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Medical Information

When you want, or need, to know more than the superficial, such as when you are

where there is no access to a physician.

Prototypically: Medicine at Sea

Comments/Disclaimer

This medical information is provided for education purposes only. I am making no attempt to practice medicine over the internet. This is being written to give some basic knowledge for those that are physically isolated from access to professional medical care, such as sailors at sea. This is to help in deciding whether an emergent medical condition exists, how to initially deal with it, and whether evacuation is needed. It is by no means exhaustive or meant to replace personal medical attention. Please do not contact me regarding your personal condition. Over the years I have received many emails from people asking for help with their personal chest pain, or whatever. Sometimes they write during acute pain. This is ridiculous. You can't practice medicine over the internet. If I find their email, after it has been filtered by my spam filter, it may be days or weeks later. My response, if any, will be to contact their regular provider. Even a bad doctor in person is better than an email. Please use this information in the spirit in which it is intended.

Sincerely, Mark R. Anderson, M.D.

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my other interests

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If you would like to

purchase a package of my recommended prescription medications

through me, please email me.

I am considering starting up this purchasing opportunity but will need to receive sufficient input from my readers to determine if there is sufficient need to justify it.

CRUISING MEDICAL KIT v. 5.1

Updating in process November 2010

Mark R. Anderson, M.D. 2000

Tools and materials

Dressings, splints, wound care

OTC Medications

Rx Medications

Rehydration

Introduction:

This medical kit is designed to be of use to cruising sailors and to anyone else that may need to function independantly of traditional medical resources. This article has evolved over the past few years and I'm always free to consider the advice and experience of others. The info here may go way beyond your needs or you may have special needs. I don't attempt here to teach you the judgment as to when to use the materials and drugs mentioned here. You use the information here at your own risk. I assume no responsibility or liability.

Why not buy a medical kit? Well the ones I've seen give far too much emphasis on bandaging and injury care and not much on medical needs. Commercial kits are available that generally are designed to meet statutory requirmentsn for commecial ships. I've looked at the contents of these kits and come away feeling that they were designed quite a while ago. Nevertheless, if you contact official medical advice such as through the Coast Guard they will probably start with the assumption that you have what's mandated for commercial ships. One such source is: http://www.seasidemarinedrugs.com/home.html Be careful about deciding if the kit meets your needs. I was shocked to see that their recreational offshore kit ($1295) contains 100 tablets of 5 mg Valium plus 3 syringes of Valium. It is however a company that is set up specifiacally to supply ships and boats with medical needs, including prescription drugs and they say they will do custom kits.

You may also want to check out available books. Several have been written aimed at the medical needs of cruisers and wilderness travelers. I haven't yet found one that I can whole-heartedly recommend, but some are pretty decent. I think that a general problem with the books I've seen is that they don't diagnosis in a logical manner. They may have decent entries about, say, heart attacks, but not help guide you as to whether you should be considering that diagnosis vs. heartburn. They also tend to be very deficient regarding physical diagnosis. They may also totally ignore major common problems, and they're getting out of date. If your need is only in the first aid realm only a short distance to port or within ready availability of a medical evaluation, The Boater's Medical Companion by Robert S. Gould, M.D. is pretty good. Advanced First Aid Afloat by Peter Eastman, M.D. is more extensive, as is The Ship Captain's Medical Guide from Her Majesty's Stationary Office. A basic CPR course is highly recommended. First aid knowledge is mandatory but where you may be going is grossly inadequate because I'm assuming you've got no other access to "second" aid.

Remember that if your radio can reach someone you can be patched through to a physician or other clinician that can help you decide what to do. Near shore a call on VHF 16 may get you assistance within a couple minutes. Sitting in a quiet anchorage in Barclay Sound, B.C. the silence was broken by a frantic call, "Coast Guard, Coast Guard, my son just put sunflower seeds up his nose." A physician was on the radio within a minute to assess the situation and calm the frantic parent. The US Public Health Service can be contacted through the USCG or a general call to ships in the area with medical staff on board may bring advice. The Centro Internazionale Radio Medico (C.I.R.M) is based in Italy and provides round the clock free medical advice world w ide. "Safety and Survival at Sea" by E.C.B. and Kenneth Lee lists the following frequencies for the International Radio Medical Centre: http://www.cirm.it/eng/telesoccorso_eng.html 4342 kHz, 6365 kHz, 8685 kHz, 12760 kHz, 12748 kHz, 17105 kHz and 22525 kHz. The 1st, 3rd and 4th are listed as continuous. Communication is in English, French and Italian. I cannot find this information on their website. (All medical assistance provided by C.I.R.M. is completely free of charge Telex 612068 C.I.R.M. I Telephone [+39 ] - 06.54223045 Mobile GSM Telephone [+39 ] - 348 - 3984229 Fax [+39 ] - 06.5923333 E-mail telesoccorso@cirm.it ) If not able to be contacted directly, use may be made of IRM through USCG. If you've got the international signal code, notice that there is an extensive section on medical problems and you can cross language barriers and do a complete history and physical and relay that info. using just 2 and 3 letter codes that can be spoken over the radio to anyone else with the code.

As a last resort in a situation where you need help and can't reach anyone by radio, you can consider activating your EPIRB.

Remember that 90% of the time the patient will get better even if you do nothing so first do no harm!

