Upgrading your Boats Medical Locker

[GordMay]

Originally Posted by s/v Jedi

... More problematic is stopping bleeding. Very few boats are equipped for this while it is often needed. You bleed out before help arrives if the bleeding can not be stopped. This is why I always stress to carry plenty Israeli battle dressings in several sizes, quick clotting agents like Celox or even Celox impregnated gauze and, if willing to study it’s use, a tourniquet...

INDEED!

The (Israeli) Emergency Bandage (Battle Dressing) combines a sterile dressing, elastic bandage and pressure applicator capable of exerting up to 30 lbs. of pres
sure on a wound.
The closure bar, which secures the bandage at the end of wrapping, can also be used to exert additional pressure.
It’s a multi-purpose bandage, and can be used as a make-shift tourniquet, ACE Wrap, or even a sling to immobilize an appendage.
It’s truly a versatile item to include in your trauma kit or first aid kit. It can also be self-applied, even one-handed.

[Discovery 15797]

Originally Posted by Paul L

Not sure the stats listed here have much application to remote cruising. In the study the EMS shows up on average in less than 6 minutes. Then the patient is whisked to a trauma center. Any patients that didn't have an EMS show up were excluded.
The definition of survived is discharged from the hospital. Many of those discharged will be to nursing homes with significant disability, aka a major reduced quality of life.

An AED used in a remote cruising environment is very unlikely to end with a good outcome. For most cruisers, you'd probably get a lot more benefit spending the AED initial cost and maintainance cost (expiring battery, pads and unit) on remote medicine courses for all the crew.

Having an AED onboard may give you a comforting feeling that you are addressing all risks. At usd1,400 plus maintainance costs it isn't that much in the scope of running a cruising boat.

Hank asked for data, I provided the data.

I would like to see the medical journal article with data that supports your statement of

Many of those discharged will be to nursing homes with significant disability, aka a major reduced quality of life.

You're correct, even with an AED in a remote location the outcome MAY not end well. But, without an AED it will definitely not end well.

(By the way, I am currently at Ko Olina Marina in Hawaii. They do not have an AED. If someone on the docks suffered a sudden cardiac arrest and I am there with my AED within minutes, their probability of surviving is greater than zero. Ko Olina is not exactly remote, but emergency response is > 15 minutes.)

Yes, maybe you're right....maybe it is just a placebo; sort of like a life raft. Things we have that we hope we never use. I also hope I never have to use skin staples. (Maybe I should not have skin staples as well in my kit.)

I am not recommending that everyone carry an AED. I simply stated I have on in my kit.

But, it also makes an excellent piece of kit to donate to clinics on remote islands, along with reading glasses and school supplies. Such donations go a long way in building good will, and has opened up some atolls/islands that I might not otherwise have been permitted to visit.

[Paul L]

Originally Posted by Discovery 15797

Hank asked for data, I provided the data.

I would like to see the medical journal article with data that supports your statement of


You're correct, even with an AED in a remote location the outcome MAY not end well. But, without an AED it will definitely not end well.

(By the way, I am currently at Ko Olina Marina in Hawaii. They do not have an AED. If someone on the docks suffered a sudden cardiac arrest and I am there with my AED within minutes, their probability of surviving is greater than zero. Ko Olina is not exactly remote, but emergency response is > 15 minutes.)

Yes, maybe you're right....maybe it is just a placebo; sort of like a life raft. Things we have that we hope we never use. I also hope I never have to use skin staples. (Maybe I should not have skin staples as well in my kit.)

I am not recommending that everyone carry an AED. I simply stated I have on in my kit.

But, it also makes an excellent piece of kit to donate to clinics on remote islands, along with reading glasses and school supplies. Such donations go a long way in building good will, and has opened up some atolls/islands that I might not otherwise have been permitted to visit.

If you are in area where quick EMS and a trauma hospital is available, then having an available AED, whether it is on the boat or on the dock, is a good thing.

Even in those cases the odds are not good, but they aren't zero. When you get to remote areas without access to fast care, such as cruisers in the S Pacific, etc I don't believe you will get any meaningful advantage having an AED onboard.

As to data supporting the condition of cardiac patients when they are discharged from the hospital. I don't have specific data on cardiac arrests that occurred outside the hospital where an AED was applied and the patient survived to discharge. Here is data on a most likely better scenario where cardiac arrests occured in the hospital and the patient survived to release.
" At hospital discharge, 48.1% of the patients had mild or no neurologic disability, and the rest of the patients had moderate-to-severe disability or were in a coma or vegetative state. More than half the patients (55.3%) were discharged to an inpatient skilled nursing or rehabilitation facility, 40.0% were discharged home, and 4.8% went to hospice"
https://www.nejm.org/doi/full/10.1056/NEJMoa1200657
So for the few who make it to hospital discharge, it still isn't a rosy picture.

