative.

Note

1. Antibiotics interfere with the metabolism of the oral contraceptive pill and if applicable you should use another method of contraception, while continuing to take the pill as normal. Refer to manufacturers instructions for specific details.

2. The following information refers to adults -- for children you would need to specifically enquire about antibiotics and their doses. NB: Ciprofloxacin is not recommended in children or growing adolescents.

3. Tetracyclines are a photosensitising drug and therefore often not ideal when the risk of sunburn is high, as in the tropics.

4. If pregnant, do not take any medication without checking with a doctor that it is safe.

MALARIA

While tropical diseases are not in the scope of this article, it is only prudent to mention malaria as it remains of major concern to travellers in tropical countries.

Malaria Prophylaxis

Check via your doctor whether any areas along the planned route are malarious. If so, find out which specific malarial prophylactic tablets will need to be taken for individual areas. Remember to start one week before reaching the area and to continue the tablets for at least four to six weeks after leaving a malarious area.

Cause and symptoms

Malaria is caused by a parasite which is spread by mosquito bites. The main symptoms are fever, sweating, chills, headaches and abdominal pains, in addition to feeling generally unwell. It is important, therefore, to remember that if you have been in a malarial area in the past year and develop these vague types of symptoms or fever, always to contemplate the possibility of malaria.

Prevention is the best action

Reduce the number of mosquito bites by covering up well, especially in the evenings, and applying insect repellent to exposed parts. At night in such areas use nets or hatch covers impregnated with Permethrin.

Also remember that despite taking the prophylactics correctly you can still get malaria! If you are going to be a long way from medical help it may be appropriate to carry a proper treatment course for actual malaria and, if symptoms occur as listed above, start the treatment. This would need the advice of your doctor.

If pregnant (or thinking about it) you will need to discuss the risks with your doctor.

OCEAN PASSAGES AND PREGNANCY

This advice is specific to ocean sailing and would be different for coastal. I do not wish to alarm, but to give the facts so that unnecessary risks are not taken.

First three months -- this is not a time for ocean passages. There is a roughly 1 in 5 risk of miscarriage for any pregnancy. This usually needs medical assistance due to being incomplete with bleeding or infection, problems that require hospital care. Additionally there is a 1 in 200 risk of any pregnancy developing in the tube -- Ectopic -- rather than in the womb. The embryo outgrows the tube, leading to its rupture and serious potential haemorrhage only treatable in hospital.

Also at this stage morning sickness may make even the hardiest of sailors unable to do anything, not funny when facing several weeks at sea and, because of the pregnancy, unable to take anti-seasickness pills. If there is any possibility of being pregnant, do a pregnancy test before setting off.

Middle three months -- this is controversial.

(Just before departing from Antigua on our return transatlantic passage we spent a week anchored off the idyllic reef-strewn beaches of Barbuda. Sarah found her expected period did not turn up -- we had carried our pregnancy testing kit some four thousand miles and to our happy surprise it came up trumps! This meant a sudden change of plans.

While Sarah flew passages during the first three months, she rejoined me for the passage back from the Azores in the middle of her pregnancy. However her `all day' sickness, not just morning, made the passage very difficult and she spent several days laid low in a bunk living on Diarolyte.)

Last three months -- also not a time to be crossing oceans due to the risk of premature labour as well as the fact that other complications of pregnancy are more common during the last trimester.

CONCLUSION

These notes concentrate on a few areas on which I feel cruisers could most benefit from having some extra advice. I felt it best to cover `infections and antibiotics' relatively thoroughly as improvements in this area could save lives.

Antibiotics would need to be prescribed by your own doctor on a private prescription, but other than Aprofloxacin a full complement of different types as suggested should only cost between œ15 and œ20.

While it would have made rather more exciting reading for me to detail the many events and illnesses which I treated during our year, it would not be ethical and also many of the patients have become friends!

I have done my best to ensure all details are correct, but cannot take any personal responsibility for any treatment undertaken on the basis of these notes as it is impossible to cover all aspects of treatment and risks without seeing the patient.

(Michael and Sarah's daughter, Florence, was born in January. Dr Sandberg qualified in 1983 and specialised in general medicine and cardiology for eight years before moving to general practice.)