On that line take this warning. Anything you do to or give to another individual beyond first aid can be considered practicing medicine without a license. Aside from being technically illegal even to help, you take on all the liability for what you do. Use the information here or elsewhere at YOUR OWN RISK! I'm certainly not going to assume the liability for your actions. That said, we both know that there are times when the humane thing to do is to help within the limits of your knowledge and even to take risks. This self-dependence is one of the attractions of cruising. Besides, out in international waters, for all I know, your actions may not be illegal. Certainly if you do have access to medical attention or can reach higher level medical advice by radio, take advantage of it.

Back to supplies. My kit is intended for long distance cruising and intended to be simple but versatile. Aside from just going out and buying them, e.g. from a surgical supply house or pharmacy, go to your local ER and talk to the head nurse. Explain what you want to do and see if you can get any outdated dressing supplies that were to be thrown out or even outdated, unopened, meds such as Epinephrine, Xylocaine, Benadryl, Compazine, Phenergan etc.. This may be a long shot if they don't know you but you may be lucky and I don't think these things immediately are "bad" if "outdated" officially. I can't tell you how long they will be "good" however. Often the only degradation is in potency. Explain what you're doing to your regular doctor and see if he/she can supply any sample meds. Samples are generally fairly new and expensive meds. With some advice on what they're good for they are a great deal. In general there are a lot of older and excellent meds that are quite cheap and more and more are becoming over the counter (OTC). A general exception in the USA is antibiotics. Your doctor may also be willing to give you prescriptions for meds listed here and may have other recommendations. Do get all legally required travel meds and immunizations.. A gamma globulin shot used to be standard to prevent hepatitis A. Now the vaccine is pretty standard and even better. Are you going to a malarial area and need malaria prophylaxis? I've heard that there is a book entitled "How to buy almost any drug legally without a prescription". In some countries, especially those of the third world, you can buy a lot of medication in any pharmacy without a Rx. You've just got to know what to ask for. Whenever you replace a prescription medication from home with one you get elsewhere, be sure that they are equivalent. If someone has been getting a sustained release medication and is unknowingly switched to a more rapid acting medication there'll be problems. Either the medication will act too fast and hard, or it won't last long enough. Remember though, that if you're on shore and someone needs medical attention, go to a doctor. Even if not up to your usual standards I'm sure you'd be better off than on your own and at least in developing countries medical care is a lot cheaper than in the US.

I'm going to recommend what I think is general purpose stuff. Then I'll go on to more specialized suggestions. If I've left out something important, please let me know, for consideration in a future version. My tendency on meds is for general applicability, low cost, and preferably being available OTC (over the counter). Remember that many of these meds have been prescription in the past and may be available OTC only in the lower dose form. In that case I'll often recommend the Rx dose which may considerably exceed the dose on the OTC bottle.

Tools and materials:

Metal tools may be sterilized by dropping in boiling water for 20 min. to kill the usual bacteria. Adding some household bleach to the water will also work. Thorough washing with soap and water will often be good enough. Dry thoroughly and rapidly to reduce the chance of rust. I believe that the sterility extremes that modern medicine goes to are often in the realm of diminishing returns. E.g. some years ago a study showed that there were no more wound infections in laceration repairs when the suturer simply did a thorough 10-15 min. scrub of his own hands and worked with bare hands compared to wearing sterile latex gloves.) A more recent study has shown that there are no more wound infections if lacerations are repaired wearing 'clean' rather than 'sterile' vinyl/nitrile gloves. If you don't shrinkwrap your instruments to keep them clean and dry, consider wrapping them with cloth sprayed with WD-40 to prevent rust. Salt air will be bad on instruments.

Fluids:

IV Fluids and infusion tubing, needles, etc. This could be lifesaving in a major trauma or severe dehydration situation, but the likelihood of needing these is small. A couple hundred dollars of fluids, etc. may be worth carrying if you have the skill to start IVs and want to go that step. In the old days fluids were given by sticking the needle just under the skin. This works but is necessarily slow and causes large swelling and pain. The need for IV's can usually be minimized by conscientiously taking frequent sips of some oral rehydration fluid and trying to control the vomiting.

Oral Rehydration Fluid: The cheapest, but hard to get in the US, is the World Health Organization's packets of powder to be mixed with water. Easily available in the US is Pedialyte. You may substitute a combination of flat 7up, Gatorade, Ginger ale, apple juice etc. Any one alone is not ideal but using a variety will generally average about right.

Sources for powdered oral rehydration salts:

Jianas Brothers Packaging Company, 2533 Southwest Blvd., Kansas City, MO 64108-2395, Phone: 816-421-2880 Fax: 816-421-2883 http://rehydrate.org/resources/jianas.htm A 27.9 gm packet mixes to a liter of fluid. A pack costs $ 0.55 but you have to buy a minimum of 1 carton, (125 packets) for $68.75.

Cera Products, 8265-I Patuxent Range Road, Jessup, MD 20794, Phone: 301-490-4941, Toll free: 1-888-CERALYTE (1-888-237-2598), www.ceralyte.com It is available in 10 gram size packets to mix into 7 oz (200 ml) clean drinking water. 10 packets cost $20. That's far more expensive than mixing your own.

Jianas sells the WHO formula that is rather salty since it's optimized for the types of losses that occur with cholera. Cera's packets are available in various salt concentrations up to the WHO amount. For most episodes of diarhea and vomiting, the lesser amounts of salt are adequate and more palatable.

A reasonable approximation may be made as follows:

Doc Anderson's oral rehydration formula:

1/4 tsp salt,

1/4 tsp "Lite salt, i.e. partially potassium chloride, if you don't have this, drink 1 oz. orange juice or 2 oz. grape or apple juice for every 3 oz. of formula.

