The Best Trip

© 2010 Jeffrey E. Isaac, PA-C

Lousy Weather and a Few General Principles

By Jeffrey Isaac, PA-C, published in Ocean Voyager 2010

“This is the worst trip I’ve ever been on”. The refrain from the old folk song about the sloop John B ran though my mind so often I still can’t get it out of my head three months later. What was supposed to be a routine yacht delivery to the Caribbean turned into a series of gales, breakdowns, medical problems and perpetual discomfort. On the bright side, I got exactly what I was looking for; a hard-core adventure to dispel the lethargy of professional life ashore. An additional benefit that I was not looking for was the refresher course in offshore medicine and decision making under stress.

I am pleased to report that everyone survived and nobody left the boat saying “never again”. I was also reassured to see that what we teach people about medical judgment in remote and high-risk settings actually works! I was brought face to face with the practical application of my own curriculum. I was reminded of why we start every offshore medicine course with a section called General Principles, rather than in-depth discussion medical problems. There is too much going on aboard a small boat in heavy weather to consider much of anything in great detail.

Traditional medical education starts with the building blocks of physiology and biochemistry, progressing to the memorization of various disease states and treatment protocols. Anatomy lab progresses by body region from head to toe because this is the most efficient way to dissect a cadaver. It can take years of medical practice to finally connect the dots and understand the whole patient. Unfortunately, this same format is usually extrapolated to basic level courses like EMT and first aid where nobody ever sees a cadaver or has any real use for biochemistry. Training focuses on parts not systems and includes interesting but irrelevant details and terminology. This makes it much more difficult for the basic level provider to understand how the body actually works.

Imagine how much easier it is to learn to sail by considering the wind, sails, rigging, rudder and keel to be an integrated system of propulsion rather than a bunch of separate parts learned in order of appearance from bow to stern. “Here’s the anchor, that’s the forestay, that’s the jib, and that thingy is the windlass. When you’ve memorized that, we’ll talk about the chemical composition of the deck”. It seems to be a silly analogy but that is the way most medical education is offered. This trip provided a wonderful example of why a systems and principles-oriented approach works so much better in difficult circumstances.

As usual for November, the schedule was pressing and the weather forecast was not good. But, the crew was skilled and experience even if a little past physical prime. “Age and treachery trumps youth and strength”, so the saying goes. Nevertheless, the skipper was smart enough to recruit young and strong foredeck hand for those moments where intellect alone would not be adequate.

We left port motor sailing in light air and calm seas which provided an opportunity to eat the deliciously greasy meat and cheese lasagna baked just before departure. Shortly thereafter, the sun set and the wind came up. The low we had been expecting tracked south of its predicted path and intensified, gathering much more energy from the Gulf Stream. Within hours we were reefed down in 35 to 40 knots from the east. The building seas crossed a remnant swell and quickly became steep and confused, gathering much more energy from the lasagna. The young and strong quickly became the down and out. Even our Old Man of the Sea skipper developed his only bout of sea sickness in 50,000 miles of voyaging aboard this same vessel.

By the time we approached the north wall of the Stream, twenty-four hours later, we were all cold, dehydrated and sleep deprived. Of the four of us I was the one least affected, being merely staggering-tired and hallucinating. Our stalwart skipper was getting tired out and had bounced off the bulkheads a few times striking his head hard enough to see stars. Normally, this would not be too much of a problem except that he chose that evening to reveal that he takes blood thinners and is at risk for internal bleeding. This is a big red flag in brain injury, adding to the banner already earned for his advanced age.

Meanwhile back in the quarter berth, young and strong was involved in a prolonged retching match with the meat and cheese due to a previously undisclosed stomach condition that prevents regurgitation. What goes in stays in regardless of how unpopular. His nausea was completely indifferent to the antiemetic medications we had on board including the latest and greatest from the pharmaceutical industry. He was uninterested in taking more than sips of liquid and was pretty useless for boat handling in spite of being very brave in trying.
The other crewmember of advanced age was seasick and tired but still awake and functional. Unfortunately, his fatigue lead to some confusion about left and right, up and down, and tack and jibe. He was, however, good moral support while conscious and able to keep a watch on the autopilot while the rest of us reconnoitered below.

We now had a bouquet of red flags and it was still blowing hard from the east. It was like being trapped in one of my training scenarios without the option of calling a time out. The problem list included four medical issues; a brain injury at risk for internal bleeding, uncontrollable retching at risk for visceral rupture, and dehydration and fatigue all around. On top of that it was cold, putting everyone at risk for hypothermia. We considered heaving to, turning around, or running off to the west. I tried to envision a medical evacuation if one of these concerns became serious but the darkness, high wind and rough seas would have made that a very high-risk operation. The best plan was simply to keep going and start drinking.

