I remember when I got my first Deck/Stew position and was responsible for the Medical Kit. The official Medical Kit arrived from the authorised Medical Company and while it contained everything we needed to sail the world, I felt compelled to create a separate Crew Medical Kit, so we did not dive into the official Medical Kit Provided.

I went out and purchased everything I thought would be needed day to day. I stocked it, not only with dressings, but with all the over the counter medicines I could purchase. I added numerous anti-inflammatories and analgesics, all placed carefully in a plastic box that I named “pain relief” one named “allergies” and another “sea sickness”. We ate those medicines like sweeties. If someone went into the box to get an anti-inflammatory, such as ipubrufen, the whole crew would claim they needed one too. Consequently the box would be passed around the crew mess and be literally consumed in one sitting!

During my years on Yachts, I have seen everything from the “Morning After Pill” to Sedatives in these Crew Med Kits. I have seen sedatives such as Diazepam (better known as Valium)  labelled as “muscle relaxant”, or worse still, antipsychotics such as Chlorpazamine, labelled for head aches in home made crew medicine chests.This, I believe is downright dangerous and unnecessary. This is an extreme example, so today I will focus on the basic over the counter medicines we find in pharmacies, supermarkets and fuel stations world wide.

I have come to realise that many people do not understand simple “over the counter “medicines such as non steroidal anti-inflammatories or antihistamines and their side effects, contraindications and consequences when self administered.

I have not spoken to one crew member who consults their 24/7 Medical provider or the recommended guidelines, such as the “Ship Captains Medical Guide” when administering drugs from the crew meds, the reason being, is that they are just “over the counter medicines” and, apparently, entirely safe.

The reason I am so passionate about writing this article today, is that in the last year 3 people, I know of, lost their lives by self administering anti-inflammatories at sea. The problem is, these drugs have contraindications such as stomach ulcers and asthma, take a look at the “Ship Captains Medical Guide” Drug index and see for yourself.

Furthermore, many people do not realise natural medicines, including the widely used natural anti-inflammatories, such as the cucumin (tumeric) can combine with pharmaceutical ant-inflammatories and act as a double dose, this can be a lethal combination which may cause extreme side effects in high risk individuals.

The other issue is, is that these self made crew medical kits are unregulated, so we do not know who is taking these medicines or why. Personally, I want to know if someone is taking pain relief or antihistamines, such as sea sickness tablets on my watch. If someone is taking these drugs regularly, we need to ask the question, why!

First of all, lets remember that, according to the experts…

“The medical kit should include details on the safe usage of all its contents to optimise benefits and minimise risks, especially in remote locations where complications of treatments will be challenging to manage…” (Nikolec et. al 2017).

I believe this refers to the crew meds, as well.

Prescription and over the counter (OTC) drugs may enable users to continue working during periods of acute or chronic illness. However there is an increased risk that impairing side effects of such medication, e.g. fatigue or disorientation, could jeopardise personal safety and in some cases, the safety of others. At sea this can be a particular problem, and recent accidents have highlighted impairing medication as a contributory factor. Employers and seafarers should therefore be aware of their particular roles in helping to prevent such incidents, and the following guidelines should be followed whenever necessary. (MCA MGN 296)

I also believe that anyone who is self administering or dishing out these medicines onboard, requires professional Medical Training, and guidance from their Medical Provider, or at the very least the recommended texts.

“The Medical Training program of the crew should be based upon instruction on what resources are available in the medical kit, how it is laid out and how to use the contents to the best effect.” (Nikolec et. al 2017)

When we set up the crew medical kits ourselves, we are often not adhering to the carefully researched guidelines set by governing bodies such as the MCA, nor utilising the systems we have in place to minimise risk, such as tele-medicine from our authorised Medical Provider.

In this article I will focus particularly on anti-inflammatories & anti-histamines, the most widely self administered drugs of the crew meds, and hope to encourage you to rely on your Medical providers to provision your Crew Medical Kits and the 24/7 tele-medicine services they provide.