1/2 tsp baking soda, (especially important if there's been a lot of green bile vomit or you're using this for diarrhea)

2 1/2 tbsp sugar, (preferably corn sugar though table sugar, sucrose, is fine)

Dissolve in 1 qt. (or liter) water.

Drink frequent small amounts. The victim may need 3-4 quarts or more over a day if severely dehydrated. Even if vomiting continues, generally enough is absorbed to make progress against the losses.

Instruments and other physical supplies:

Enema bag: This could come in handy if lack of activity and a shortage of fluids leads to severe constipation. 

Forceps (i.e. tweezers): Preferably small "Adson's" without teeth. Strong sharp "splinter" forceps are occasionally useful but definitely a splurge. Be gentle holding tissue with forceps and don't use a clamp.

Gloves: (Latex or Nitrile examination) for general touching of yucky stuff, inserting suppositories, and for suturing if you don't also get the sterile kind. Latex free gloves if anyone is latex allergic.

Hemostat: For clamping vessels and may double as a suture holder. I recommend the size with approx. 1 in. jaw sold as "Kelly's" as first choice, and for extras I'd suggest the smaller "mosquitoes". Suture holder also if you want to splurge. Needle nose pliers in a pinch. Some ERs and perhaps offices use cheap disposable instruments that are adequate. Even Radio Shacks sell these (for use as a heat sink when soldering).

Lubricant: (Lubafax or KY jelly) for suppository.

Needles: 1 1/2 in. 21 guage. and 5/8 in. 25 or 27 ga. most useful. The larger for IM injections and to draw from bottles and the smaller for subcutaneouse (SQ) meds and SQ injections of anesthetics.

Scalpels: (disposable): No. 11 for lancing abscesses, no. 15 for other use. A razor blade or X-acto blade is a good substitute.

Scissors: Ideally about 3 in. blades for suture and 1 in. "iris" scissors for tissue but anything sharp will do.

Stethoscope: Optional. Certainly you should use your ears and all your senses to diagnose but within this context the usefulness comes down to evaluating breath sounds, (extremely useful but something that needs to be taught aurally and can only be approximated in writing, and not here) and to determine the presence or absence of bowel sounds. Both of these functions can adequately be performed by the ear being placed against the chest or abdomen. By the way, the stethoscope was invented to preserve the female patient's modesty. Another use is to measure blood pressure and for that you need a:

Sphygmomanometer: To measure blood pressure (BP) can be useful. Perhaps the best use is to provide info you can relay to radio medical help. Are you are prepared to act on it? That requires specialized drugs to lower blood pressure or even more specialized IV drugs &/or IV fluids to raise it.

Syringes: 1 cc insulin type with needle for subcutaneous (SQ) meds. 10 cc otherwise most useful.

Test Strips:

Blood sugar strips: Some simple blood glucose test strips would be vital for monitoring anyone with diabetes. If there's a diabetic aboard, insist that he/she bring along their strips and testing equipment. Simple strips that require no device to read other than your eyeball are available, but trickier to use. They would be the choice for completeness if there's no diabetic aboard but you want to be prepared.

Urinalysis: A jar of urine dipsticks would be useful to check for urine blood, infection, dehydration, and sugar to screen for diabetes. Shelf life is not that long however.

Thermometer: optional, your fingers can tell you if you've got a significant deviation from normal. Personally I'd rely on a mercury thermometer if I could get one. Digital thermometers are nice and fast, but subject to failure.

Flashlight: It's usefulness is obvious.

Flourescein and a Cobalt Blue penlight: Invaluable to look for corneal injuries.

Where do you stop in your quest to be prepared? That all depends on your degree of caution and the cost.

Dressing, Splinting and Wound Care Materials.:

Ace wraps: 2 inch and 4 or 5 in.

Alcohol wipes: Or use stove alcohol or rubbing alcohol and a bit of tissue.

Bandaids: Both the common ones about 3/4 in. wide and large 1 1/2 - 2 in. wide. Remember though that you can make any bandage with gauze and tape, so the basic supplies are far more versatile.

The specially shaped finger tip and knuckle bandaids are often useful.

Betadine swabs: Excellent for cleaning skin and wounds prior to suturing but forceful irrigation with water, e.g. squirting from a 10cc syringe and/or firm scrubbing with soapy water is an excellent substitute. Get all visible contamination out of the wound.

Note: The preferred method of wound cleansing now is pressure irrigation with saline or even water.

Benzoin: This could be very handy and is available in small breakable ampules. It makes tape really stick and also helps to protect the skin from breakdown under tape.

Gauze pads: 2x2 and 4x4 and ABD pads. (Army Battle Dressing) Clean cotton rags or diapers can always double for this.

Gauze rolls 2 in.

Semipermeable membrane dressings: E.g. Opsite or Tegaderm. This is like a peel-back adhesive membrane that looks like cellophane. Applied to clean dry skin it can last for days, even if it gets wet. It's great for abrasions and burns. Don't apply over infected wounds.

Skin staples: These may be a reasonable option to suture material. They are easy to use with minimal skill but they are not as versatile as sutures because you can't vary the width or depth. They also may be uncomfortable to the patient and some types are a nuisance because they may snag on clothes, etc.. You need a suture remover instead of scissors. A wire cutter and needle nose pliers will do in a pinch. The disposable kits are convenient but I'm sure much more expensive than a pack of sutures. You may only need a few sutures or staples and that leaves many unused. Do you throw them away or save for the next time and use the unsterile remaining staples? Overall I prefer sutures.

