MARINE MEDICAL KITS Michael Jacobs, MD Following this presentation, participants will beable to:
1. Select appropriate medical supplies for a personal and ship’s medical kit. 2. Understand the specific use of these items. Medical Care At Sea
Ask Dr. Bill Forgey, an expert in wilderness medicine, to identify the most important component of aback country snake bite kit, and he’ll quickly reply, “The car keys.” Ask Viktor Yazykov, a sailor whocircumnavigated the globe in the 1998-99 Around Alone Race, what he considers the most essential itemsin a marine medical kit, and he’ll certainly respond: “A satellite telephone and computer.” Indeed, hecould not have drained a potentially life-threatening abscess in his elbow without a detailed, 14-stepsurgical procedure e-mailed to him from physicians at WorldClinic, a medical practice that uses phones,satellites, and the Internet to treat patients around the globe.
On land, access to definitive medical care for a critically sick or injured person involves rapid transportto a medical facility, hence Forgey’s car keys. At sea, direct radio consultation with the medical facilitymay be the only way to obtain medical expertise; evacuation of crew may be too hazardous or impossi-ble. In the South Atlantic, a satellite phone was Yazykov’s best option.
Modem radio and satellite communications have fostered an over-dependence on search and rescue formariners in times of peril. Paradoxically, a call for help during a medical emergency may actually facilitateself-reliance and eliminate the necessity for evacuating the patient.
In order to treat a broad range of medical problems at sea, a cruising sailor needs to focus on three key ar-eas: basic medical skills, radio equipment for consultation, and appropriate medical supplies. Basic Medical Skills
The boat’s medical officer should know how to treat common ailments as well as life threatening emer-gencies, and be able to stabilize a crewmember with traumatic injuries. Communications
The medical officer must also be well trained in patient assessment so he can transmit a precise and de-tailed report of the patient’s medical condition when consultation with a medical advisory service is re-quired. These companies provide the mariner with 24/7 access to physicians trained in the art of remotemedical support (see list of telemedicine companies). Coastal cruisers therefore require at a minimum, aVHF radio, and offshore sailors need a single side band radio, satellite phone, or ham radio. Consider thisequipment an integral component of the medical kit. Medical Supplies
The comprehensive list of medical supplies listed below is divided into two main groups: items that belong in the crewmember’s kit and those that belong in the ship’s primary medical kit. Thoughtful selec- tion of medical supplies involves consideration of the following factors and how they specifically relate
• Common ailments at sea. For example: sunburn, skin infections, and seasickness. • Common onboard traumatic injuries. Sailors frequently suffer head, chest, and hand injuries. • Number of crew and duration of trip. This determines the quantity of medications and supplies. • Environmental extremes on the trip. Remember, suppositories melt and liquids freeze. • Endemic diseases in cruising areas. • Medical problems associated with specific activities in the aquatic environment e.g., scuba diving,
• Medical expertise of crew (surgical types love to stitch and start IVs; medical types favor glue and
• Access to reliable and comprehensive medical care.
Don’t expect to treat every medical or surgical emergency. However, don’t omit items simply becauseyou’re going on a short coastal trip. The same medical problems may occur on a weekend cruise ormonth long trip. Drugs and supplies useful for a variety of medical problems should be selected. The Crewmember’s Medical Kit
Each crew member needs a personal kit. Alternatively, the ship may stock a conveniently accessiblecrew medical kit for a variety of simple and common medical problems. Keeping this kit separate ensuresthat supplies in the ship’s primary medical kit remain intact, organized and protected. Items should begrouped and packaged in zippered plastic freezer bags, and stored in a watertight container that floats. The following is a list of suggested supplies and non prescription medications. Brand name drugs (in Ital-ics) can be substituted with other brands or less expensive generic preparations. Seasickness Medication:Bonine, Dramamine, ginger capsules or other remedies that work for you
and your crew. Add Sudafed or No-doz to counteract drowsiness from antihistamines. Anti-inflammatory and analgesic medications for aches and pains: Ibuprofen (Motrin) or
Naproxen sodium (Aleve), and enteric coated aspirin (Ecotrin); acetaminophen (Tylenol) for painrelief and fever. Many nonsteroidal anti-inflammatory drugs (NSAIDs) may increase sensitivityto the sun, so minimize sun exposure when using them,
Sun Protection: Waterproof sunscreen with SPF 25 that blocks both UVA and UVB, Labiosan lip
balm, zinc oxide for covering the nose, 100% Aloe Vera gel and topical 1% hydrocortisone creamfor serious sunburn. Special-purpose, high-grade polarized sunglasses that block 99% of UVBand 60% UVA. Minor wound care materials: Waterproof adhesive bandages in a variety of sizes including finger
