Dr Iona Taylor / Emergency Medicine SHO / South Wales
When Iona Taylor set off on her transatlantic voyage as Watch Leader on a 72 ft sailing yacht, she had little idea of the challenges that lay ahead for her and the crew. Weather and mechanical faults blighted their first attempts to make progress, returning them to shore twice. Subsequently, an unexpectedly unwell crew member required Iona to step up and manage and coordinate medical care, made specifically testing by their remote location, limited resources and challenging seas. Here, she recounts her journey, the challenges she faced, and lessons learned along the way.
The Atlantic Rally for Cruisers
Every year over 300 boats rock up in Las Palmas, Gran Canaria to take part in the annual ‘Atlantic Rally for Cruisers’ (ARC): a race, rally or cruise across the Atlantic for the novice or experienced sailor. This year, I participated as one of two Watch Leaders onboard a 72 ft yacht, alongside a professional skipper and mate, and twelve amateur paying crew members. This was a commercially run, unrestricted category zero yacht designed to face and withstand all elements. The medical supplies must conform to strict criteria and, alongside crew medical proformas, are checked prior to every offshore passage.
The crossing
Our ‘once in a lifetime’ Atlantic crossing started like a fairy-tale story with pods of dolphins lighting up the phosphorescence. We were way out in the front of the fleet and blissfully unaware of what was in store for us. After only three days, things started to go slightly downhill as our first issue reared its weary head: a key structural element holding our mast started to split, forcing us to retire from the racing division and head swiftly to the closest landfall for urgent repairs.
The repair was unfortunately faulty and after sixteen hours we were faced with an uncomfortable motor back upwind in heavy weather and big waves to get the whole system replaced. Even after this disheartening start and the loss of a few crew members along the way (retired due to personnel reasons and time constraints, not lost overboard), we finally left land ten days after our initial start, with a powerful optimism to cross this ever-expanding ocean, and the promise of rum on the other side. For the most part (of our now third attempt at crossing) we were blessed with steady north easterly winds, beautiful blue skies and great sun-bathing weather. Our progress was good, and morale was on the rise.
By day five, our luck started to run out yet again, this time in the form of an unwell crew member. He complained he had been feeling slightly under the weather (no pun intended) during his night watch. We agreed it was most likely due to the scorching hot temperature of the previous day and planned to see how he was feeling after some rehydration and time in the shade. Unfortunately, however, I was woken from my off-watch sleep six hours later to be faced with the unmistakable signs of an acute lower limb cellulitis, smack bang in the middle of the Atlantic Ocean. After consultation with the skipper and email communication with MRCC UK (British coastguard who provide offshore medical advice to British flagged vessels) we started an initial course of oral erythromycin. This proved futile given the severity of his infection and we promptly had to escalate treatment to IV benzylpenicillin.
The reality
As easy as this scenario would be to manage on-land, the reality, in this setting, was a completely different ball game. The obstacles we faced fell into three categories:
The ‘who, what, when, where, and why’
The overall responsibility for medical care onboard legally lies with the skipper (when a doctor is not officially employed onboard). In this scenario, I was asked by the skipper to be the primary provider of care. I had telecommunication support available to me provided by the coastguard in the UK and Martinique (our closest landfall and, of course, French speaking). The skipper and I discussed our limitations in effectively and safely managing the patient in the non-sterile, unstable environment on board the yacht, and decided that ongoing treatment on board was likely going to be challenging.
We had several theoretical evacuation options including a helicopter transfer, transfer onto a military vessel or a larger commercial vessel with better medical facilities. Unfortunately, we were six days away from being within helicopter range for a retrieval. There were also no military vessels in the area, therefore our only other evacuation option was to transfer onto another commercial vessel. It was decided that given the significant risks involved with a transfer, the fact that the patient’s condition was currently stable and with no guarantee of better treatment facilities at the other end, the best option was to continue treatment onboard with regular review.