[HankOnthewater]

Originally Posted by Discovery 15797

US data here from NIH



Agree with comments regarding suturing. Topical lidocaine hydrochloride putty is about as effective as injected lidocaine. But, again...a class such as Mastering Fundamentals of Skin Laceration Repair is important.

Thank you D-15797.
The data looks better than I thought it would be. The investment in AED remains high in Oz just up from $2000, and for top of the range $3000 plus, and then pads have an exipry date 3-5 years, batteries to be replaced 3 to 4 years, and the unit itself to be tested regularly (monthly, quarterly or yearly). Hehehe, all not unlike an Eprirb.

[s/v Jedi]

Originally Posted by Paul L

Closing a wound that could be dirty or have forgeign material with sutures or staples is certainly not the advice I've received from remote medicine docs.
WHO states
"Do not close contaminated and infected wounds, but leave them open to heal by secondary intention"
https://www.who.int/surgery/publications/WoundManagement.pdf

to die of thirst and hunger in the middle of an ocean? Or may that advice be for patients in a hospital? My point: you need to study field medical guides, or expedition medical guides. You’re on your own, a couple on a boat in the middle of nowhere and only you are gonna save the day. And we all know what to do with dirty wounds and foreign material in wounds. Why would you try to put that in my mouth when I explicitly tell the opposite?

[Paul L]

Originally Posted by s/v Jedi

to die of thirst and hunger in the middle of an ocean? Or may that advice be for patients in a hospital? My point: you need to study field medical guides, or expedition medical guides. You’re on your own, a couple on a boat in the middle of nowhere and only you are gonna save the day. And we all know what to do with dirty wounds and foreign material in wounds. Why would you try to put that in my mouth when I explicitly tell the opposite?

Mainly because that's what you wrote in your post, in contrast to what remote medical guides suggest, including the one I referenced.
I have no idea what you are talking about or how it is relevant to this discusion when it comes to your comments on dieing of thrist and hunger.

[Pelagic]

I think i understand where Nick is coming from in that the environment and common sense dictates whether you need to seal the wound from further contamination and infection when you don't have the time or conditions to cater to frequent dressing changes.

[s/v Jedi]

Originally Posted by Paul L

Mainly because that's what you wrote in your post, in contrast to what remote medical guides suggest, including the one I referenced.
I have no idea what you are talking about or how it is relevant to this discusion when it comes to your comments on dieing of thrist and hunger.

You really do not see the difference between being in a hospital or being just a couple aboard a boat during offshore passage? Who is going to sail the boat? Again, study field medical guides which are better than the regular medical documentation for offshore cruisers.

Also, I never said to leave foreign matter in a wound or leave it dirty, then close it up. Thise are your words and when you use them while replying to me, with my quoted comment above it, you imply that that is what I recommend. Are you a politician?

[Paul L]

Originally Posted by Pelagic

I think i understand where Nick is coming from in that the environment and common sense dictates whether you need to seal the wound from further contamination and infection when you don't have the time or conditions to cater to frequent dressing changes.

Of course you close the wound using bandages tightly. Then inspect each day, with additional cleaning and rebandaging. You do not suture a wound that is not absolutely clean. In a remote cruising situation it is pretty much impractical to get a deep, ugly wound clean.

Suturing down well might reduce the scarring, but the risk of infection is too high.

[NorthCoastJoe]

As an x paramedic and ACLS instructor. Defibrillator = Done ... As a paramedic in the SF bay area and over 200 codes, saves 2. In the middle of the ocean hopeless even with full ACLS resources.

I can think of more valuable things.

[Singularity]

Originally Posted by Pelagic

I think i understand where Nick is coming from in that the environment and common sense dictates whether you need to seal the wound from further contamination and infection when you don't have the time or conditions to cater to frequent dressing changes.

Some peoples' common sense can get other people killed. The idea to close wounds to keep stuff out is very simplistic that neglects to understand how wounds work, how bandages work, etc, etc. Getting this wrong may be fatal; parsing why this is so takes effort that frankly is why people who know better don't contribute. You get to fight everyone's recollection of 50 year old basic training or whatever. Who needs this?

Any wound that requires more than 2-3x/day dressing changes is not a candidate to be closed in the first place. Each dressing change <5 minutes. We're talking real-world here, not the perfect storm meeting the perfect storm meeting the other perfect storm. In that case, sutures/staples won't hold anyway. Staples/sutures basically only intended provide enough strength to counter-act normal skin tension (for the first few days anyway)....not resting skin tension + dynamic loading.

Otherwise, tugging/pulling on a fresh wound that has been closed should be assumed to increase the bleeding into the wound (i.e. the deep tissue will ooze more into the wound cavity). While blood contains antibodies against common bacteria it's seen before, overall adding to the seroma/blood blister just creates more buffet for any ambient bacteria that were closed over (by suture) or that migrate down through the wound edge hours/days later. Any wound that is prone to bleeding/leaking because of dynamic conditions more likely ought to be left open (but bandaged) anyway. This is real-world middle of nowhere advice.

