Risk Management and Offshore Voyaging

© 2013 Jeffrey E. Isaac, PA-C

Originally published in Ocean Voyager Magazine 2013 Edition. Updated 2023.

Risk management and offshore voyaging may be a contradiction in terms to most people. But, we know that we’re really just trading one set of probabilities for another. You will stand a better chance of drowning but less of a chance of being run over by a bus. You might avoid catching influenza in a crowded subway, but be more available to feed a mosquito carrying lymphatic filariasis. Preparation for medical emergencies includes identifying and mitigating risk where you can, and preparing for the consequences when you can’t.
 
Nobody wants to think of their dream trip as an impending disaster, but this is actually a useful frame of reference. Offshore voyaging shares the far end of the spectrum of pre-hospital medicine with activities like space flight, remote land expeditions, and natural and man-made disasters. You are largely on your own, access to medical care may take days or weeks, and the environment you are working in is at least as big a problem as the medical issue itself.
 
On the friendlier end of the pre hospital spectrum are the shore-side emergency medical services. These offer a rapid and standardized response to medical emergencies by trained ambulance and rescue personnel, and is what most of us in the developed world have become accustom to. In this part of the spectrum, we don’t need to know much more about medicine than the numbers 9-1-1.
 
The middle of the spectrum is the world of backpacking and river trips, coastal cruising, and combat (at least for the winning side). The environment is still often working against you and evacuation times may be measured in hours, but you can still expect an organized response to a medical emergency. You need to have enough medical skill to keep somebody alive long enough to reach port or for the Coast Guard to reach you.
 
Long distance cruisers, like other true wilderness travelers, move from one part of the spectrum to another, often without being aware of it. The temptation, of course, is to carrying the comfort and complacency offered by 9-1-1 out to sea with you, well beyond where any such response is safe or even possible. Ironically, sat phones, EPIRBs, PLBs, and reality TV shows may actually increase risk by creating an unrealistic expectation of rescue in remote and dangerous places.
 
You might be able to call, but in heavy weather the deck of a container ship coming to your aid could be as inaccessible as the surface of the moon. If you don’t have reasonable resources for treating injury and illness on board you will be pressured to take unreasonable risks to evacuate. It will also encourage rescuers to take unreasonable risks to help you. You don’t have to look far for accounts of helicopter crashes and yachts smashed to pieces against the hulls of rescue ships.
 
What constitutes reasonable preparation for medical care at sea is considerably greater than the basic first aid that you use while waiting for an ambulance, and more extensive in terms of duration of treatment than that needed by an EMT on a search and rescue team. Fortunately, good field medicine is not rocket science. It is not even advanced diesel mechanics. Being a competent medical officer is a critical and attainable part of your risk management program, just like your navigation, communication, and firefighting skills.
 
You will be encouraged to know that, in the study of medicine, mariners have a clear advantage over most people. You understand concepts like integrated systems, fluids under pressure, leaks and blockages, and are not afraid of working in damp and dark spaces with strange looking instruments. Most significantly, mariners are more comfortable making real risk vs benefit decisions.
 
Risk Management: Probability
 
Diving off the spreaders or playing human slingshot with the spinnaker is good fun in Key West. The low probability of injury is made even more acceptable by the presence of the coast guard and a hospital. But that same probability without the rescue and the hospital makes that same activity a much higher risk in the Tuamatos. That’s why you won’t see a lot of horsing around in remote anchorages. Sailors inherently know that risk is a function of probability and consequence.
 
In town, we rely on code enforcement officers, police, and school crossing guards to reduce the probability of an adverse event. We depend on the fire department and the emergency medical services to reduce the consequences. Offshore, you do it all.
 
Reducing the probability of illness or injury requires a comprehensive program of preventive maintenance that starts before you set foot on deck. A pre-departure check up with a medical provider should focus on mitigating small problems that could evolve into big ones when you are far from help. You need to schedule this far enough in advance to schedule the studies that will schedule the procedures that will schedule the cure before your scheduled departure. Of all of medical gear and training that you can spend money on, health preservation is your best investment.
 