The medical kit
Whilst alongside in Gran Canaria, the medical kit initially appeared reassuringly comprehensive and extensive, but its limitations became more apparent throughout its use mid voyage. Even the insertion of the first cannula was a memorable event on the downhill side of an unforgettably large wave. Issues began to arise whilst drawing up and mixing the antibiotics for injection. It turns out that cheap plastic syringes do not stand up well to the friction of mixing solutes, and with a limited range of syringes available, each injection was given via 5 x 2ml boluses to try to preserve the remaining stock.
With the injecting routine down to a fine art, the day to day maintenance of the line became the next difficulty. With temperatures below deck reaching 32 degrees and the sea state building, keeping the line clean, active and dressed became near impossible. The sticky back of a Tegaderm dressing supplied little resistance to the inevitable layers of sweat and no amount of duct tape and cling film kept it in place for long. With the constant attempted adjustments and reinsertions, I set up a regular IV infusion for boluses to ensure ongoing patency of the line and to preserve our diminishing supplies. Unfortunately, despite our best efforts, the first line (a nice friendly pink cannula on the dorsum of the hand) lasted less than twenty-four hours. The second cannula was therefore upgraded to a grey (with our total stock of 2 pink and 2 grey) located in the antecubital fossa with parts of a sawed-up broom handle as a make shift splint secured with a washing up sponge, yet more duct tape, cable ties and a few towels for comfort. Even with extremely careful rationing, our supplies of needles, syringes, alcohol wipes, gauze, cannulas, sterile water and saline started to run worryingly low.
Sailors always pride themselves with their ability to cope and survive in extreme situations, but even with the best improvisation, it is not possible to create sterile medical supplies, and once again we had to call for support. By contacting the race headquarters, within thirty-six hours we were able to achieve an alongside transfer of equipment with another vessel from the same rally. The pure adrenaline and excitement of receiving a sterile dressing pack and flare box filled with needles and syringes more than compensated for the stormy conditions and difficulties of the transfer itself. These resupplies gave us an extra day of IV treatment before we had exhausted our supply of penicillin. As the patient was showing significant signs of improvement and we were now only two days offshore, we were advised by our medical support to complete the last two days of our journey with once daily intramuscular Ceftriaxone. Without any IM (blue) needles I was restricted to an overgenerous green or inadequate orange. Given the persistent two metre swell and unstable conditions I decided the safest was a whole-hearted insertion of an orange. This whole series of events was unfortunately performed within our one and only spacious area around the saloon (living room) table, with some procedures occurring amidst an array of breakfast cereals or midnight watch change, attempting as best we could to preserve the patient’s dignity and others’ appetite.
Mid ocean isolation
When practising in a large medical multidisciplinary facility you bounce ideas of your colleagues, seek reassurance over a management plan and chat about concerns over a mid-morning coffee. When isolated in the middle of an ocean with professional sailors and a selection of business men there is little medical support immediately available. I was hugely thankful for our midday satellite emails and daily satellite calls providing brief spouts of reassurance, but for the remaining twenty-three hours every day, I could not have felt more alone. The development of some local lymphadenopathy suddenly appeared suspiciously like a groin abscess, and the erythema from the cannula site looked suspiciously like a line infection. Not to mention the rapidly developing oedema caused by the cellulitis making me question the possibility of a DVT. In some respects, it seemed isolating and yet in others, sharing a sailing yacht with ten other people all struggling to cope with the psychological demands of managing care for an unwell crew member, at times it felt crowded and as if there were nowhere to hide.
Conclusions
This ordeal was a demonstration of the camaraderie and strength that can be sourced from a team of complete strangers under challenging circumstances.
Medicine outside of the hospital environment will always churn up unexpected challenges and provide you with new priorities in care and safety. Working as a lone medical practitioner you are wholly reliant on your own skill set for clinical decision making and prescribing and administration of appropriate drugs. You must engage your initiative to provide safe and effective care in resource-limited situations and know when and how to call for help.
For anyone venturing on an expedition as the medic or as a crew or team member I’d advise to make sure you are familiar with your kit and your limitations, with a good understanding of the environment you are entering in to and methods of escape if necessary. But most importantly, to enjoy every single moment of it: the good, the bad and the ugly.