Originally Posted by s/v Jedi

You really do not see the difference between being in a hospital or being just a couple aboard a boat during offshore passage? Who is going to sail the boat? Again, study field medical guides which are better than the regular medical documentation for offshore cruisers.

Also, I never said to leave foreign matter in a wound or leave it dirty, then close it up. Thise are your words and when you use them while replying to me, with my quoted comment above it, you imply that that is what I recommend. Are you a politician?

You don't know what you don't know and you seem resistant to learn while simultaneously shutting down people offering appropriate advice to the community. You do not seem to understand that at the Mayo clinic with every resource imaginable that doctors will routinely leave traumatic wounds open after thoroughly cleaning the wound under anesthesia in the operator room/theatre. The sugeon doesn't leave the wound open thinking "hey, this hospital is clean." Hospitals have more nasty bugs in them than a boat in the tropics. Moreover...said doctors would be more inclined to leave wounds open on a boat than in the hospital given less capacity on a boat to slice/dice/inject if things go sour (hence the WHO guidance that is wholly appropriate).

You worry about a wound getting more bad guys into it; a doctor worries about lots and lots of other things that individually or cumulatively offer a greater threat*. A lot of non-viable material in the wound will be trapped if the wound is closed primarily, invariably with some bacteria present (no matter how hard you scrub). And putting antiseptic junk directly onto wounds that aren't formulated to be applied directly to open wounds can just add to the non-viable tissue +/- screwing up immune/repair system activity in the wound.

Certainly many wounds can be closed DIY. We've all done it. But the one time where things don't work out, you are screwed without at minimum some appropriate antibiotics, maybe IV/injectable type, and likely the need to cut back open the wound anyway. This is why places like Mayo and WHO do the "better safe than sorry" approach...depending on the wound type and circumstances.

The capacity for an animal's immune/repair system to deal with wounds evolved long before the frontal lobe did. Wet to dry dressings after soap/water cleansing is very complimentary to normal healing, so much so that a physician might not initially use antibiotics at all on his/herself if experiencing a large (non-puncture) wound that was treated with cleaning/bandaging. The question becomes "do I want to waste good antibiotics on this?" instead of "now I get to use those antibiotics." I do not mean to say that antibiotics are not needed (certain wounds definitely should receive antibiotics), and it's long to get into which to use, but I mentioned the doctor's-own-wound example to emphasize that plain old soap and water and clean bandages work without concern for bad guys getting in.

The above doesn't apply to cruisers in remote tropical environments engaging in combat, unable to wash out a wound, cover it with a bandage and ace wrap 2-3x/day.

*there are many caveats, obviously, but notably scalp wounds can bleed like stink while they otherwise aren't so prone to infection and are suitable, after cleansing, for a) stapling, b) using hair on either side of the wound tied together in a knot ~over the wound, where the knot's tension re-approximates the wound edges.

**clearly all wounds, closed or open, should be protected from sea/river/lake water ideally at minimum 2 weeks or until the wound is healed over for a week or so, whichever is longer.

[s/v Jedi]

Originally Posted by Singularity

Some peoples' common sense can get other people killed. The idea to close wounds to keep stuff out is very simplistic that neglects to understand how wounds work, how bandages work, etc, etc. Getting this wrong may be fatal; parsing why this is so takes effort that frankly is why people who know better don't contribute. You get to fight everyone's recollection of 50 year old basic training or whatever. Who needs this?

Any wound that requires more than 2-3x/day dressing changes is not a candidate to be closed in the first place. Each dressing change <5 minutes. We're talking real-world here, not the perfect storm meeting the perfect storm meeting the other perfect storm. In that case, sutures/staples won't hold anyway. Staples/sutures basically only intended provide enough strength to counter-act normal skin tension (for the first few days anyway)....not resting skin tension + dynamic loading.

Otherwise, tugging/pulling on a fresh wound that has been closed should be assumed to increase the bleeding into the wound (i.e. the deep tissue will ooze more into the wound cavity). While blood contains antibodies against common bacteria it's seen before, overall adding to the seroma/blood blister just creates more buffet for any ambient bacteria that were closed over (by suture) or that migrate down through the wound edge hours/days later. Any wound that is prone to bleeding/leaking because of dynamic conditions more likely ought to be left open (but bandaged) anyway. This is real-world middle of nowhere advice.