Splint packages: 3 and 5 in. splint material rolls, and Webril cotton batting for splint padding. Plaster splint material is available, easier to use and probably cheaper than fiberglass, but can't stand exposure to water. Therefore I'd recommend fiberglass splint materials, e.g. 3M. Remember to pad well, especially over areas of bone with little overlying tissue. Creativity can do wonders in the absence of purpose made material. Look at an old boy scout or first aid manual for ideas. Malleable aluminum splints (SAM splints) are easy but less versatile and durable.

Steristrips: 1/4 and 1/2 in. wide. Can close lots of wounds if there isn't too much tension but can be difficult to keep sticking to the skin, esp. if you don't first degrease the skin with alcohol wipes and then apply benzoin to the skin before laying down the steristrips.

Superglue: Dermabond is a very expensive superglue intended to be used in place of sutures. Grocery store superglue will work, but it stings ALOT!

Suture materials: The most useful size for general suturing would be 4-0 Nylon with a PS-2 needle. If you buy several packs I'd also add 5-0 Nylon on a P-3 needle for delicate work. Those more fully equipped would include an absorbable suture for tying off small briskly bleeding vessels and for bringing lower layers together in deep gapping lacerations. To do either of these however requires much more judgment and knowledge and presents more risk of damage by suturing the wrong thing, e.g. putting a suture around a nerve. You can usually stop bleeding with sustained pressure and you can therefore probably get by with only skin sutures. A substitute suture would be light weight monofilament fishing line, e.g. 2-4 # test or fly fishing leader material. The problem is that using a small sewing needle may not work so well as the cross section is not triangular to poke through skin easily and they are not curved like the usual suture needle that is also swaged directly to the thread. I've known people to use dental floss but I don't recommend it because it may act like a wick to bring dirty surface water under the skin. Xylocaine is recommended as the anesthetic.

Tape: 1 and 2 in. cloth for general strong use and paper tape if allergies. Knowing how to make a butterfly bandage can reduce the need for steristrips. To make a butterfly bandage, take a strip of tape, (2-3 inches). Make 4 cuts, as 2 pairs, about 1/3 the way across the tape and opposite each other. These cuts should angle in toward the portion of tape between the pairs. Then fold the intervening tape over itself to cover up the stickum. The result is vaguely butterfly shaped.

Coban: This is an excellent alternative to tape in many cases. It sticks to itself, but not to skin. Get 1 inch and 3 inch rolls.

Large triangular bandage, (or cut from a 36-40 inch square piece of sheet sheet). Use as a sling or to wrap other large areas. Very verastile. There are good YouTube videos of its use, or go to http://www.tpub.com/content/medical/10669-c/css/10669-c_110.htm

By the way. If you have an old Boy Scout or First Aide manual you'll find a lot of info on bandaging.

Splinting:

A lot can be done with creativity and padding a board or stick and holding it on with tape or Coban. Very useful are malleable aluminum splits such as the padded straight ones that are 1/2 or 1 inch wide and can be cut to length with scizzors and bent to shape to splint fingers. A large malleable aluminum splint can work for arms and legs. Examples are the 18 or 36 inch "SAM" splints. An advantage is reusability. A versatile option would be packages of fiberglas splint rolls padded w/ cotton (Webril) and halrd on by an Ace wrap. 3M Scotchcast is prepadded and an excellent product. Anything that can be splinted with these but they require some skill and can't be reused.

 

OTC Medications:

Analgesics: (pain pills)

Aspirin: 1 a day keeps the heart attack or stroke away in the older individual if no allergy, bleeding, ulcers or other reason against it. One aspirin taken early in the coarse of a heart attack can reduce damage. 2 every 4 hrs. for fever or minor pain. (Don't use aspirin in kids without medical advice)(Substitute tylenol dose based on weight (10-15 mg./kg, i.e. approx. 4-6 mg./lbs) in kids). 2-3 pills of aspirin 4 times a day taken consistently gets an antiinflammatory effect (after 3-5 days) for things like tendonitis or arthritis. Ringing of the ears means you've taken a bit too much, back off a bit. Take w/ food or antacid. It's the miracle drug. Can cause ulcers, bruising, heavy periods, and, in the sensitized individual, hives or asthma. Take with food &/or antacids if GI upset.

Ibuprofen: Basically the same effects as aspirin though not given for the blood thinning effect because the effect wears off in a few hours. Perhaps better pain relief, fever control and antiinflammatory effect than aspirin. Somewhat less stomach upset but still causes a lot of that. Also risk of bleeding, ulcers, allergy. Occasional dose, 200 - 800 mg.(i.e. up to 4 OTC pills) every 6-8 hrs. Don't exceed 2400 mg./d. High dose for antiinflammatory effect 600-800 mg. 3 x/d consistently. Take w/ food etc.. Some caution in the elderly or if there's a history of kidney disease.

Tylenol: (acetaminophen) Only good for fever and minor pain. No blood thinning effect or antiinflammatory effect. But it rarely causes indigestion and never causes bleeding. Full dose in children is 10-15 mg./kg. every 4-6 hrs.. Overdose, e.g. more than 140 mg./kg. may cause liver damage leading to slow miserable death. Frequent heavy use can also damage the liver.

