Medical Care at Sea Explained

Prerequisites

This is a Yachtmaster Ocean lesson. Before starting you should:

Hold the Yachtmaster Offshore Certificate of Competence (or equivalent).
Hold a current first aid certificate (RYA First Aid or an equivalent one-day course). A valid first aid certificate is required for a commercial endorsement, and for ocean passages a more advanced course is strongly recommended: the STCW Elementary First Aid, or better, the MCA Medical First Aid or Medical Care Aboard Ship (Proficiency in Medical Care) courses.
Be familiar with the primary survey (DR ABC), CPR, recovery position, bleeding control, shock, hypothermia and seasickness from the RYA First Aid syllabus.
Know how to make a Pan-Pan Medico or Mayday call and how to contact a Coastguard/MRCC (SRC syllabus), and how long-range communications work (see the Long-Range Communications lesson).

This lesson is not a substitute for hands-on medical training. Its purpose is to give the ocean skipper the knowledge to prepare, to make good decisions and to work effectively with a doctor ashore.

Learning Objectives

By the end of this lesson you will be able to:

Explain how medical care on an ocean passage differs from coastal first aid and what extra competence the skipper needs.
Assemble, store and manage an ocean medical kit and its records.
Prepare for and conduct a telemedical consultation with a TMAS doctor, using a structured report.
Manage common ocean problems: wound infection, dental emergencies, seasickness and dehydration, trauma and psychological crises.
Apply clear criteria to decide between treating aboard, diverting and requesting evacuation.
Recognise and manage the major medical emergencies (chest pain, stroke, anaphylaxis, diabetic emergencies, sepsis, acute abdomen) until help is reached.
Prepare a casualty for helicopter lift or transfer to another vessel.

RYA Yachtmaster Ocean syllabus items covered: medical care at sea for the ocean skipper - the composition and management of the medical kit; telemedical advice and radio medical procedure; assessment, monitoring and recording of a casualty; treatment of the common and serious illnesses and injuries met on long passages; dental and psychological problems; and the decision to treat, divert or evacuate. It extends the RYA First Aid certificate (a prerequisite for the practical exam) and the Offshore lesson on medical emergencies.

What the examiner expects: in the Ocean oral you may be asked "What would you do if a crew member develops severe abdominal pain 800 miles from land?" or "What is in your medical kit and who would you call?". A sound answer follows the structure DR ABC, vital signs, call TMAS with an SBAR report, treat as advised, record, re-assess, then decide on diversion or evacuation. The examiner wants a calm, organised, safety-first answer, not a diagnosis.

Important: doses and drug names in this lesson are for orientation and exam preparation. At sea always follow the label, the advice of your TMAS doctor and your own training. Know your crew's allergies before giving anything.

How Ocean Medicine Differs

On a coastal passage, first aid means keeping a casualty alive for an hour or two until a lifeboat or helicopter arrives. On an ocean passage, the nearest hospital may be a week away and no helicopter can reach you. The diagram below shows how the skipper's role expands.

Advanced first aid beyond coastal level: coastal basic life support and bandaging, ocean-level suturing, IV access and pharmacology, and critical triage, evacuation decisions and telemedicine

The ocean skipper must be able to:

stabilise injuries and illnesses for days, not hours;
give medication, including prescription drugs, safely and under medical advice;
monitor a patient over time, recording vital signs and changes;
coordinate with a telemedical doctor ashore and, when necessary, a Rescue Coordination Centre;
decide whether to continue, divert or seek evacuation.

Prevention matters most of all. Most medical problems at sea come from falls, winch and boom injuries, burns in the galley, cuts that become infected, dehydration and seasickness. A safe, tidy deck, clipped-on crew, galley straps and good hygiene prevent far more harm than any medical kit can treat.

The Ocean Medical Kit

What to carry

A UK commercially coded yacht on an ocean passage (Category 0 or 1) must carry the medical stores specified for Category A vessels under MSN 1768 (or its current replacement). A private yacht should use this as its guide. The diagram below shows the main categories and how to manage them.