You might ask your doctor to remove that funny looking mole now rather than wait and watch for another few months as is often suggested. Ask your dentist to find and fix that sensitive tooth even if it only bothers you when eating raspberry gelato. But beware of excessive paranoia; removing your appendix now would only trade the risk of appendicitis for the risk posed by surgical adhesions and bowel obstruction.
 
Complete your vaccinations. You may have heard that vaccines can be harmful, and in vanishingly rare cases, they are. But for the vast majority of people the risks associated with vaccines are vastly outweighed by the benefit of avoiding the disgusting, debilitating and fatal diseases they prevent. Start early. The hepatitis B series, for example, is given over 6 months.
 
For some diseases, there are no vaccines and no reliable cure. To avoid many of them you will need to get as serious about not feeding mosquitos as you are about keeping your teenagers from jumping off the spreaders.  The insect repellants to use are DEET and Picaridin. Period. Both are thoroughly studied, safe, effective, and a lot easier on the body than malaria or elephantiasis.  Permethrin is also useful as both a repellent and insecticide on screens and clothing, and will last for days or weeks. Nothing else works as well or as long as these three products. Even prophylactic antibiotics for malaria are no guarantee of safety, especially considering the emerging strains that are resistant to all treatment.
 
A travel medicine clinic can be a good source of information, vaccines, and other necessary meds. They may be more sympathetic than the average doctor when you ask for enough antibiotics and pain medication to treat the problems anticipated on a three year circumnavigation. Please be aware, however, that you are not a normal patient and you are not an average traveler. It may take some research to find a physician who really understands that “return to clinic if worse” is not an option.
 
Carry your medical records. Your baseline lab values, chest x-ray, and ECG can be very helpful if you do end up in a hospital somewhere. Records that used to be dense folders of paperwork can now occupy just a few megabytes on a thumb drive, smartphone, or on a micro SD card taped to your passport. Scan everything. Include eyeglass prescriptions and the generic names and dosages for any medications you take.  If you don’t already have these baseline values, get them.
 
Risk Management: Consequence
 
Decide what level of medical care you are going to equip and train for and decide to do it well. Competent first aid is more useful than bumbled brain surgery at any latitude. As a good reference point, make it your business to understand medicine in at least as much depth as you do your diesel engine. You might not invest in the equipment and training to bore out a cylinder, but you certainly can inject antibiotics, swap out an injector, pass a urinary catheter, and troubleshoot a fuel pump (you will be amazed at the similarity between boat maintenance chores and basic medical procedures).
 
If all of your sea time is coastwise, in the middle of the pre hospital spectrum, you will be need to handle an immediate emergency and the consequences for several hours afterward. This is mostly focused on trauma because any illness that seems to be getting worse can get ashore before it becomes serious. Starter doses of pain medication and antibiotics are sufficient, and well monitored emergency splints and bandages are tolerable until you make port. You will need to learn a few skills beyond first aid, like wound cleaning and reducing simple dislocations. Most shore side wilderness first aid courses are directed at this level of care and duration of treatment.
 
For blue water passages and remote cruising grounds you will need a medical tool box equipped for self-sufficiency and the long haul. The first aid procedures and techniques are pretty much the same, but any evacuation will likely be dangerous, expensive, and prolonged, if available at all. You will want to incorporate some more advanced procedures and know a lot more about long term nursing care. Specific training for this unique environment and skill set is not easy to come by and should be researched carefully. You may need to acquire your skills from several different sources.
 
Courses that meet STCW requirements are generally designed for a large vessel and crew on a stable platform, but can be a good source of training in the more advanced procedures at the Person in Charge level. This can be a considerable investment in money and time, but usually well worth it. You will need to extrapolate the big ship perspective to your small yacht or fishing vessel.
 
