I usually steer clear of addressing medical issues as it is too close to the day job but it is an obvious omission from this Forum thus far. It occurred to me that amongst our members we, collectively, must have vast experience of the medical issues a cruiser might confront in the course of their sailing lives. I am certainly aware of some very challenging problems that have arisen on board member 's vessels in recent years. The aim of this thread is to get people thinking about the unthinkable and reflect on how things might have been done better. Who knows it might even save a life one day?

So my first case report is an account drawn from my knowledge of what happened to a member during her OCC qualifying passage. It may not be entirely accurate as this is obviously written third hand but it raises many issues worthy of comment.

On passage from Las Palmas to St Lucia a 40 ' yacht with a paying crew of 4 and a professional skipper were a 1,000 miles from Rodney Bay when one of the crew, a male in his late 60 's, suddenly died at the saloon table. There was no warning, no symptoms. One moment he was alive the next moment he was dead. A retired doctor was on board who led a fruitless attempt at resuscitation. What is not taught in first aid courses is that the success rate of a resuscitation attempted in the community is in the region of 5%. It 's how quickly to being defibrillated that really makes the difference and even in the best equipped centres the success rate is not much more than 50%. Though my figures might be out of date they do give an idea that the odds of successfully reviving someone in cardiac arrest mid ocean are poor. If the resuscitation had been successful then how would that crew have coped with a critically ill patient who would have presented a challenge to any fully equipped coronary care unit or ITU? Should a charter yacht taking ageing clients across an ocean carry a defibrillator and train their skippers to use them. I think not but it is worthy of debate.

Anyway the man was dead and the latitude was about 17 degrees north with 1,000 miles to a safe haven. The boat was making about 130 miles a day but the wind was declining and they only had enough fuel to motor for 2 days. For some reason (I am not sure why) the SSB couldn 't be coaxed into action but fortunately the OCC member had borrowed an Iridium phone and a mini solar charger so that she could ring home from time to time. The call was made to Falmouth and the advice received was to keep the corpse on board and continue towards St Lucia. Was that good advice? Hot climates and decomposing corpses are not a good combination and the risk of infection to the survivors is very significant. Again comment very welcome.

Charter boats crossing oceans apparently carry body bags and this was no exception. The trouble is the bag was too small to be sealed so the crew tried their best to use other plastic bags to wrap the remains before placing them in the forepeak and duck taping around the doors in an attempt to seal off that part of the boat. I don 't want to be too gruesome but this did not work and of course the bilge drained the forepeak so the boat soon became a floating hazard to health. Meanwhile the ARC controllers coordinated other boats to standby and supply fuel in case of calms. The boat forged on and made reasonably good time to St Lucia where it was immediately quarantined and the traumatised crew were brilliantly supported by the ARC organisers.

A sad tale of a probably unique qualifying passage but it does for me raise all manner of questions and I would be grateful for comment not least because we will soon be sailing over the horizon and want to prepare, but not over prepare, for the worst that might happen. So here are some suggestions for discussion.

Should we all carry defibrillators and insist that everyone is trained to use them?
If we are all going to be equipped for advanced life support then how are we going to care for that critically ill survivor for the following week and what additional kit should we carry?
I am reminded of our first Atlantic passage when a cruising couple sought advice from Falmouth for the husband who had had a heart attack mid ocean. A cargo ship was diverted and an attempt made to transfer the critically ill gent from yacht to ship in rolling seas. Thankfully the attempt was quickly abandoned and he survived on board his own yacht with the help of a nurse and some additional crew scavenged from yachts in the vicinity. My guess is that the advice issued came from some medical registrar on call who hadn 't any idea of the consequences of his advice. So should common sense have prevailed over 'official advice '?
Again should official advice have been ignored and the body disposed of at sea in a dignified fashion? Would that have been the safest option? Should we be writing down such advanced directives when we put to sea in good health to make it simpler for those left behind?
If they had disposed of the body what would have been the legal consequences of ignoring Falmouth and should the relatives back home have contributed to that decision to sail on? Were they even consulted?
Should we all be carrying bomb proof-ways to communicate across the water or should we stay in blissful isolation and just get on and do what ever needs to be done? I think there is no question that skipper
There is no doubt that skippered charter yachts must have very robust and reliable communications that must work and the skills must be on board to use them. However should all us amateurs be similarly equipped.
What would you have done differently and why?
Should the OCC provide a panel willing to advise in such situations to avoid crass rescue attempts etc?

If there is interest in this thread I will, from time to time, post similar case stories for comment but would very much welcome contributions from any member with their own first hand experiences.

Simon

Simon thank you for starting this discussion and I am sure you will get a lot of personal views from our members.

On the question should every yacht carry a defibrillator and should everyone be trained to use it. These days every defib machine carries simple instructions on how to use it the biggest question would be how do you look after the patient until help arrives which would probably be anything from 3 to 5 days or longer the most critical period for a person to survive is 24 hours, so are we all to train as medics before we take to the high seas. On land when you have to use one of these machines you also call for an ambulance to get the person to hospital.