Medication inventory management: categories, storage rules, quarterly audit cycle and essential documentation for each container and an administration log

Main categories:

Category	Examples	Purpose
Antibiotics	Co-amoxiclav, a quinolone such as ciprofloxacin, a macrolide for penicillin-allergic crew, metronidazole	Wound, dental, chest, urinary and abdominal infections
Analgesics	Paracetamol, ibuprofen, codeine-based, stronger opioids (controlled drugs, only where licensed and trained)	Pain relief stepped up as needed
Anti-emetics	Prochlorperazine (including buccal tablets), ondansetron, injectable or suppository forms	Vomiting, seasickness, preventing dehydration
Allergy	Antihistamines, adrenaline auto-injectors	Allergic reaction, anaphylaxis
Wound care	Irrigation syringes, sterile saline, wound closure strips, tissue adhesive, suture kit, dressings, burn dressings, cling film	Cleaning and closing wounds, burns
Trauma	Tourniquets, haemostatic dressings, SAM splints, cervical collar, triangular bandages	Bleeding and fractures
Dental kit	Temporary filling material (e.g. Cavit), clove oil, dental mirror	Lost fillings and broken teeth
Fluids	Oral rehydration salts; IV fluids and giving sets only if someone aboard is trained	Dehydration
Monitoring	Thermometer, blood pressure cuff, pulse oximeter, stethoscope, torch, observation charts	Vital signs for TMAS
Reference	Ship Captain's Medical Guide (MCA) or equivalent	Step-by-step guidance

Ask your GP or a specialist travel or maritime medical supplier to help with prescription items, and make sure crew with their own conditions carry more than enough of their own medication, in two separate places aboard.

Storage and records

Waterproof, clearly labelled containers, organised by category. Dosage instructions printed or laminated inside the lid.
Expiry dates visible. Cool, dry stowage; some drugs degrade quickly in tropical heat.
Controlled drugs locked away, with a register.
An administration log: date, time, patient, drug, dose, route and effect, for every dose given. TMAS doctors will ask what has been given and when.
An audit cycle: a full check before departure, quarterly inspection, restock after every use, replace expired items.
A confidential crew medical information sheet for each person: conditions, medication, allergies, blood group if known, next of kin.

There is no pharmacy at sea. What you carry is all you have.

Telemedical Advice (TMAS)

What TMAS is

Every coastal state provides a Telemedical Maritime Assistance Service (TMAS): free, 24-hour access to a doctor experienced in maritime medicine. You do not need to be a commercial vessel to use it.

UK: contact HM Coastguard (any MRCC, or by satellite phone to MRCC Falmouth for vessels far offshore), who connect you to the duty TMAS doctor (Queen Alexandra Hospital, Portsmouth).
France: CCMM, Toulouse (via the French MRCC/CROSS).
Italy: CIRM, Rome, which also offers international radio medical advice to vessels of any flag.
Elsewhere: contact the MRCC responsible for the area where you are; it will connect you to the appropriate TMAS. The Admiralty List of Radio Signals (Vol 1) lists the services.

The communication route can be HF/MF radio (via a coast station), satellite phone, or satellite email for photographs. The diagram below shows the link.

Telemedicine consultation via satellite: patient and skipper aboard pass vital signs and symptoms to a 24/7 TMAS physician, who gives a treatment protocol and evacuation advice

Preparing the call

Gather information before you call:

Vessel name, call sign, position, course, speed, destination, distance and time to nearest port.
Patient: age, sex, weight, medical history, regular medication, allergies.
What happened, when symptoms started, how they have changed.
Vital signs: pulse rate, breathing rate, blood pressure, temperature, oxygen saturation, level of consciousness (AVPU), recorded with the time. If possible take two sets 15 minutes apart, so the doctor can see the trend.
What you have done so far and what drugs have been given (from your administration log).
What medical stores you have aboard (have the list to hand).

Making the report

Use a structured format such as SBAR:

S – Situation: "I have a 45-year-old male crew member with severe abdominal pain for 6 hours."
B – Background: relevant history, medication, allergies, what happened.
A – Assessment: your findings and vital signs, and what you think is going on.
R – Request: what you need ("advice on treatment and whether he needs evacuation").

Write down the advice, read it back, agree when you will next report, and follow the protocol exactly. Record times and the patient's response. If the doctor advises evacuation, the TMAS and MRCC coordinate: you will be told what is possible and what to do while waiting.

Always call TMAS early, before making major treatment or evacuation decisions. It is free and they would rather hear from you sooner.

Common Ocean Medical Problems

Wound infection

In warm, salty, humid conditions, even small cuts can become infected within hours. The diagram below shows the escalation sequence.

