Medical Needs Aboard Hokule'a
"Kauka" Pat Aiu, M.D.
[Drawing below: Awapuhi / Ginger: the dried root is a traditional medicine for preventing seasickness (Illustration by Susan G. Monden, in Kahuna La'a Lapa'au (Honolulu: Island Heritage, 1976). Today modern medicines are also used to treat illnesses and injuries on the canoe.]
Some hints and thoughts from the medical side of long canoe voyages: It is very important to be in good health, in good shape and to be in good physical condition before embarking on any open ocean voyage. The reason being that, although we wish all voyag es were smooth without inclement weather, viral and bacterial onslaught, the reality is, that these adversities do exist. The healthier and in shape you are, the better able you will be able to cope and recover from any ill that may come upon you. Being s o, you'll better be able to stand your watch, cook, wash dishes, etc. etc. In all honesty, aside from jesting, the trip becomes fun and a joy instead of being a total drag. This is for every one on the crew.
Now this part pertains more to specific medical issues and is appropriate to and for the Doc on board. I'll discuss first the medical needs from the past voyages, then the medical kit, some preventive measures and helpful hints learned over time, and fina lly some emergency procedures.
Skin Problems: Folliculitis; Fungal rashes; SunburnÑfirst degree and second degree; Carbuncles; Paronychia; Lacerations; Splinters; Non-specific rashes; Cracked skin; Dry skin; Abscess.
Folliculitis, particularly on hairy guys, is the most encountered complaint. Fortunately it is a minor problem and is easily treated with Mycolog cream.
Sunburn is prominent the first week at sea. First degree burns are common, but second degree blistering is not uncommon. Sun screen helps prevent burn if the crew will use it.
Tinea of every variety show up with surprising frequency and Lotrimin works well. Dry, cracked skin occurs often enough to be a problem. Any of the dermal creams and lip balms work well. The other problems listed above do occur and other docs and I have e ncountered them but infrequently.
Cardiovascular-Respiratory Ailments: Upper respiratory infections are by far the most common ailment. Any of the decongestant/expectorant and analgesic/antipyretics can be used. These meds get used up very fast, so be well stocked. I never encountered any of the crew with suspicious signs of Strept, so I never had the occasion to use injectable penicillin. I did see a lot of suspicious Strept. in the islands and treated a number empirically with oral antibiotics. Cultures, as you would suspect, were unava ilable. I think a Strept screen kit would be useful today.
Bronchitis: infrequent. Saw 4 cases between 1980 and 1987.
Hypertension: six (6) people were on antihypertensive medication and needed to be monitored. I feel that because of the possibility of water rationing during protracted voyages, individuals who must be on diuretics should not be on board.
Pneumonia: no acute pneumonia seen so far.
Cardiac compromised status should disqualify a person from becoming a crew member.
Gastro-intestinal Ailments: (a) Motion Sickness - Common. Most cases resolve after twelve (12) to twenty-four (24) hours. Dermal patch would probably help but most actually say, "Nah! I don't get sea sick." End quote! One individual required IV solutions to counter dehydration; (b) Gastro-enteritis - This is usually seen on land or soon after leaving land. All were short termed, twelve (12) to twenty-four (24) hours. Imodium, Donnatal tabs or Lomotil all worked. Some preferred taking their own Pouchai pil ls; (c) The scariest case was one of acute Gastro-intestinal bleeding. By all means of rough estimation, individual dropped 5 - 6 grams of hemoglobin. His conjunctiva and other mucous membranes showed a distinct pallor. He also had all the signs and sympt oms of acute severe blood loss except shock which spoke well for his good physical condition.
Genito-Urinary Ailments: (a) Urinary tract infection was seen in only one female; (b) Individuals with history of gout, those on allopurinal, those with history of kidney stones all should be on special precaution for dehydration and water intake should b e monitored. Don't want a kidney stone out there. Water rationing on a long voyage would definitely exacerbate this condition and the placement of a person with this condition on such a voyage should be carefully considered.
Musculo-Skeletal Ailments: One incidence of dislocated shoulder. One dislocated finger. One broken toe. Remember to stress safety, safety, safety and be prepared for whatevers.
