M 2011

SEASICKNESS, HYPOTHERMIA Safety at Sea – MARION BERMUDA 2017

Michael Jacobs, MD MFAWM saildoc@vineyard.net

HOW TO DIE UNDERWAY

◆SEASICKNESS ◆COLD SHOCK RESPONSE ◆DROWNING ◆MAJOR TRAUMATIC INJURY ◆HEAD/BRAIN INJURY ◆ANAPHALAXIS ◆HEART ATTACK/STROKE/AAA

Seasickness

Seasickness• A common threat to crew safety at sea, and

the most common medical disorder at sea. • Seasickness may be at least annoying or

disabling, but may also lead to fatal consequences e.g. falling overboard.

• Nearly everyone will develop seasickness with sufficient stimulus; individual susceptibility is enormously variable, and increases with heavy weather conditions.

NEWPORT-BERMUDA RACE 1998-2006 863 yachts

Every year, many seaworthy yachts are abandoned because their exhausted and despondent crews have lost their collective will to persevere.

Seasickness

“They are wet, seasick, scared, and want to go home,” observed a merchant marine captain.

•Too often, mariners consider seasickness a medical emergency and justification for medical evacuation.

•Waiting just 36 to 72 hours often allows symptoms to subside, and weather conditions to improve. “Getting your sea legs”

• MEDICATIONS FOR SEASICKNESS MAY IMPAIR CONGNITIVE FUNCTION

• DEHYDRATION (FLUIDS) • LOW BLOOD SUGAR (FOOD) • SLEEP DEPRIVATION (FATIGUE) • FEAR, PANIC, INJURY (FITNESS) • HYPOTHERMIA (FARENHEIT) THE FEARSOME FIVE

FACTORS CAUSING IMPAIRED JUDGEMENT

Seasickness: Mechanism

• The brain’s balance center receives sensory data from the eyes, inner ear (vestibular apparatus), to estimate motion and spatial orientation of the head and body.

• A sensory conflict is generated when data from these structures arrives in the brain in conflicting combinations.

• Conflict activates the vomiting center in the brain

“INFLATABLE VOMITORIUM” WHY?

It’s a sensory conflict chamber!!

If your eyes are seeing what your ears are feeling, and what your brain is expecting, you have a good chance of having a great day at sea.

Seasickness Prevention Eliminate the conflicts: vestibular cues cannot be manipulated, but you can provide visual information that contains equivalent motion information sensed by the vestibular system

Seasickness Prevention (and early Rx)STAY ON DECK

• “Fight back and act quickly-” Take the helm • Steer boat by reference to oncoming waves, clouds,

horizon and distant marks-

• Obtain good broad view of horizon: – Use “earth-fixed” (“outside”) reference frame

• Ride the waves with your whole body Alter boat’s course for comfort & wear a safety harness

• Our brain can utilize the self- generated motor commands used to balance ourselves and control the boat’s motion to help anticipate and orient our body to the motion

Why Take the Helm?

“Well, for one thing, it’s in the stern!!!”

“Outside world’s frame of reference””

“Local frame of reference”

Wave Riding: Posture yourself to anticipate the boat’s motion and “ride the waves.” Keep your head and shoulders balanced over your hips and gain postural control gracefully.

“GIMBLE YOURSELF”

Sea Sickness: PreventionAfter Departure: • Stay on deck, amidships • Avoid areas with fumes & odors • Avoid close-focused visual tasks- e.g., reading,

using binoculars • Look at the horizon, take the helm • Take medication at regular intervals (Use long-

acting drugs while offshore ) • Sleep/nap- avoid sleep deprivation • Snacks and fluids: granola, trail mix, fruit,

crackers, pop corn, energy bars, Gatorade

***Medication is more effective in preventing symptoms than in reversing them- start trip on medication!!

Seasickness: Prevention

gosling

So what’s wrong the “placebo effect”??

NOTHING! IF IT WORKS, WE’LL TAKE IT (even kids “queasy pops”!!)

Prevention

Other measures after Departure • Avoid areas with fumes & odors, stay on deck • Avoid close-focused visual tasks- • Take medication at regular intervals • Sleep/nap- REDUCE sleep deprivation • Snacks and fluids: trail mix, PBJ on crackers,

string cheese, HBEs, fruit, pop corn, energy bars, Gatorade

Seasickness: Early Signs ( the window of opportunity for Rx)

• Yawning, Profound Drowsiness/Lethargy/Apathy* • Salivation/Dry mouth/Belching/Passing gas • Stomach awareness/ Mild nausea • Dizziness, Headache, Hyperventilation • “I don’t feel good” • IT TAKES TIME FOR THE LINKAGE BETWEEN

SENSORY CONFLICT AND NAUSEA TO DEVELOP

Seasickness Medication: (best for prevention)

• OTC Diphenhydramine 25-50mg liq/cap/chew 6-8 hrs

• OTC Bonine 25 mg chew 6-8 hrs

• OTC Meclizine 25/50 mg tab 6-8 hrs

• OTC Stugeron * 15mg tabs 6-12hrs

• Rx Transderm-Scop 1.5mg patch 2-3 days

• Rx Phenergan 12.5,25,50 mg tab, 12 hrs

suppository, deep IM injection

• UK, Canada, Mexico, Europe & Bermuda

• All medications have side effects- know the common ones, and DO EXPERIMENT WITH DRUGS ONSHORE!