Prevent: clean every cut immediately with plenty of clean drinking water, cover it, and keep it dry.
Recognise infection: increasing redness, swelling, heat, pain and pus, then fever.
Irrigate: flush with large volumes of clean freshwater or saline under pressure from a syringe to remove debris and bacteria. This is the most important step.
Remove dead tissue and debris carefully with sterile instruments if trained; apply a clean dressing, and change it daily.
Start antibiotics early on TMAS advice, rather than waiting until the infection is obvious and spreading.
Escalate to TMAS urgently if redness is spreading, red streaks run up the limb (lymphangitis), the temperature exceeds 38.5°C, or the patient becomes unwell. These are signs of a spreading infection that can become life-threatening sepsis.

Mark the edge of the redness with a pen and record the time, so that you can tell whether it is spreading. Check temperature every 4 hours.

Dental emergencies

Toothache, lost fillings and abscesses are common on long voyages and can be disabling. The diagram below shows the decision flow.

Dental emergency procedures: abscess symptoms, temporary filling with Cavit, pain control with clove oil and analgesics, antibiotics if infection spreads, extraction as last resort, and documentation

Lost filling or broken tooth: dry the cavity and pack it with temporary filling material. Covering exposed dentine stops much of the pain.
Pain: clove oil (eugenol) on a cotton bud applied locally; regular paracetamol and ibuprofen together.
Abscess (throbbing pain, swelling of the gum or face, fever): antibiotics on TMAS advice; warm salt-water mouthwashes. Spreading facial swelling, difficulty swallowing or breathing is an emergency.
Extraction is a last resort only for those trained and equipped.
Prevention: every crew member should have a dental check-up before an ocean passage.

Record all treatment for the dentist ashore.

Seasickness and dehydration

Seasickness is not trivial on a long passage. Prolonged vomiting causes dehydration, exhaustion and hypothermia, and a seasick crew member can become a casualty. Give prevention (e.g. cinnarizine, hyoscine patches) before departure; once vomiting starts, oral tablets are not absorbed, so use buccal (gum-dissolved), suppository or injectable forms on medical advice. Give small, frequent sips of oral rehydration solution. Watch for signs of serious dehydration: no urine for 8 hours or more, very dark urine, dizziness on sitting up, confusion. These need TMAS advice. IV fluids are a treatment for those specifically trained, carried out under a doctor's direction.

Trauma

Boom strikes, falls down the companionway and winch injuries are typical. Control bleeding with direct pressure (a tourniquet for catastrophic limb bleeding, noting the time applied), immobilise fractures with a SAM splint in the position found, and monitor for shock. After any head injury monitor consciousness, pupils and behaviour every hour at first and then every 2 hours for at least 24 hours; deterioration needs urgent TMAS advice.

Psychological crises

Isolation, confinement and stress are real mental health risks on ocean passages. The diagram below summarises psychological first aid.

Psychological first aid: recognise withdrawal, irritability, sleep and appetite changes and anxiety; listen, reassure, maintain routine, encourage rest and food, reduce stressors; escalate to TMAS for suicidal ideation, self-harm, psychosis or breakdown

Recognise early signs: withdrawal, irritability, poor sleep, loss of appetite, anxiety or panic.
Respond: listen without judgement, reassure, keep the routine going, encourage rest and food, reduce stressors (for example a change of watch partner).
Escalate to TMAS if there is any suicidal talk, self-harm, loss of touch with reality (psychosis, delusions) or complete breakdown. Keep the person under supervision, remove means of harm (knives, medication) and consider diverting.
Prevent: fair watch rotation, shared meals, respected private space, a skipper who checks in daily and deals with conflict early (see the Extended Crew Management lesson).

Assessing and Monitoring a Casualty

Primary and secondary survey

The primary survey from first aid training is unchanged, and applies even with TMAS advice available: DR ABC (Danger, Response, Airway, Breathing, Circulation), with catastrophic bleeding treated first. Once life-threatening problems are controlled, carry out a secondary survey: a head-to-toe examination for injuries, with a note of everything found, then a full history (AMPLE: Allergies, Medication, Past medical history, Last meal, Events leading to the problem).