Psychiatric Problems: No real psychoses appeared but three (3) individuals needed "talking out" sessions and psychological support to help maintain equilibrium. Just be on the look out, observe and talk to and most important, listen a lot.
The Medical Kit (Packed in one to four coolers!)
Topicals: (a) Antibiotic--creams, ointment; (b) Cortisone/antibiotic/anti-fungal combinations Mycolog, Mycelex--these go out like no nuff; (c) Emollients--dermal creams, moisteners, sun screens, tanning oils, mono'i, etc. Most guys have their private stoc k.
Antibiotics: Doxycyline; Penicillin; Amoxicillin; Cephalosporin; Cipro or Floxin; Septra (for the one wahine!); Vag cream for monilia; Erythromycin; Indocin (for the gout guys).
Gastro-intestinal Medicines: Imodium and or Lomotil; Donnatal; Tagamet; Laxative/softener; antacid
URI Meds: Decongestants - I would suggest Seldane to avoid drowsiness; Expectorants/cough suppressants
Analgesics: ASA; Tylenol; Tylenol 3; NSAID - Motrin, Clinoril, Naprosyn, whatevers.
Injectables: Morphine 504 - lOmg size - (2); Demerol - 50mg - (4); Epinephrine 1:1000 - (4); Benadryl 25 mg - (4); Valium lO mg - (2); Vistaril or Compazine - (2) Would suggest using tubex mode for uniformity.
Dressings (Need plenty!): 4 x 4 lots and lots; kling; telfa; Xeroform gauze (1/2 inch, one bottle for packing); Cloth tape - 1, 2 and 3 inch size; Micropore tape - 1, 2 and 3 inch; Ace bandages - 3" and 4" - dozen of each
Splints: Air splints only, otherwise can improvise a board
Scrubs: Betadine scrub - 250 cc size; Betadine solution - 500 cc - this doubles as a water purifier; Hibiclens or Phisohex; some sterile scrub brushes
Cuts and Bruises Department: Suture sets (2) - set up sterile, if more needed can re-use soaking in betadine or hibiclens, unless you can bring along some cidex. Set to include a needle holder, pair of pick-ups (Brown-Adsens or toothed) two(2) crile or mo squito clamps, scissors. Keep the set small. Space is tight. Stick to one size of suture, i.e., 4-0. Use monofilament nylon for skin, vicryl for subcutaneous or muscle. Because of the incessant moisture, all the casting material I brought turned to concre te before Tahiti. I think a Colles fracture can be splinted to a formed board with ace bandage and worked to good apposition over time with gentle lomi. All other large bone fractures should be air evacuated.
Eye and Ear Tray (keep it small, mark it well): fluorescein strips; topical ophthalmic analgesic; topical ophthalmic antibiotic; Irrigation solution, option use IV sol'n but waste a lot usually; Can substitute 4 x 4 gauze for eye patches; brew hot tea, th en use the tea bag for a warm compress, works well; otic solution - Cortisporin; bulb syringe.
Dental Kit: temporary filling kit (these come prepacked, I've used them in the field with soldiers); tooth puller plier - if gotta - numb it first; one or two foley catheters - some guys are over 50 and their prostates might obstruct! Foley can double as a posterior nasal pack for the high ethmoid bleed.
OCP: The wahine member always forget
IV solutions: LR - 4 liters - intracaths, tubing, and those things.
Spirits: I prefer cognac or brandy - medicinal; We all needed some after Kimo came back on board.
Preventive Measures and Helpful Hints
Skin ailments and upper respiratory gunk are the most common problems, so, topicals, decongestants and expectorants along with the aspirins and tylenols go really fast. A surprising amount of antibiotics get used up, primarily for dirty or infected cuts, abscesses, bronchitis, tooth and gum abscesses, enteritis and urinary tract infection. They also get used up on land when you treat the natives. Next most used stuff are the GI ones, imodium, lomotil, donnatal and doxycycline, particularly when on an isla nd and the crew is eating everything under the sun.
Expect Islanders to seek aid when Hokule'a is in port and they discover a doctor is on board. Supplies get use up fast in this situation. Occasionally other ships in port will seek medical aid and this was always rendered cheerfully.
It was surprising how many gouty and / or bursitis flareups occurred. Indocin worked well in these cases. Lots of Tagamet was used but only on two (2) individuals.