Anti-histamines: (for allergies, itch, nausea and sea-sickness)

My general preference is diphenhydramine (Benadryl) for it's reliability. Use for anything that itches or sneezes, e.g. hay fever, allergies. 25-50 mg. every 4 hrs. (Up to 1 mg/kg in children) Rarely more. Unfortunately often causes drowsiness and may cause dry mouth, blurred vision, difficulty urinating. The same can be said for other anti-hist's. (2nd choice is chlortrimeton 2-4 mg. every 4-6 hrs. Benadryl also can treat side effects (shakes and spasms) from phenothiazines. Can be used for nausea and to treat or prevent sea sickness. Injectable can even be used in place of xylocaine for local anesthetic. Very useful for serious allergic reactions ( injected, if possible).

Dimenhydrinate (Dramamine): I mention this in passing because it's well known for sea sickness but since it actually turns into diphenhydramine in the influence of stomach acid I think this is a duplicate.

Non-sedating antihistamines: Claritin is fine if it works for you, but it's not as potent, or as versatile. Zyrtec (cetirizine) has low sedation and I believe to be more reliable.

Meclizine 12.5-25 mg. for sea sickness prevention (1/2 - 1 daily) (Dramamine II and Bonine are brand names but it's much cheaper if you ask your pharmacist for a bottle of 100 generic.) Also can be taken 25 mg. 4x/d for vertigo.

Decongestants:

Afrin spray: For nasal congestion, especially if totally blocked. Lay with head back sev'l. min. after 2 sprays for max. effect. Your nose gets addicted to it if used more than 3-4 d. Can also be helpful to stop a nosebleed that doesn't stop w/ 15 min. sustained nostril pinching. Spray twice every 15 min. up to 3 times.

Pseudoephedrine (the original Sudafed) (30-60 mg. every 4-6 hrs) for nasal congestion of a cold. Can combine with an antihistamine and you've essentially created something like Actifed. Has arousing effect like caffeine and can cause tremors, raise blood pressure etc. In many areas you can still get this OTC, even if it means asking the pharmacist directly for it. Sudafed PE, the more readily available form is now phenylephrine and may not be as effective.

Gastrointestinal Medications:

Acid neutralizers (antacids): Liquid antacids such as Maalox or Mylanta, (or your personal preference) are better than tabs for heartburn because they coat on the way down. They prevent the absorbtion of some medications, e.g. tetracycline and doxycycline, cipro. The neutralize the acid that is there, but don't stop production of it.

Acid secretion blockers: Stomach acid secretion blockers: cimetidine (available OTC as Tagamet HB 100mg), famotidine (Pepcid(available OTC 10-20mg.), ranitidine (Zantac OTC 75-150 mg.) These are a different type of anti-histamine and are the drugs of choice for things like ulcers and acid reflux (heartburn). Consider these for sustained burning or gnawing pain in the upper mid stomach or below the breast bone that persists after liquid antacids. Full prescription dose is: Cimetidine 400 mg. 2x/d or 800 once a day. Pepcid: 20 mg. 2x/d or 40 mg. once a day, Zantac 150 mg. 2x/d or 300 mg. once a day. Cimetidine is more likely to have side effects such as confusion. Generally well tolerated. Can also reduce itching in combination with the other anti-histamines.  

Biscodyl (Dulcolax): For constipation. Don't get paranoid that you have to have a stool every day. A change in bowel habits is common with a change of diet and activity. The suppositories usually work within an hour (be prepared) and the pills usually work overnight. Try to prevent constipation by lots of fluid intake, lots of vegetables, fruits and other fiber and by staying active. If you are often troubled by constipation, increasing fiber by diet or psillium seed (Metamucil) taken regularly is the way to go.

Loperamide (Imodium AD): For diarrhea. 1 after each diarheal stool. Not more than 4/d. OTC and probably just as good as Lomotil (Rx). Don't use if there's blood in diarrhea and there's always a risk of holding in the bad bug by stopping the diarrhea. Excess use can cause constipation so start with just replacing the fluid lost with lots of clear liquids. Imodium also has antispasmotic action.

Gynecological and Urological:

Consider various OTC yeast treatments ( e.g. Monistat or Gyne-lotrimin vaginal tabs or cream) for vaginal or skin or penile yeast infections.

Sanitary napkins: Hopefully they didn't forget. Can also make good absorbent dressing for major bleeding.

Tampons: Not only useful as intended, but they can also be used up the nose as a nasal packing. Lubricate first.

Azopyridine (AZO, Uristat): Does an excellent job for the symptoms of a UTI but don't use it for more than 2 d. because it hides the infection and you want to know if the antibiotics are working. Don't take without antibx because it doesn't treat the infection. Makes the urine orange. May stain soft contact lenses.

Condoms: Not for first aide, but certainly recommend if you sexually fraternize with the locals.

Dental:

Toothache kit: This should include Oil of Cloves (Eugenol) that acts as an anesthetic when applied as a bit of soaked cotton into a cavity, dry socket, or where a filling has fallen out. Also the kit should include some zinc oxide powder that will form a temporary filling when mixed with the Eugenol as a paste and packed into that cavity. A eugenol soaked packing will treat toothaches due to exposed nerve endings such as when a filling falls out, a tooth is cracked or deep cavity without swelling or redness of gums to point toward infection. One brand is called ZOE.

Skin Meds:

Antiinflamatory:

2 1/2% cortisone cream applied 3 x/d for localized itchy rashes such as local contact allergy, which is what poison oak is. Stronger Rx steroid type creams work even better.

