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Medical Preparedness

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Compared to many life endeavors, cruising is safe. I'd much rather take my chances sailing to Central America than driving most highways. Some could even argue it's safer than staying home. The 20-year Framingham heart study recently found that women who seldom took vacations or never traveled at all were twice as likely to suffer a heart attack or die from heart disease as women who took vacations at least twice each year. As Paul Theroux puts it, "It is not possible to travel without coming down with something, but no one should stay home for that reason. Apart from terminal boredom, there are plenty of serious ailments available at home."

Most people cruise successfully for years without a single mishap or illness aboard. Said another way, the probability of any serious medical emergency occurring aboard your boat is, realistically, remote. Nevertheless, someone has to be in charge of getting the medical act of the boat together. Usually it's the most medically qualified onboard, but ultimately it's the skipper who's responsible for the overall well-being of the vessel and crew.

Let me suggest that your personal success with medical problems will depend on the right combination of luck and good preparation. Luck we can't do much about. You got it or you don't. Preparation is another matter entirely. When it comes to maintaining health aboard, preparation and prevention go hand in hand. Just like everything else about a boat, it's far better to avoid a problem than deal with it under less than ideal circumstances.

Here are seven tips toward achieving that goal:

1) Anticipate potential problems by knowing the medical history of everyone onboard. Obvious concerns such as heart conditions, diabetes, ulcers, seizures must be discussed openly and honestly. I personally know of a boat where the skipper had not informed his crew of his peptic ulcer condition and ended up being airlifted - too late - back to land, where he died of a perforated ulcer. In another case, a boat was forced to quit a Pacific Cup race early because of the skipper's chest pain. The crew had been made aware of his coronary artery disease, and so didn't delay having him medevac'ed to shore. Because he had taken this simple precaution, this skipper happily lived to sail another day.

2) Medications should be the responsibility of the person taking them. That said, consider splitting the supply in two; half to be under the control of the person taking the medication and the other half in the vessel's medical kit. That way there will less chance of the medication getting lost.

Also, talk to your doctor before you leave. Let him or her know if you'll be cruising in a third-world environment. This could have important consequences. For example, if you are taking one of the popular stomach drugs like Pepcid, Zantac, Tagamet, etc., you should know that your reduced stomach acid makes you more susceptible to GI infections. Like good old Montezuma's Revenge in Mexico. That decreased acid level allows certain micro-organisms easier access to your stomach and intestines.

3) Physical conditioning should be considered important, especially for any crew who are clearly out of shape. Although sailing/cruising is not in the same league as running marathons, there is no question that being in good physical condition gives that extra energy, strength, and mental edge handle emergencies. Try to incorporate some program of daily aerobic exercise as well some way to keep your joints flexible. A big problem on long cruises/races are the hours of doing not much more than sitting or sleeping - then expecting your stiff joinst and muscles to propel you into and out of foulies, respond to sudden sail changes, or compensate for unexpected motions of the boat. It's those stiff joints and muscles that most often get injured - or lead to other injuries.

4) Having at least one person on board with CPR / First Aid training should be a priority. If you as a skipper can't find someone who knows it, learn it yourself. (Courses are widely available through any Red Cross center.) Not only is this good for immediate, 'hands-on' action, it also imparts valuable knowledge if you or someone aboard has to be talked through some procedure over the radio. Even though you're seldom entirely alone out there as long as you have a radio, it's good to know something about the medical advice being given. In any case, remember there's no 911 at sea. You are it!

5) Immunizations should begin at least six weeks prior to sailing for foreign countries. At this time, the only immunizations absolutely required in certain countries are yellow fever and cholera. This primarily affects travelers to Africa and South America. Between the years of 1991 and 1993, 750,000 cases of cholera were reported in Latin America. The speed and extent of its spread continues to reflect the absence of sanitation and safe water supplies in most parts of the developing world. Unfortunately, the current cholera vaccine is only 50% effective in protecting against the disease.

Other suggested immunizations include tetanus and polio boosters, as well as typhoid and hepatitis vaccines. If you'll be traveling to a malaria-infested area, there are recommended precautions - and considerable controversy. A recent survey found that visitors from different countries to the same part of East Africa followed no fewer than 80 different antimalarial regimes. To get the latest info, contact the CDC or your local health department. In the San Francisco Bay area consider contacting Kaiser, UCSF or Stanford, which all have traveler's clinics.