Whenever making landfall it is imperative to check the on board water supply and then to check the local water supply. Definitely check it's source, treatment if any, and testing facility for water potability. Then use your judgment whether further treatm ent is needed. I used halogenation to purify water. Two cc of betadine solution was added to a gallon of water (or 10 cc to a five gallon container) and let stand for an hour. The water did have a faint yellow color but did not have a bad taste. Most on b oard did not know I treated much of our water supply in this manner and did not complain of any taste to the water. We did not have a problem with water borne disease. Water caught off of the sails tastes yucky, but in a pinch is o.k. to drink after treat ment. When on island, advise some inquisitiveness (niele ) and check out the food sources. We always found food well prepared except in one area. Pig cooked in an umu in Samoa sometimes tends to be under cooked, raw actually. But looking at the plethora o f Samoan physical specimen, guess it doesn't hurt them! Pig cooked in Umu/Imu elsewhere was excellent.
When at sea, check the galley all the time to keep it clean, the utensils washed and air dried properly and check the status of all left overs. Use your judgment, sense of taste, and your nose.
Some people will become constipated and will not tell, so again be nosey but not irritating. When the guys trust you, they'll usually tell you everything. Crew members as a whole are a tough minded, independent, "macho" lot and generally don't tell the Do c their problems until very late. This I noted early on in 1980. However if you communicate to them your competence and concern and they take you for one of them rather as the "doc" over there, then everything works out very well.
Make a strong pitch for tooth and gum care. Pass out floss or stimudents after each meal. A dental emergency is a bad problem at sea.
A fun thing to do if you can and have the time, is to weigh and tape every crew member prior to sailing. Generally on any trip lasting twelve (12) to twenty-four (24) days, there will be a marked weight loss and the addition of real muscle mass. Weight lo ss can be as high as thirty-five (35) pounds for a large man. Trips shorter than nine (9) days generally don't have much change and those twenty-four (24) to thirty-five (35) days have the effect of compensation and regaining of lost weight if eating habi ts remain the same. The Rangiroa to Hawai'i sail in 1987, the crew ate an average of 3500 calories per person per day, with a range of 2700 to 5200 calories per person per day. So it is easy to see that sailing on Hokule'a causes a tremendous caloric expe nditure with concomitant weight loss in spite of such high caloric intakes. With this in mind, watch for the individual not eating for any reason because he'll go down fast.
Medical Emergency Procedures
During a crisis emergency, the doc will have to use the radio. I have an advantage in that I know how to run radios from my military experiences. If you don't already know how to operate a radio, I would advise you to learn. In an emergency, the call is y ours and you must speak one on one to the Coast Guard or Navy Doc in charge, who will then decide if a ship or plane should be sent out, particularly if the distress is farther than 500 miles from land.
Our Coast Guard is good for 600 miles plus or minus a few and the Navy may go further, but generally they like you to be inside of 500 miles. At sea you get help from any source you can. On every island group we visited, I met, talked to and learned the c all sign of every radio operator who came forth. Then at sea, I would call all of them to stay in contact. Since I was the radio operator on board, I felt it was within my job to be able to contact any one
IF YOU HAVE AN EMERGENCY AT SEA, DO THE FOLLOWING:
Six hundred to a thousand miles out from Hawai'i where no one is close or in range, the decision is yours; to turn around, or push for our Coast Guard or Navy safety net, and obviously the condition of your patient would dictate what you decide.
If you are in the vicinity of an island group, then you can if you have kept in touch, call a local radio ham and they can patch to Hawai'i or a facility by phone. You must let someone know if you have an emergency. Often the escort vessel will not have a ny more luck than you on their radio. If you happen to be in an inversion zone and can not send or receive, the escort will probably be in it too. Just keep trying, don't give upÑever.
Recruit other crew members to help care for the injured or sick. Our guys are sharp and willing to help. It's also a good teaching opportunity and they like to be involved. Snake and Stanley were able assistants when we did skin and ulcer debridement ever y two days the last long trip out. They were really top notch.
Keep yourself fit physically and mentally so you won't go down with anything. Be available on sea and on land, ready to listen, help, treat and comfort. And even if those "Macho" buggers won't usually admit to you, they feel comfortable with their "Doc" a round.