Antibiotic ointment:

Bacitracin, polysporin, or neosporin. (Note that allergy to neomycin, (one of the ingredients in neosporin) is fairly common.) An even better topical antibiotic is Bactroban, but it requires a prescription.

Antifungal:

Lotrimin or clotrimazole, or tolnaftate cream applied 3x/d for fungal infections and taken until at least 14 d. after the rash disappears (to prevent recurrence). I.e. for ringworm, crotch rot, athlete's foot. Lamisil (terbenafine) is also OTC and is even better.

Insect repellent of choice.

Those w/ DEET are especially effective.

Moisturizers:

White's A & D ointment or Desitin good for general skin protection, e.g. from salt water boils. Practical Sailor even documents that Desitin rubbed on your hull, prop etc. has excellent antifouling properties, but only so long as it stays on the hull, which usually isn't long. If it's available, Penitin may be even better.

Sunscreen:

You should definitely use it regularly. SPF over 15 is probably of little extra benefit.

 

Prescription Meds:

Analgesics: (Pain pills)

Narcotic pain pills: Recommend Vicodin type (hydrocodone 5-7.5 mg. with acetominophen) as it's at least as effective as codeine and less likely to cause nausea. Either will affect your alertness, concentration, coordination, etc.. 1-2 pills every 4-6 hrs. for pain. Same if Tylenol #3. A half pill of either will suppress a cough. Keep it locked up. Beware sedation, diversion to get high, addiction potential and theft potential.

Ketorolac (Torodal): a NSAID (Non-Steroidal Anti-Inflamatory Drug) that can give excellent pain relief without affecting alertness. 10 mg. 4x/d. The injectable form, 30-60 mg. IM or IV can relieve the severe pain of a kidney stone or gall bladder attack. Too bad you can't use those larger doses orally. It's hard on the stomach.

Ultram: This relatively new analgesic gives excellent relief to some without narcotic problems. It's better for persistent, rather than acute, pain. 50-100 mg. 4x/d.  

Antibiotics:

There are zillions but you can generally do well with only a few general cheap ones. Your doctor may have some excellent broad spectrum samples that can substitute.

Amoxicillin (250-500 mg. 3x/d) : Good for lung, throat, nasal, ear, urinary and to lesser extent stomach infections. Also 3 1/2 gms all at once can cure usually gonorrhea. Amox. is a modified penicillin, so don't use it when there's a history of penicillin allergy. Augmentin is a much more expensive variant, (which is a combination with a 2nd ingredient to minimize resistance to amoxicillin.) Plain Penicillin VK is now of very limited use due to resistance. It is still usually good for strep throat, dental infections, and some pneumonias. Generally amoxicillin will adequately cover the same things plus others.

Amoxicillin w/ clavulanate (Augmentin): Good back-up, broader spectrum for similar reasons as amoxicillin. Good for animal bite infections.

Cephalosporins come in three 'generations' of differing uses, but here I'm considering the 1st generation, such as cephalexin (Keflex). This is usually good for urine infections, some sinusitis and bronchitis, some pneumonias, strep throat. It was a standard for skin infections, but it's usage for such is much decreased now due to drug resistance. It's likely to still work if the skin infection is not forming a pus pocket.

Dicloxacillin or Cephalexin (Keflex) (250-500 mg. 4 x/d) or TMP/SMX: Generally best for skin infections, especially such as boils/abscesses. But more important than antibiotics for abscesses is heat to bring it to a head and then lancing it when pointing, i.e. there's a soft spot of thin skin where it would ultimately drain spontaneously.

Doxycyline (100 mg. 2x/d, not for children under 10, or if pregnant): Good for nasal, throat, lung, urine, skin, diarrhea, VD (chlamydia) and urinary infections. Use for "Montezuma's revenge". May cause sun sensitivity leading to severe sunburn.

Erythromycin (250-500 mg. 4x/d): Good for ear, throat, nose, lung, skin, VD, and some intestinal infections. Often causes stomach upset.) Biaxin and azithromycin (Zithromax) have about the same effectiveness at greater convenience, but much greater cost.

Flouroquinolones are other common antibiotics of general use, but some are much more expensive. They include Cipro, Floxin, Levaquin, and others. Over the last couple years I've taken to regularly using Cipro (500 mg twice a day), despite its cost for urine infections, and in combination with metronidazole for diverticulitis. Not for children or the pregnant.

Ciprofloxin (Cipro) pretty cheap and good for urine, diarrhea, diverticulitis and skin.

Floxin and Levaquin: Expensive but good for pneumonia. Not for urine.

Metronidazole (Flagyl)( 500 mg 2x/d): For some intestinal parasites (e.g. that cause chronic diarrhea) and serious intra-abdominal infections, i.e. those that should be hospitalized. A common outpatient use is for Trichomoniasis, (1 type of VD) and for common non-VD bacterial vaginosis. Also as partial treatment for diverticulitis. Avoid alcohol while taking this as the combination with alcohol may cause acute illness, as it can work like antabuse. Not for use in pregnancy.

Nitrofurantoin (Macrodantin 50 mg. 4x/d or Macrobid 100 mg 2x/d) is an old cheap antibiotic that is useful for urine infections.