So, let´s start by talking about pain relief, particularly anti-infalmmatories, also known as NSAIDS (Non-steroidal anti inflammatories).

Case Study.

Kate is a 32 year old chef who has suffered back pain, she also had a past history of stomach ulcers. After a busy day in the galley, her lower back ached. She went to the crew medical cabinet and took 2 Ipubrufen, which were 600mg each and had been purchased in Thailand. In the UK Ipubrufen is only 200mg and the recommended dose is 400mg in total. Kate took 2 Ipubrufen, which was 3 times the recommended dose. She also took a 100mg Voltaren, also purchsed in Thailand (The UK dose of Voltaren is 50mg).

It must be noted that Kate had also taken a natural anti-inflammatory, widely known for its numerous health benefits, Cucumin. She had a glass of red wine to relax her back and then went and had a long hot shower, where she started vomiting blood and passed out.

She was found unconscious by a crew member, who arrived moments before she stopped  breathing and CPR was commenced. Kirsty was resuscitated and survived to tell the tale, none the less, she suffered great blood loss and brain damage, due to a Stomach Ulcer Bleed cause by an overdose and combination of NSAIDS.

Could this have been prevented?

Yes. If Kate had spoken to the Medical Officer and used the provided Tele-medical service, she would have been prescribed the correct dosage and not doubled, or tripled her NSAID dosage.

As it turns out Kate was a high risk individual, due to her prolonged self administration of both natural and pharmaceutical anti-inflammatories. The National Institute for Health and Care Excellence (NICE) defines high-risk patients as: aged >65 years; interacting medications (including 20% of patients >75 years); patients with diabetes, hypertension, cardiovascular disease, renal or liver impairment; patients with a history of peptic ulcer or GI bleeding; and those taking long term NSAIDs or maximum doses.

So why did this happen and most importantly how can it be prevented?

Let us look at the facts….

• What many people do not understand is that from the first day of use, all NSAIDs increase the risk of gastrointestinal (GI) bleeding, myocardial infarction, and stroke. (Davis 2016)

• Bleeding is the better-known consequence with all types of NSAID use. GI bleeds while taking NSAIDs are more likely to be fatal, with a mortality of 21%, whereas in patients not taking NSAIDs it is 7%. (Straube 2009)

• Preventable adverse drug reactions (ADRs) are responsible for 10% of hospital admissions people. Non-steroidal anti-inflammatory drugs (NSAIDs) are responsible for 30% of hospital admissions for ADRs, mainly due to bleeding, heart attack, stroke, and renal damage. (Pirmohamed, 2004)
• NSAIDs  also increase systolic blood pressure by 5 mmHg and increase fluid retention. (Bhala, 2013)

• NSAIDs can precipitate bronchospasm  and Asthma and 5–10% of adult patients with asthma will have an acute deterioration in symptoms after taking NSAIDs. (Lemanske, 2006)

Therefore, I believe the use of NSAIDs is long overdue for system-wide attention. Please think twice before you pop that next pill and always consult your Medical Officer or Provider.

Another drug we often will help ourselves to for hay fever or sea sickness. As we all know, Allergic conditions are common, although most individuals with allergies do not seek medical care (2014) Asthma and Immunology Allergies. American College of Allergy.)

Case Study 2 – Antihistamines

Steve is a 28 year old Engineer who suffers from allergies and sea sickness. Steve was suffering from a Pollen allergy and was self administering an over the counter medication daily, from the crew meds. While en transit between ports, some foul weather hit and Steve also self administered a common, yet prescribed, sea sickness tablet found in the home made over the counter the crew medical kit.

While on this delivery Steve felt increasingly drowsy, yet did not disclose his fatigue, nor drug administration to the Captin or Meical Officer on board. During a sailing manoeuvre Steve put his hand through the winch and caused himself and another crew member great bodily harm, it was discovered that Steve was suffering fatigue caused by the medications and in actual fact should not have been operating heavy machinery under the influence of these drugs, at the time.