6) Prescription medications can sometimes be difficult to obtain for your medical kit. Especially narcotics. Many physicians are reluctant to write prescriptions for medications that could end up being abused or taken by persons who could be allergic to them. The best advice I can give is to meet with a physician you know personally (and better yet, who is a sailor) and explain exactly what your plans are and why you need the medications. If you don't have a personal doctor, the next best thing is to go to one of the local traveler's clinics where they'll likely have more experience and understanding of your needs. If all else fails, be aware that in many foreign countries prescription regulation (and enforcement) is significantly different than in the U.S., and you can often obtain antibiotics and sometimes even narcotics over the counter. I was on a surfing trip in Baia three years ago with a friend. Somewhere near Guerrero Negro he severely strained his back. The strongest medications I had with me were some non-steroidals (ibuprofen, naproxen, that sort of thing). They didn't touch his pain. So we went to a small local farmacia to see what we could find. We asked for Tylenol with codeine or Vicodin, but the man behind the counter politely informed us he had none. When I mentioned that I was an American MD, he simply rolled his eyes and said "Como no, se´┐Żor" - essentially, "Oh sure, bud."

I was about ready to give up when he turned and unlocked a cabinet, pulled out some packets of pills and set them on the counter. "But maybe, instead of, codeine, these will help?" he said. I picked up the packet and quickly agreed that these pills would do. Five minutes later my friend and I walked out of the store with 20 pills of morphine sulfate. No prescription. No ID.

Just to set the, record straight, this is not likely to happen very often because Mexico has some very strict narcotics laws. But sometimes...

7) Water and food precautions. Dr. Richard M. Dawood, editor of the excellent book, Traveler's Health (Random House), states that two-fifths of all Americans who travel abroad suffer from traveler's diarrhea. Often, this is just a minor inconvenience, but sometimes it can escalate into a major illness, disrupting sailing plans, costing money, and sometimes resulting in prolonged disability and hospitalization. Since traveler's diarrhea reduces the absorption of such things as birth control pills, it can even be responsible for unwanted pregnancy!

If you use a reverse osmosis water system on your vessel there is little chance of contracting a water-borne infectious organism. The PUR and other systems can theoretically filter down to the viral level. But to be extra safe it's a very good idea to have a UV light attached to the outlet of the system.

If your boat doesn't have a filtration system and you take on water in foreign ports, then use either chlorine or iodine. Liquid chlorine laundry bleach contains 46% available chlorine. Use 1-2 drops per quart of water. Iodine, which is probably more effective than chlorine (especially, against amoebic cysts, the cause of amoebic dysentery), is available as tablets or a tincture. When using the tincture (2% iodine), add four drops to each quart of water. If you want to get rid of that 'iodine taste', consider the trick of adding a 500-mg tablet of Vitamin C to each quart of water.

Drinking water ashore is a different matter. It's almost a cliché now to say don't drink the water and beware of eating raw fruit and vegetables. My usual procedure has been to drink only beer ashore and bring the fruits and vegetables back to the vessel for a good washing. In any case, the best documented treatment of traveler's diarrhea is the combination of sulfamethoxazole-trimethoprim plus loperamide (Septra DS or Bactrim plus Imodium). This conclusion was reached in 199.0 after a double-blind study on U.S. adults residing in Guadalajara.

The bottom line: water from the public water supplies in the developing world is likely to be just a very dilute solution of sewage, and should be regarded as such.

Obviously, these suggestions are only the tip of the iceberg. Because boats, destinations and crew vary so widely, it's up to the skippers and 'medical officers' out there to determine the needs of a particular boat going a particular place. For more detailed information, please refer to the list of references accompanying this article.

Finally, never discount the luck factor. With so many pissed-off managed-care physicians quitting medicine these days, you probably have a better chance of encountering a doctor in Turtle Bay than in Marin.

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- kent benedict, md

This story was originally published in the November 1996 issue of Latitude 38. We may have a few copies left. To order one (complete with black & white photos), use the subscription order form, and specify the 11/96 issue, or just drop us a note with a check for $7 to Latitude 38, Attn: Back Issues, 15 Locust Ave., Mill Valley, CA 94941.

Please note: Once the actual issue is no longer be available, we will still be able to make photocopies or PDFs of it.


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