Trimethoprim/Sulfa double strength (e.g.,TMP/SMX DS, Bactrim DS, Septra DS) (1 pill 2x/d): Good for ear, nose, throat, lung, urine. Possibly the most prescribed antibx for urineinfections though effectiveness is decreasing. Also good for Monte's revenge. Sulfa allergy is common. Recently this has become the preferred antibiotic for skin infections as resistance has developed for older antibiotics. Specifically I'm referring to community acquired MRSA.

My top 4 for general use and cost effectiveness would be Amoxicillin, doxycycline or erythromycin, TMP/SMX and Cipro. Remember that the penicillins and sulfa's (SMX) are the ones that cause the most allergies. 10% of those allergic to a cillin will be allergic to a ceph. drug like cephalexin, up to 50% likely if there's a history of a serious allergy to penicillin such as with wheezing or the rapid development of throat swelling or shock.

Cortisporin otic suspension: These ear drops are the routine treatment for external ear infections, i.e. "swimmer's ear". Dilute vinegar (50/50 with water can also work.

Antiemetics (for nausea and vomiting)

Phenothiazines: Compazine (prochlorperazine) 5-10 mg oral or IM or 25 mg. rectal or Phenergan (promethazine) 25-50 mg. oral or IM or 25 mg. rectal every 4 hrs.

These are generally the most effective meds for vomiting. Definitely have suppositories on board (not to mention gloves and lubricant) for that suffering victim of mal de mer. (By the way, here's your trivia tip: The word nausea comes from the Latin nausia that means seasickness, and is derived from the Greek word for ship, naus.) Phenothiazines have the same risks as antihistamines with more drowsiness and occasional tremors and rare total body spasms, arching, eyes rolling back, feeling like swallowing tongue. These severe reactions are very frightening and incapacitating but not truly dangerous and can be cured with diphenhydramine 50 mg. Cured in seconds if given IV. These drugs can also be helpful with migraines.

Other types of phenothiazines, e.g. thorazine and others are given as major tranquilizers and your suppositories are probably the strongest sedatives you're likely to have. Fortunately no one wants to take them to get high.

Metoclopramide (Reglan): 10 mg 4 times a day. Another good nausea med that is also good for migraines.

Odansetron (Zofran, especially the ODT oral dissolving tablet type) is excellent but very expensive.

By the way, Lord Nelson reportedly had the perfect cure for Mal de Mer. If you're feeling seasick, sit underneath a tree. I wonder if that worked aboard the yacht I saw that had an inflatable palm tree on the stern?

Antiinflammatory Steroid pills:

Prednisone 10 mg.: Start w/ 40-60 mg. per day and taper off over a few days or a week or 2 depending on response for its great effect (though delayed 6-24 hrs.) with severe allergic reactions and asthma attacks and extensive itchy rashes, e.g. poison oak. Also causes GI upset (take w/ food) and possible ulcers/bleeding and rare mental effects. Given as a single 60 mg. dose in the first few hrs. after excessive sun exposure (that you know will cause a significant burn) it can lessen the burn. It may interfere with your ability to fight infection and can cause diabetes to get out of control.

Antispasmotics:

To reduce stomach cramping antispasmodics such as Donnatal or dicyclomine (Bentyl: 20 mg 4x/d) are useful. Don't reduce cramping accompanied by bloody diarrhea, high fever or severe tenderness. Your gut may be trying to get rid of what shouldn't be in there. Imodium and Benadryl also have antispasmotic activity.

Epinephrine:(Adrenaline, 1:1000 dilution)

The one med that may really save someone's life if there's a serious allergic reaction. 0.3-0.5cc SQ every 20 min. as needed. Also it's the old treatment for asthma. Available in ampules and set up for self injection in various bees-sting kits, e.g. EpiPen and Anakit. May use for any serious wheezing (with caution if elderly), or hives or serious swelling that threatens airway. May even dilute 1:10 and spray in nose for serious nosebleed. Also diluted 1:10 with sterile water and given IV it's given for cardiac arrest. End concentration is 1:10000.

Xylocaine 1% (Lidocaine)

Local anesthesia. That without Epinephrine has more general use. Stings as it's injected. Should be used minimally or avoided in finger, toe, and nose tips because of minimal space for swelling and endangering blood supply. Inject just under cut skin edges. Don't use more that 20cc total in an adult. If you know what you're doing it could be diluted 1:10 and given 4-7cc IV for life threatening heart irregularities. A drop or two in the eye (will sting a lot) will give anesthesia for removing eye foreign bodies.

Specialized drugs:

These are far more limited but some could be life saving. I might carry these but you may not carry the prescription ones unless you feel likely to need them and can get a prescription. This may depend on your crew's needs. For example, if there's a heart history in them the likelihood of need rises.

Cardiac Meds:

I write this with trepidation because it is here that inappropriate use is most likely to get you in trouble. If at all possible, get professional medical advice by radio. Hence my instructions remain minimal. On the other hand, appropriate use when you have these available may be life saving and certainly improve comfort and reduce risk of progression to even more serious problems. Here I repeat the usefulness of a CPR course. In the lack of follow-up intensive care however, CPR is most likely to be of lasting benefit in fewer circumstances, such as near drowning and electrocution and certain self-limited heart rhythm problems.

Nitroglycerin tablets: For heart attacks and angina and esophageal spasm. Takes a lot of clinical judgement that you may not have but particularly if you've got people over 55 on board the risk of heart attack goes up. 1 tab under the tongue every 5 minutes up to 4 or 6 until heart pain goes away. Here is not the place to try to teach you to recognize heart pain but someone with a history of angina will usually recognize it. Keep tightly capped and preferably unopened if not used as potency declines over a few mos. once opened, esp. if not tightly capped and exposed to air. Sit down as this can cause dizziness by drop in BP and often causes headache. Both only last a few minutes. Lie down with feet up if very dizzy.