Allergy medications are readily available over the counter. While most people will report relief of their symptoms with readily available allergy treatments, approximately 7% of patients who take these medications will experience adverse effects (AEs), which can be severe (Flynn, 2002)

What many people do not realise is that Antihistamines can cause undesired anti-cholinergic effects including mydraisais, sedation, dry eyes, dry mouth, constipation and urinary retention. Significant overdose of antihistamines can cause serious toxicity and even death. (Malone 2017)

What about the common decongestant for the annoying blocked nose?

I was shocked to discover that even the every day decongestants have side effects. Decongestant side-effects include nausea, vomiting, insomnia, dizziness, elevated blood pressure, restlessness, anxiety, hallucinations, seizure, psychosis, headache, urinary dysfunction, stroke, intracranial bleed, arrhythmias, and myocardial infarction. (Malone, 2017)

What is the answer?

Do not self medicate at sea. Always inform your Captain and or Medical officer when requiring medication on board, even in port. Establish a culture where it is the norm to request a medical appraisal from your Medical officer or authorised telemedicine provider.

The MCA 296 (M) states Operators, employers and masters with input from masters and other senior personnel as appropriate, should establish the required level of protection and, based on advice from their Medical Advisors, and governing bodies, and put it into practice.

I believe the only way to reduce illness and accidents in terms of accidental drug reactions on board is to request your Maratime Medical Provider provisions your complete Yacht Medical Kit, including the Crew Meds and that we treat these kits with the utmost respect and always seek medical advice prior to prescribing or self prescribing medicines.

I also recommend that any crew member who is responsible for the provisioning and administration of drugs on board, including over the counter medications, seek yearly training to refresh Medical knowledge and to be reminded of the due diligence and utmost respect we must have for all the medicines we carry on board.

Amanda Jean Hewson-Beaver, Medical Trainer & High Performance Coach (BHSC, Nursing, MIPH)

REFERENCES

1. Marine Guidance Note 269 (M) MCA. This notice should be read in conjunction with Merchant Shipping Notice MSN 1765(M), Marine Guidance Note MGN 219(M)+ amendment and Merchant Shipping Notice MSN 1768(M+F) + amendment

• A Medical Support in Offshore Racing – Workshop on Medical Kit Inventory in Offshore Yacht Racing, 12-13 May 2017, Lorient, France, Nikolic, Nebojsa, Nilson, Briggs, Fimbault, Jean, Auffray, Jean, Gac, Horneland, Jean, Alf
• Straube S, Tramèr MR, Moore RA, et al. Mortality with upper gastrointestinal bleeding and perforation: effects of time and NSAID use. BMC Gastroenterol. 2009;9:41. [PMC free article] [PubMed] [Google Scholar]
• The dangers of NSAIDs: look both ways Abigail Davis, GP Registrar

Centre for Primary Care and Public Health, Queen Mary University of London, London.

5. Pirmohamed M, James S, Meakin S, et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18 820 patients. BMJ. 2004;329(7456):15–19. [PMC free article] [PubMed] [Google Scholar]

6. Bhala N, Emberson J, Merhi A, et al. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials. Lancet.

7. Lemanske RF, Busse WW. 6. Asthma: factors underlying inception, exacerbation, and disease progression. J Allergy Clin Immunol. 2006;117(2 Suppl Mini-Primer):S456–S461. [PMC free article] [PubMed] [Google Scholar]

8. Michael Malone^1* and Tara M Kennedy , 2017, Review: Side Effects of Some Commonly Used Allergy Medications (Decongestants, Anti-Leukotriene Agents, Antihistamines, Steroids, and Zinc) and Their Safety in Pregnancy

9. (2014) Asthma and Immunology Allergies. American College of Allergy

10. Flynn CA, Griffin G, Tudiver F (2002) Decongestants and antihistamines for acute otitis media in children.

Medical Support OffShore (MSOS)

By Nick Stael Von Holstein

nick@msos.org.ukwww.msos.org.uk