The next question would be supposing someone had a burst appendix in the middle of the ocean. In other words anything unexpected could happen when you are on a long voyage. I think the best advice would be before departure have a complete medical check-up, have a well-stocked medical kit and medical book, and make sure everyone has completed a first aid course and prey that nothing serious will happen but at least you are semi prepared for any emergency.

I think we must have crossed the Atlantic at the same time because I remember listening to the radio and the drama of the wife whose husband had a heart attack and feeling very helpless at not being nearer but relieved when we heard that a nurse had managed to get aboard to help. On that trip the only illness or injury received by the crew was to myself when I broke a toe. Got a bit worried when it went black and the discussion on the net was whether to cut it off with a knife but someone said a chisel would be better. Needless to say I did not take their advice and bound the broken toe to the next one with duct tape. Worked a treat.

Lastly if someone dies at sea. We had an elderly gentleman crewing with us and this question came up before we set sail. The gentleman himself said that if he died at sea we were to bury him at sea. To be on the safe side of the law we packed large black bin bags and duct tape and would put him securely in the dinghy and tow with a long rope off the back of the boat until we reached land. On the other hand I would like to think we granted him his last wish to be buried at sea and probably tell Falmouth that a crew member had fallen overboard and that we had carried out a search but could find nothing.

Frances thank you very much for your thoughtful comments. This is exacactly the type of discussion I was hoping to encourage.

We crossed in '99 so yes we must indeed have listened to the same medical emergency evolve on the SSB.

Interestingly bin liners and duct tape were used to augment the small body bag but neither prevented the contamination of the rest of the boat. Your idea of using the tender is an excellent one. I wonder if anyone has actually done that?

Intersting too to hear that you sought out individual 's wishes upon their demise.

I wouldn 't though over estimate the value of pre-departure medicals as I think there is very little evidence to support their worth. We have organised a lot of mountain adventures in our time and it is almost always the most unexpected person that falls victim to an accident or illness and our pre-trip medicals have been useless as a way of predicting. This doesn 't mean that they are a bad idea but it does mean they should not be relied upon. I am sure some will want to challenge this.

Of course medical kit is important and the training to go with it as well as the Captain 's Medical Handbook but how many of us actually tick all those boxes? To cope with appendicitis you would need intravenous antibiotics, fluids and strong pain killers. Could, or should, we all skill and equip up to this level. Do we all now have sat phones to summon advice and is the quality of that advice as good as it should be? What do you do if you don 't like the advice received? Frances I think you would have been very brave to pretend that that demise had been caused by a "man over board". Would that have been legal or ethical? It would have been a pragmatic solution but would it not have been better to have sought and received pragmatic advice rather than falsify the cause of death?

Simon

Yes we crossed in 1999.

Agree that the burial at see is probably unethical and we would have followed the rules which are to keep the body with you or you could possibly be charged with murder. It is alright for large cruise ships when this happens as they have refrigeration so maybe it it something that has to be discussed and possible solutions sought for yachtsmen.

On medical matters the unexpected will usually happen and sat phone and SSB I think are important items to have on board and keep your fingers crossed that nothing serious happens, if it does then you have the means to contact someone for help.

Look forward to seeing other members thoughts on this thread.

Interesting discussion...

Can I get clarification: if someone dies, does the law require you to keep the body aboard? Why?

Seems that if one goes out for a hike and over does it, someone might keel over and die - they 're basically in the same spot. I don 't imagine there are many defibrillators in hiker 's back-packs - so no, I would not want to have one on board and then suffer the consequences of dealing with a very sick patient afterwards.

When we crossed last year, Laurie kitted the boat with all sorts of medicines and medical books - to deal with less than life threatening emergencies. (Would have been fun lying there in pain trying to work out what was wrong!) We figured that after that, perhaps an overdose of something could be taken! This brings us back to the legal requirements for keeping a body aboard - it had been our plan to chuck it over - but I suspect that would have been wrong. (We 're lucky that we have a watertight bulkhead up front to store a body - but I seriously doubt that Laurie would have been able to lug my dead weight up from the saloon and all the way forward.)

I think Laurie 's concern was more centered around how she would be able to manage the boat when suddenly alone - but that 's another whole discussion...


Bill
s/v Toodle-oo!

Bill Balme

Before we crossed the first time in 2008, we took every precaution. Had medical checkups, ticked off every vaccination box (we had intended to keep going but family responsibilities and other factors made us take a break), took CPR and first aid courses, and put together a very extensive medical kit which my sister (an ID physician) and my doctor (a cardiologist) helped me put together. I had surgical equipment, IV fluids, antibiotics for every type of infection, bandages and stabilizers for every type of break or fracture, aspirin, nausea preps of every kind, electrolyte replacement and so on. I am not a doctor or a nurse, but I 've been involved with medicine and pharmaceuticals for my entire career. I also had very reliable wilderness medicine books and other books on board to assist with diagnosis and management. We tried to anticipate major injuries and illnesses and have what we needed onboard.