Nitroglycerin paste: 1/2 to 2 inches applied to the chest every 12 hrs. Most commonly 1 in.. Used for persistent cardiac pain and extreme high blood pressure. Too much will drop BP too far. Headache is common side-effect.

Digoxin: For heart rates over 150/min. and for heart failure (water on the lung) Again this takes more judgement than I can give you here. But it sure would be nice to have this if the need arises and you get medical advice to give it.

Furosemide (Lasix): For the swelling and wet lungs of heart failure. Dose 20-160mg./day individualized to the patient.

Amlodipine (Norvasc): Calcium channel blocker. Useful in high BP and angina.

Also see lidocaine.

Diabetes:

This should generally only be needed if there's a diabetic on board, who should supply the necessary meds. If however you want to be prepared for even more eventualities, and if you have the test strips mentioned earlier, you should have some method of treating the diabetes.

Oral meds are available, especially for the adult onset diabetic. Metformin and Diabeta are common. For serious diabetic problems, insulin would be needed.

Insulin is OTC, but the knowledge of how to use it must be gained elsewhere than here. The ability to closely monitor the blood glucose, (with the test strips) is mandatory. Inappropriate use can easily kill the patient. If you were to carry insulin, you should carry both the N and R types, plus plenty of insulin syringes. Get medical advice by radio.

Hypoglycemia, (low blood sugar) is probably more commonly deadly than high blood sugar. High blood sugar isn't generally acutely deadly except in the uncommon event of diabetic ketoacidosis, to which insulin dependent diabetics are more prone to. Too much insulin and the patient gets hypoglycemia. The treatment of hypoglycemia is sugar, preferably glucose. The symptoms are: rapid heart rate, tremors, sweating, weakness, and confusion or agitation that may progress to coma. Have the subject drink OJ or other natural fruit juice if alert enough, dissolve hard candy under the tongue or glucose paste if available. You can make a paste of sugar and water and put some under the tongue. Corn sugar would be better but less available.

Respiratory (Breathing) Medications:

Inhalers: Albuterol (Proventil, Ventolin)

Use for wheezing e.g. with life threatening allergic reaction or asthma or emphysema. (I hope you have no smokers on board.) This inhaler is not dangerous and can be given as 2 inhaled puffs every 3-4 hrs. If serious wheezing it can be given every few minutes. Primatene mist is available OTC but, ironically, is quite dangerous if used frequently or with heart problems. Primatene, however, is epinephrine and could be life-saving in a severe allergy.

Also see Epinephrine, Antibiotics and Prednisone.

Other injectable meds:

Due to expense and limited use I believe these are clearly second or third line. Nevertheless, the following could be considered.

Injectable pain meds: Injectable narcotics such as morphine would certainly be appreciated with serious injuries but remember that no one died of pain and too much pain relief from narcotics could drop blood pressure and precipitate shock or even stop breathing. This is not to mention that the doped out individual may fall overboard. Another alternative could be ketorolac (Toradol), which is a non-narcotic antiinflammatory pain med that can give relief equivalent to morphine in many cases. The down side is that in the elderly or those with kidney disease, it can shut down the kidneys and shouldn't be repeated very often. Duragesic skin patches that release a slow steady dose of Morphine, or oral morphine, could be considered in lieu of injectable narcotics, but are generally given only to those with terminal intractable pain, such as from cancer.

Injectable nausea meds: Promethazine (Phenergan) is good and may be better than suppositories but at this point I'd consider the more potent droperidol (Inapsine) or odansetron (Zofran). Promethazine and droperidol are both potentially quite sedating but could stop the slide down into serious dehydration. Persistent sips of small amounts of fluid can usually get around this. Side effects of inapsine can be like those spasms described with the phenothiazines. Often the patient first says he/she feels like crawling out of his/her skin. This is treatable with diphenhydramine.

Injectable antibiotics: With some of these you could really save a life, but the need for these statistically is low, they're usually expensive, several doses at least would be needed and for these serious infections I'd really have to recommend several to cover all the major possibilities. The choice between them, not to mention their administration, requires medical guidance. Hence, I'd not carry them and if their need arises, try really hard to arrange an evacuation. That said, if I carried only one, it would be ceftriaxone 1 gm. (Rocephin) given once a day.

INDIVIDUAL NEEDS:

Any crew members that have some underlying medical condition should be sure to bring enough of their own medications to last for the entire cruise plus any reasonable delays. They owe it to the captain to inform him/her of their needs, where their medications are kept, any special instructions and in general try to educate the captain regarding their medical condition.

LOCATION:

The medical kit should be kept in a secure place and all medication use should be logged. Prescriptions to the kit in general, (as opposed to individual crew members) should be made out in the name of the vessel and these prescriptions should be kept under lock with the captain in possession of the key. I believe that this is needed in foreign countries to avoid potential charges of smuggling drugs and to give the skipper the authority to dispense meds.

I hope that this has been of help. If you've got questions about some specific need, etc. please contact me. I may have skipped something obvious and I'd appreciate the feed back. Let me know if there's something else you need to know and if I'm not overwhelmed with requests I'll see what I can do.

 Have fun and may you need none of this,

Mark Anderson, M.D.

Email: capn-shanghai@comcast.net

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