“BEST BET ”: Bonine (Meclizine) + Sudafed Use Phenergan 25 mg when necessary or Zofran

least sedation and cognitive side effects

Seasickness- Late Signs stomach emptying inhibited • Hands and face sweat, feel cold and clammy • Pallor • Waves of nausea become stronger ➔ vomiting • Cycles of nausea and vomiting Q 15-30 min. • Anxiety/Depression

• The protection conferred by drugs is a matter of degree

• No drug (or non drug therapy) has been found which can act as a magic bullet, totally preventing seasickness in everyone

• All drugs have side effects-

Finally, if all else fails “To cure seasickness, find a good big oak tree and wrap your arms around it.”

Samuel Johnson’s 18th century advice:

HYPOTHERMIA

Fahrenheit: Hypothermia

• ACUTE: Rapid drop in core temp over hours • Overboard: Immersion in water < 25˚C (77˚F) • Water conducts heat away from the body up to

25X faster than air at the same temp

• CHRONIC: Slow drop in core temp over hours to days • prolonged exposure to elements, wet

clothing

COOL AND WET: Risk Of Chronic hypothermia

•Mild (95ºF) Mental Impairment Physical Impairment Shivering •Moderate (90ºF) Maximal Shivering ___________________________________________ Below 90º ↓Level consciousness

(86ºF) Shivering stops Deep coma •Severe (82ºF) Vital signs deteriorate Cardiac arrest

Hypothermia Signs STANDARD CLASSIFICATION BASED ON CORE TEMPERATURE

◆Mild 95ºF-90ºF Mental Impairment Physical Impairment Shivering ◆Moderate 90ºF-82ºF Shivering max➔less effective !Level consciousness 86ºF(30ºC) Shivering stops Deep coma ◆Severe <82ºF Vital signs deteriorate Cardiac arrest (VF, asystole)

Hypothermia Signs STANDARD CLASSIFICATION BASED ON CORE TEMPERATURE

NOTE: a cold shivering person with a core temperature above 95°C is “cold stressed” but not hypothermic- you need to make a clinical decision: The person is normal functioning, alert, able to care for themselves, not incapacitated. e.g. sudden brief immersion in cold water, wind chill while wet, etc.

• Shivering is the an important dx sign • Skin sensors trigger reflex shivering • Starts early, before a drop in core temp. • Shivering powers metabolic (muscle) heat production (5X resting) • Once shivering stops, the body has lost the capacity to actively rewarm itself

Hypothermia-Mild (95°F➔90°F) •Sustained uncontrolled shivering •Change in fine motor coordination •Loss of strength •Loss of balance-ataxia •Impaired judgment, confusion •FULLY CONSCIOUS •“THE UMBLES”

THE “UMBLE” FAMILY OF SIGNS ⬥ Victim’s mental status changes: •MUMBLES •GRUMBLES

⬥ Victim’s physical changes: •STUMBLES •TUMBLES •FUMBLES

Rx: Mild Hypothermia

•Protect from further cooling •Shelter, remove wet clothing*, dry skin •Dress in layers, wrap with insulation*, vapor barrier* •OK to give sweet high carb fluids, snacks if victim alert (calorie replacement) •External heat not necessary-may be harmful •Let victim shiver, limit exercise- “no standing or walking first 30 minutes”- limit afterdrop

Rx: Mild Hypothermia •Get out of the cold •Shelter, Dry skin •Dress in layers, Wrap with insulation •OK to give sweet fluids, snacks (fuel) if victim is alert •External heat not necessary-NOT helpful-may be harmfull •Let victim shiver, limit exercise

•Active external heating warms skin and shivering heat production ! core temperature is unaffected

•Never substitute a hot shower. Victim may collapse and die

•Core temp afterdrop from exercise

Perils of Rewarming

Rx: Moderate/Severe Hypothermia Same as for Mild with changes: ⬥No standing or walking-keep horizontal ⬥No fluids or food orally unless still awake and able to swallow ⬥Try some method of rewarming: apply heat to axilla, chest, and back ⬥Plan medical evacuation

⬥Handle gently

⬥No CPR if signs of life or perfusing rhythm