In 2006, a review article about sailing injuries appeared in the BJSM and I wrote an article for our website in which I also summarised the medical report Beth Leonard had compiled from their circumnavigation aboard Silk. http://www.coastalboating.net/Cruising/Seamanship/Medicine/ShipboardMedicine.html

Afterwards, I also compiled a list of items that might be useful in a medical kit and references to have onboard. These served me well as repositories of information that I could go back to for reference over time. http://www.coastalboating.net/Resources/Safety/medicalkit.html

I have to concur with Beth that we never experienced colds or flu during our year sailing and I came back with my full reserves of medicines. That makes sense as you really come across fewer people and certainly do not take on any new foreign microorganisms while underway at sea. I had terrible difficulty with heat rashes and allergies. I also became extremely ill with most likely a streptococcal infection in Martinique after going for a swim in the anchorage at Trois Islets. I treated myself with amoxicillin/clavulanic acid and improved rapidly. I managed to replace the antibiotics with amoxicillin alone in Dominica without an Rx.

Alex was hit by a flailing sheet and knocked unconscious. Fortunately, I was right there, he was not out for long and he fell into the cockpit. I was able to support him as he collapsed. We have strict rules about not coming up on deck without being clipped in and we both were. Staying on the boat is the number 1 priority.

We pay careful attention to hypo and hyperthermia. Alex is highly susceptible to hypothermia and I to hyperthermia. We watch for signs of irritability, irrationality, change of coloration, etc and correct it before it gets out of hand. That 's very important because it affects judgement and people don 't realize it 's happening.

We did think about what would happen with a heart attack or stroke, both of which are in our family histories. I had a good supply of aspirin on board but other than that, we know that relying on CPR is unrealistic. We have thought about a defibrillator but so far have not gone for it. As we age, perhaps... or perhaps going quickly would not be such a bad thing at some point in time.

Just before we left there was a story about a woman winched to the top of the mast by her husband to replace a bulb. While she was up there, he had a heart attack and died. I do not remember how she got down but she must have because she was alive to tell the story. We now always use two halyards if at all possible: one for climbing/winching, one as a fail safe rigged for getting down as well. And we always have a knife handy when doing any kind of deck work.

Our different crossings were very different and had completely different challenges. in the first we sailed through 6 gales and avoided one strong storm across the northern N Atlantic. There injury and hypothermia were the risks. I was black and blue but managed to avoid breaks. As I recall, we did not have any significant injuries. The other two crossings were benign, but we had minor injuries. So I always wear shoes on deck to prevent breaking toes. We have both had knee surgery and have back problems. So we carry knee braces and back braces.

In short, we tried to prepare for things that were likely. You cannot prepare for everything. There are medical services that provide remote medical consultation which would be useful to hear about from anyone with experience.

We don 't have a body bag. We both would prefer to be buried at sea. But I do not know how we would deal with the situation when faced with it in reality.

Vice Commodore, OCC 

Simon, perhaps a survey of ocean voyagers would prove useful. I just found a couple of studies focusing on racing sailors but nothing on distance sailors.

http://www.wemjournal.org/article/S1080-6032(10)00204-8/pdf
http://www.wemjournal.org/article/S1080-6032(08)70170-4/pdf

Vice Commodore, OCC 

Bill,
I am not aware of any legal imperativeto bring the body to shore. My comment to Frances was really about pretending someone went overboard rather than being honest at the inquest (for there inevitably would be one) and saying the person died in these circumstances, this is the advice we received and this is what we did and why. I really would caution against presenting anything other than the truth at an inquest not least because you are on oathe and to otherwise could land you in gaol.

Lugging bodies is around is a very serious consideration for sailing couples and I know that even with 4 survivors on that boat they struggled to get him to the forepeak.
Simon

Daria,
Thanks for the links and I agree a survey would be a good idea once everyone has got over the regalia survey. My hunch is that the cruising community is somewhat older than the racing community so the nature of the problems encountered would be different. Maybe we could do our own bit of comparative research over the next year and get a paper out of it? On second thoughts I leave that to someone else!

Another thought is how do long term cruisers replenish their kits. Easy at home to stock up with drugs but they will be out of date by the time you get to the more distant spots. Do "we" ignore those dates, ship out replacements or try and buy them locally or get them prescribed locally? Moving controlled drugs around the world is very difficult so what do you do if you do have morphine aboard when you get to Thailand where possession may be a capital offence?

I would think that you would be required to keep the body, this rule applies to cruise ships who have on average 200 deaths a year.

other questions to consider will the Port Authority accept you when you arrive at your destination and who will issue death certificate or you will have difficulty with insurance and bank accounts etc.

Daria yes the wearing of shoes would have prevented a broken toe but the circumstances were that it was 90F, no wind and mid Atlantic and I was off-watch and lying stretched out in the cockpit doing a bit of sunbathing, albeit with life jacket on and line attached. The Skipper was coming out through the hatch, stumbled and fell on my upturned foot.

Accidents happen even although you may take all the necessary precautions. A friend who was crossing at the same time but further North was hit by a large wave and the boat suddenly heeled over and one of the crew asleep inside was thrown out of their berth over the lee cloth and cracked two ribs.