and knuckle strips, New-Skin antiseptic liquid bandage, Benzalkonium (BZK) antiseptic wipes,antibacterial soap, and antibiotic ointment. Medical instruments when indicated—e.g., blood sugar monitor for diabetics (with extra batteries),
blood pressure monitoring device for people with hypertension. Non-prescription pharmaceuticals: for common minor medical problems: Visine drops for sun-irri-
tated eyes, sterile eye wash, Blistex for chapped lips, Mylanta and Zantac for heartburn and indi-gestion, Milk of Magnesia for constipation, Imodium and Pepto-Bismol for diarrhea, Tinactinpowder and Lamisil cream for fungal skin irritations in the groin and feet (jock itch, athletes foot),
Monistat vaginal cream or suppositories for yeast infections, Afrin nasal spray and Sudafed forsinus, inner car and nasal congestion, Robitussin-DM cough syrup, Benadryl antihistamine for al-lergies and insomnia, Preparation H for hemorrhoids, skin fissures and skin ulcers, Eucerin withPABA for dry skin and salt sores, Otic Domeboro for treating swimmer’s car, Swim-EAR to pre-vent swimmer’s ear, and multivitamins. Insect repellent:Sawyer Controlled Release DEET Formula (a 24-hour protection for adults and
children formulated for minimal absorption of DEET). Rubbing alcohol or vinegar for inactivating the stings of jellyfish, anemones, & other sea creatures. Personal medication for existing medical problems and anticipated complications; review with your
personal physician and the ship’s medical officer. The Ship’s Primary Medical Kit
There are two categories of ship’s medical kits—coastal and offshore. Combined with the appropriatemarine radio or phone for consultation, the kit can be designated for use in either nearshore (coastal) oroffshore waters. The coastal medical kit is appropriate for cruising within the 20-mile range of a VHF ra-dio, a distance within which shore-base assistance will likely be able to evacuate the patient within 24hours. The coastal medical kit must have supplies to treat common problems as well as stabilize a moreseverely ill patient in the event that transfer to a hospital is delayed.
The offshore cruiser, with SSB (single-sideband) radio or satellite phone should be prepared to delivermore comprehensive and longer-term treatment. Professional medical care may be days to weeks away,or not available at all, and someone on board may have to provide definitive treatment.
In the list below, an asterisk * denotes drugs or items that are optional for the coastal kit but necessaryin the offshore kit.
The following medications require a prescription. They have been selected because they are easy to ad-minister, have convenient dose schedules, show little to no incidence of sun sensitivity reactions, and areeffective for a broad spectrum of applications for the sick crewmate. Antibiotics:
Cephalexin (Keflex) for infections involving teeth, ears, sinuses, skin, wounds, respiratory, and uri-
Levofloxacin (Levaquin) for infections in the bowel, gallbladder, female pelvic organs, prostate, and
urinary tract; excellent for skin, ear, sinus, and respiratory infections; slight risk of photosensitiv-ity reactions, so cover up!
Azithromycin (Zithromax) for all infections in the upper and lower respiratory tract, including ton-
sillitis, ear infections, sinusitis bronchitis, and pneumonia. Dispensed in convenient blister packfor 5 days of treatment.
Ciprofloxacin (Ciloxan)—topical ophthalmic drops for eye and external ear canal infections. Erythromycin ophthalmic ointment (Ilotycin) for eye infections and corneal abrasions. *Denavir cream for oral herpes*Valacylovir HCL (Valtrex) for Herpes Zoster (shingles) and Herpes Simplex (fever blisters). *Fluconizole (Diflucan) for vaginal yeast. *Metronidazole (Flagyl)—Added to Levofloxacin for severe intra-abdominal infections e.g. peritoni-
tis, appendicitis, diverticulitis, uterine and fallopian tube infections; also dental infections.
*Imipenem-cilastin sodium (Primaxin) administered intramuscularly (training required) for urgent
treatment of appendicitis or bowel perforation while awaiting evacuation. Seasickness:
Transdermal Scopolamine (Transderm-Scop) patches. Promethazine HCL (Phenergan) pills and suppositories for nausea and vomiting. Narcotic Analgesics:
Oxycodone with acetaminophen (Percocet)*Hydromorphone (Dilaudid) suppository
*Risperidone (Risperdal) for psychotic behavior*Clonazepam (Klonopin) for severe anxiety
AspirinSublingual nitroglycerine (Nitro stat)Nitroglycerine paste (Nitro paste)Propanolol (Inderdal)
Full-size and finger-size SAM® Splints (2 of each)—waterproof, foam-padded, flexible aluminum
High-compression elastic bandage with Velcro closure for sprains, and pressure dressingInstant cold packs14 G Angiocath for emergency thoracotomy, tracheotomyEye pad for corneal abrasions and injuries*Air cast or gel splint for sprained ankle*Ortho-Glass padded fiberglass splint material