This decision was not arrived at while comfortably sitting around the chart table discussing options. Picture, instead, one crewmember slumped in the cockpit imitating a tree stump, a second mostly unconscious in the quarter berth, and the other two jammed into the galley and aft head, totally exhausted and trying to converse above the cacophony of wind, sea, and rigging. This was not the time for filling out medical questionnaires, detailed physical exams, radio medical consults or anything more than basic assessment and treatment.

This was yet another unwelcome reminder of something I like to say in class; the problems facing the medical officer in a wilderness setting are often more complex and difficult than those faced by the average emergency department physician. In the hospital we completely eliminate the environment from the problem list. The lights are always on; the floor is flat and still and the temperature is a comfortable 78 degrees. We can even wear pajamas to work. This allows the staff to focus completely on the patient’s medical problem. For those working offshore or high in the mountains the medical problems may be only a small part of a much larger and more complex picture. We needed our medical assessment and treatment to be as simple and practical as possible.

On that miserable evening, simplification did not require formal training in physiology and biochemistry or years of medical experience. I was too tired to make much use of such intellect anyway. Instead, it was a fairly basic set of principles that told me what I really needed to know. There was no emergency, yet. Everyone’s critical systems were still functioning. Ultimately bad things would happen if there was no change in our situation, but the rate of progression was slow.

Continuing into the Stream might mean rougher conditions but it would eliminate at least one of our anticipated problems; hypothermia. There was nothing we would be able to do about intracranial bleeding or a ruptured esophagus so we stopped worrying about it. Dehydration, however, could be cured by forcing electrolyte drink and fruit juice.

This was a perfect example of Ideal to Real; one of the general principles of wilderness and rescue medicine that we teach at all levels of training. Identify what you can do, forgive yourself for what you cannot, and get on with it. This seems so obvious but I have watched physicians with years of training rendered completely ineffective in wilderness scenarios because they became caught up in an extensive differential diagnoses or could not see beyond the hospital treatment for something. In the same situation a Wilderness First Responder with 70 hours of training under her belt would solve the problem. Sometimes, knowing and thinking too much can delay an elemental decision or appropriate action.

The Risk/Benefit Ratio is another principle that applied. Every treatment or decision not to treat, and every emergency evacuation or decision to stay on the boat involves the risk that the medical problems will become worse because of what we've done. We also run the risk of causing injury or death of rescuers. Against these risks we balance the potential benefits of our actions. Good decisions reflect the clear assessment that the benefit outweighs the risk. Under our circumstances rescue was neither needed nor worth the risk if it had been.

It seems like common sense to avoid high risk rescues for all but the most extreme of medical emergencies. Yet, I have seen seasoned medics make bad decisions in blind obedience to protocol at great risk to patients and rescuers. Most of the time, the severity of the medical problem and the urgency of evacuation was vastly overstated. At sea, as in the mountains, it is just as important to know when you don’t have a medical emergency as when you do.

Recognizing what is an emergency and what is not is the goal of another general principal: Three Critical Body Systems, Three Major Problems. The organs of the circulatory, respiratory, and nervous systems perform the vital functions most essential to life. These systems are interdependent, like the legs of a three legged stool. You can’t remain upright unless all three are functioning. Learning to recognize a major problem with a critical body system is the key to recognizing a life threatening emergency. This skill is equally important in reassuring yourself when you don’t have an emergency, which is most of the time.

These principles can be learned and understood within a remarkably short period of training. Most offshore sailors already have an appreciation for risk and an acceptance of the real over the ideal. They already have experience dealing with integrated systems and the need to adapt and improvise when something goes wrong. The extrapolation to field medicine seems to come naturally. Of all of the people I train, the sailors are the best at quickly comprehending the basic structure and function of body systems. In scenarios and case studies of injury and illness at sea they often easily see what can and should be fixed, and recognize what cannot. Understanding these examples and some other basic principles of medicine can really help you round out your emergency management skills.

Most marine medical programs do a reasonable job of teaching first aid, and some offer more advanced training in medical diagnostics and procedures. However, to gain real confidence in your medical judgment and skill in a remote setting be sure to take advantage of your ability to truly understand the principles behind the procedures. Make this a central goal of your medical training regardless of what kind of program you choose. This may require extra effort but it will be well worth it when the situation doesn’t match the textbook, or you are too tired, sick or busy to read it.

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Jeffrey Isaac, PA-C is the Curriculum Director for Wilderness Medical Associates and the author of Wilderness and Rescue Medicine and The Outward Bound Wilderness First Aid Handbook used as textbooks in WMA courses worldwide.