Emergency Medical Technician training is often mentioned for sea service. But, while EMT does a fine job for ambulance personnel working with ambulance equipment, it does little to address the other parts of the pre hospital spectrum, and nothing in the way of long term care. At 180 hours plus, it would not be a worthwhile investment to use specifically for cruising.  
 
A wilderness first responder course from a reputable company would be a better introduction to the remote perspective and basic skill set, especially if you can find a course taught for sailors and fishermen. A nurse friend may be able to add the more advanced skills like intramuscular injection and urinary catheterization. Your doctor or travel medicine clinic can add the medications and instructions. Don’t expect the process to be easy or quick. You didn’t learn to sail in weekend, did you?
 
By all means, plan to use consultants and references. Doctors do it all the time. A medical advisory service is ideal if you can afford it, but your doctor friend at home or a fellow cruiser with advanced training may be a good alternative. Do remember, however, that you are the person with the best view of the patient and if anything has to be done, you are going to do it.  Our 21st century communication is no substitute for 18^th century hands on skill and courage.
 
So, what do you really need be able to do? The list that follows represents the author’s opinion. It assumes that your training also includes the background assessment skills that allow you to determine what procedures are necessary and when. The basic skills are not so basic compared to shore side first response, but still represent low risk procedures for high risk problems and should be sufficient for most voyages. The more advanced skills require more training, practice, and judgment. You will undoubtedly see different recommendations from other experienced professionals.  
 
If this seems like a lot to invest in something you’ve taken for granted all of your life, just put it on the same list as your EPIRB, fire extinguishers and other safety and survival gear. If your health maintenance and risk management programs are conscientiously followed, you will never need it. There is nothing quite as satisfying as finishing a long voyage with an unused life raft.

Basic Offshore Medical Skills
 
Basic assessment and first aid skills plus
 
Wound care

• Topical anesthesia
• Wound inspection, debridement and irrigation
• Long term dressing and wound preservation

Oral Antibiotics

• Indications
• Dosage and administration
• Side effects and precautions

Analgesia

• Oral and transmucosal Opioids
• Oral Benzodiazepines
• Oral NSAIDS and acetaminophen
• Side effects and precautions

Antiemetics

• Oral and transmucosal
• Rectal
• Transcutaneous
• Side effects and precautions

Splinting

• Fiberglass
• SAM

Rescue breathing and airway

• Pocket mask or Numask
• Basic airway adjuncts
• Manual suction

Short-handed lifting, moving, and extrication
Reduction of simple dislocations

• Shoulder
• Patella
• Digits

Unstable fractures

• Alignment
• Splinting
• Long term field management

Emergency treatment of anaphylaxis and asthma

• EpiPen
• Ceterizine
• Dexamethasone

Fluid Replacement

• Hypodermoclysis
• Oral
• Rectal

Straight urinary catheter
Stethoscope examination
Otoscope examination
 
Advanced Offshore Medical Skills
Basic skill set plus:
 
Wound Closure

• Wound infiltration for anesthesia
• Staples
• Tape
• Sutures

I&D Superficial abscess and wound infection

• Infiltrate anesthesia
• Incise and drain
• Irrigate and pack
• Follow up care

Hematoma and joint block

• Wrist
• Elbow
• Shoulder

Intramuscular and intranasal pain and anxiolytic medication

• Ketrolac
• MSO4
• Fentanyl
• Naloxone
• Benzodiazepines
• Side effects and precautions

Emergency treatment of anaphylaxis and asthma

• Draw and administer epi from amp and vial
• IM diphenhydramine

Fluid Replacement

• Hypodermoclysis
• Interosseous infusion
• Intravenous infusion

Reduction of Complex Dislocations

• Elbow
• Ankle
• Wrist

Dental injection for anesthesia
Dental procedures

• Temporary filling and crown replacement
• Antibiotics
• Treatment for broken and avulsed teeth

Opthalmic anesthesia and foreign body removal
Oxygen administration

• Barotrauma
• DCS
• Illness