Bandage scissorsUnsterile latex or nitrile glovesCotton-tipped sterile applicators and tongue bladesTweezers and magnifier for foreign body removalTopical anesthetic LET gel or 10% topical lidocaineNo. 11 scalpel blade and handle for drainage of an abscessNu-Gauze iodoform packing strips for draining woundsDisposable Skin Stapler (Ten Shot Precise, 3M)Staple remover*Sterile paper drapes and gloves*Suture kit—prepackaged kit with optimum assortment of equipment, supplies, anesthetic, and su-
Wound Care Materials:
Silver sulfadiazine (Silvadene) cream for burns20cc syringe with 18-gauge plastic catheter for high-pressure wound irrigationPovidone Iodine solution 10% (Betadine)—use 1: 10 dilution with water for irrigation solutionChlorhexidine (Hibiclens) germicide to clean open woundsSkin super glue (Dermabond) for topical closure of easily approximated lacerations on face, trunk,
Wound closure forceps for use with tissue adhesiveSkin-closure strips (Steri-strip, 3M)Benzoin swabs to increase adhesiveness of tape and skin closure stripsWaterproof adhesive tape4" Kling or Conform roll gauze bandageTegaderm—a transparent, occlusive dressing for abrasions, lets in air but not water Adaptic 3"x3" non-adhering wound dressingHydrogel occlusive dressing to absorb fluids from weeping burns and open woundsSterile gauze dressing pads—2"x2", 3"x3", and 4"x4"Trauma Pads—8"x10" and 5"x9"
Epinephrine auto-injector (Epi E•Z Pen) for anaphylaxisPrednisone for severe envenomation and allergic reactionsBetamethasone Valerate (Valisone) 0.1% topical cream for contact dermatitis*Loratadine/pseudoephrine (Claritin-D), a non-sedating 24-hour antihistamine
Albuterol (Proventil) metered inhalerOral airway kit with assorted adult and child sizesLaerdal CPR Pocket-Mask™*Stethoscope
Dental Kit: Super-Dent or Cavit dental mixture for temporary filling, loose crowns and broken teethOil of Cloves (Eugenol) for topical dental analgesia*More extensive dental kit (with instructions)
*Urine pregnancy HCG kitNorgestrel/Ethinyl Estradiol (Ovral) for dysfunctional uterine bleeding and emergency contraception
Tetracaine anesthetic eye dropsLarge safety pins (many uses)Duct tape (many uses)16 French Foley Catheter with sterile lubricant, bag, clamp, and plug for urinary retention (catheter
also useful as improvised chest tube, and posterior nasal pack)
Marine VHF Radio*Satellite Phone or Single-Sideband Radio
Optional Medical Equipment And Supplies:
Blood pressure cuffDigital thermometerIce Tape (cold compression bandage activated by evaporation or refrigeration; great for sprains)Reusable hot water bottleSawyer extractor for evenomations and stings*Injectable analgesic
Nonprescription Pharmaceuticals for children:
Oral rehydration salts for treatment of dehydrationDesitin diaper creamIpecac syrup and activated charcoal—for accidental poison ingestionPediatric strength decongestant and antipyreticAntiseptic pads with added 2.5% lidocaine (a kinder way to clean wounds, especially abrasions)Auralgan otic solution for ear painChloraseptic throat sprayBenadryl chewable tablets for allergic reactionsE.N.T. pocket waterproof otoscope for oral, nasal, and ear exams. Prescription medicine for children:
Antibiotics may need to be in a liquid suspension or chewable tablet for ease of administration and
dosage adjustment based on child’s weight.
Amoxacillin Clavulinate (Augmentin) for ear, sinus, pharyngeal, respiratory, and urinary infectionsAmericaine—a potent topical anesthetic for otitisMupirocin (Bactroban) cream for wounds and impetigo*Cefprozil (Cefzil) for severe infections
Several items have not been recommended for the offshore kit for the following reasons:
• Intravenous solutions and supplies for administering them are of limited value to the untrained per-
son, but trained medical professionals may consider adding them.
• Automatic external defibrillators are life-saving only if expert intensive care together with a full
complement of drugs and equipment is immediately available. Non-fatal heart attacks can betreated with aspirin, oral and topical nitrates, and beta-blockers. Prescription Safety
Medications and antibiotics may cause serious adverse reactions, so review the suggested list of drugswith your physician to better understand the Indications for use, side effects, and dose schedules. Stockalternative drugs If crew have known allergies to specific medications. Update and replace pharmaceuti-cals in the kit according to expiration dates. Use extreme caution when administering drugs to Infants,small children, pregnant women, and nursing mothers. When a medical problem arises, it’s always best toconsult a physician or nurse practitioner to review the diagnosis and appropriate therapy.
SF By-products: Safety, Cleaning, and Disposal Concerns U.S. EPA’s International Conference on SF6 and the Environment November 29, 2006 San Antonio, TX Slow reacting with a relatively high molecular weight and extremely stable molecular structure. Excellent insulation properties, strong arc quenching abilities, and high dielectric strengthUnder high temperature co
HITOKTATÁS 2013. SZEPTEMBER HITTANKÖNYVEK, TANÁRI KÉZIKÖNYVEK Milyen vagy Istenem? Miklya Zsolt - Miklya L. MónikaMunkáltató füzet 9-12 éves gyerekeknek. Kézimunkacsomag melléklettel. Egy tanévre való hittankönyvjellegű munkafüzet Istenről, aki olyan mint az építész, a fazekas, a pásztor, a nap, a menedék. Segédanyag 5-7 éves gyerekek hitoktatásához. Óvodá