You don't know what you don't know and you seem resistant to learn while simultaneously shutting down people offering appropriate advice to the community. You do not seem to understand that at the Mayo clinic with every resource imaginable that doctors will routinely leave traumatic wounds open after thoroughly cleaning the wound under anesthesia in the operator room/theatre. The sugeon doesn't leave the wound open thinking "hey, this hospital is clean." Hospitals have more nasty bugs in them than a boat in the tropics. Moreover...said doctors would be more inclined to leave wounds open on a boat than in the hospital given less capacity on a boat to slice/dice/inject if things go sour (hence the WHO guidance that is wholly appropriate).

You worry about a wound getting more bad guys into it; a doctor worries about lots and lots of other things that individually or cumulatively offer a greater threat*. A lot of non-viable material in the wound will be trapped if the wound is closed primarily, invariably with some bacteria present (no matter how hard you scrub). And putting antiseptic junk directly onto wounds that aren't formulated to be applied directly to open wounds can just add to the non-viable tissue +/- screwing up immune/repair system activity in the wound.

Certainly many wounds can be closed DIY. We've all done it. But the one time where things don't work out, you are screwed without at minimum some appropriate antibiotics, maybe IV/injectable type, and likely the need to cut back open the wound anyway. This is why places like Mayo and WHO do the "better safe than sorry" approach...depending on the wound type and circumstances.

The capacity for an animal's immune/repair system to deal with wounds evolved long before the frontal lobe did. Wet to dry dressings after soap/water cleansing is very complimentary to normal healing, so much so that a physician might not initially use antibiotics at all on his/herself if experiencing a large (non-puncture) wound that was treated with cleaning/bandaging. The question becomes "do I want to waste good antibiotics on this?" instead of "now I get to use those antibiotics." I do not mean to say that antibiotics are not needed (certain wounds definitely should receive antibiotics), and it's long to get into which to use, but I mentioned the doctor's-own-wound example to emphasize that plain old soap and water and clean bandages work without concern for bad guys getting in.

The above doesn't apply to cruisers in remote tropical environments engaging in combat, unable to wash out a wound, cover it with a bandage and ace wrap 2-3x/day.

*there are many caveats, obviously, but notably scalp wounds can bleed like stink while they otherwise aren't so prone to infection and are suitable, after cleansing, for a) stapling, b) using hair on either side of the wound tied together in a knot ~over the wound, where the knot's tension re-approximates the wound edges.

**clearly all wounds, closed or open, should be protected from sea/river/lake water ideally at minimum 2 weeks or until the wound is healed over for a week or so, whichever is longer.

No you don’t understand me at all. I agree 100% with you but you don’t try to get what I mean. There is no clinic and no MD to help out there. All you can hope for is assistance of one other inexperienced crew member if the autopilot and conditions allows even that. Stopping the bleeding, cleaning and disinfecting the wound, then you do what you have to do to get to that doctor and clinic. If that means staples and battle dressing then that is the right thing to do. This is not weird science, this is how every military medic was trained.

You obviously have a very different scenario in mind, coastal cruising or heli evac, sick bays, crew to care for the wounded etc. That is just fine, but it’s not the typical situation that one needs to prep for when doing offshore passaging.

[capn_billl]

Even within a days sail of USA, I wouldn't leave home without.
antacid
Pepto
Iodine
sterile wrap
medical tape
peroxide
alcohol
seasickness meds
neosporin cream
gauze pads
sterile eye wash


predosed antibiotic pack, (from Doctor).


But this takes care of most common injuries

Anything serious, i'm calling mayday. I'n not going to staple anything.

[evm1024]

This is a good thread if we can keep it on track.

>>>>> Just my opinion <<<<<
Paul, Nick, Singularity et al. I suggest you go back and read the thread again to see where it went off track. From my reading there is no actual disagreement.

Perhaps we are all cooped up with self confinement and ... tempers are frayed. We should seek understanding.
-------------------------------

I've had a good friend die from a cardiac arrest while in the backcountry. An AED would likely not have helped. And extrication took many hours. AED or no AED the key element here is that he it turns out had a series of silent heart attacks in the prior 24 hours and just ignored them.

Over the course a lifetime of sailing and climbing I've had my share of injuries in the field. Mostly places where there was no medical help. BTDT.

------------------

The last thought is that in general, we will not hear from doc's in this thread.
And, that in training for remote medical care the best training comes from ER Docs, Wilderness medicine docs and others who are trained in 'remote" medical care.

[evm1024]

Perhaps we all should review our remote medical knowledge in the light of (ever) changing protocols. I know that I am out of date and can always use a refresher.

I'm sure that no one advocates for closing dirty wounds and that good cleaning of wounds is SOP. Here is a reference RE wound management in the wilderness that may be useful.

https://www.wildsafe.org/resources/w...ical-protocol/

One of the reasons that I am interested in this thread is that we are planning a 5 year cruise and it is time for me to get a remote medical refresher and to update/upgrade the med kit.

Likely I'll take a wilderness medicine class this fall. I would recommend like to all who will be in out of the way places.