Normal adult vital signs

Vital sign	Normal resting adult	Concern
Pulse	60 to 100 per minute	Over 120 or under 50, or irregular
Breathing rate	12 to 20 per minute	Over 25, or under 10, or laboured
Systolic blood pressure	100 to 140 mmHg	Under 90 mmHg, or falling
Temperature	36.0 to 37.5 C	Over 38.5 C, or under 35 C
Oxygen saturation (SpO2)	95 percent or above	Under 92 percent
Consciousness (AVPU)	Alert	Responds only to voice, pain or unresponsive

A single set of readings tells you less than the trend. Take readings every 15 minutes in an acute problem, every hour or every 4 hours in a stable one, on a chart with the times. A pulse rate higher than the systolic pressure (a high "shock index") is a warning of serious bleeding or sepsis. Pulse oximeters read poorly with cold fingers, nail varnish and movement: warm the hand and repeat.

Serious Medical Emergencies at Sea

For all of the following, the sequence is the same: primary survey, call TMAS early, treat on advice, record, monitor, decide on diversion. The points below are the initial actions only.

Chest pain and suspected heart attack

Crushing central chest pain, spreading to the arm or jaw, with sweating, breathlessness or nausea, is a heart attack until proved otherwise. Sit the casualty in the position of greatest comfort (often half sitting), keep them calm and still, and call TMAS. Typical initial treatment (given only if the casualty is not allergic) is aspirin 300 mg chewed, and, if prescribed or on advice, glyceryl trinitrate (GTN) spray or tablet under the tongue, provided that systolic blood pressure is above 90. Record pulse, breathing, blood pressure and SpO2 every 15 minutes, be ready for CPR and a defibrillator if carried. Chest pain with cardiac risk factors always justifies evacuation planning.

Stroke

Use FAST: Face drooping, Arm weakness, Speech difficulty, Time to call. A stroke is an emergency in which time matters, but on an ocean passage nothing can be reversed at sea. Keep the casualty comfortable, check blood sugar if you can (low sugar can mimic stroke), keep the airway clear, give nothing by mouth if swallowing is poor, and call TMAS to discuss diversion.

Anaphylaxis

Severe allergy (to food, stings, drugs) causes swelling of the face and throat, wheeze, collapse and rash. Adrenaline is the first-line treatment: an auto-injector or 0.5 mL of 1 in 1,000 adrenaline (500 micrograms) into the outer thigh muscle for an adult, repeated after 5 minutes if there is no improvement. Lie the casualty flat with the legs raised (or sitting if breathing is difficult), and call TMAS. Antihistamines are secondary. Symptoms can return hours later, so continue to monitor for at least 24 hours.

Asthma

Mild attack: the casualty's own salbutamol inhaler, 2 to 10 puffs through a spacer, repeated every 10 to 20 minutes, sitting forward. A severe attack (cannot speak a full sentence, pulse over 110, breathing over 25 per minute) needs prompt TMAS advice and probably steroid tablets from the kit. Carry spare inhalers.

Diabetic emergencies

Low blood sugar (hypoglycaemia): confusion, sweating, shakiness, aggression. Give 15 to 20 g of fast sugar (glucose tablets, sugary drink, honey) and repeat after 10 minutes if no better. If the casualty is unconscious, place in the recovery position, give nothing by mouth, and call TMAS: glucagon injection may be in the kit. High blood sugar (diabetic ketoacidosis) gives thirst, passing a lot of urine, vomiting and rapid breathing, with fruity breath: it needs insulin and fluids and is serious. Diabetics on a passage should carry double their normal supplies, a glucose meter, and tell the skipper their routines before sailing.

Sepsis and infection

Sepsis is the body's overwhelming response to infection and is a life-threatening emergency. Look for a source of infection (wound, chest, urine, abdomen) with fever or low temperature, a fast pulse and breathing, low blood pressure, confusion and mottled skin. Early antibiotics and fluids make the difference, so call TMAS at once and start antibiotics as advised, plus oral rehydration. Urinary tract infection (burning, frequency, lower abdominal pain) is common, especially in women, and is treated with antibiotics and plenty of fluid. Fever with flank pain or rigors suggests the kidney is involved and needs urgent advice.

Abdominal pain

Pain that starts around the navel and moves to the lower right abdomen, with fever, loss of appetite, nausea and tenderness when the abdomen is pressed and released, suggests appendicitis. Severe, persistent or worsening abdominal pain with a rigid abdomen, vomiting or black or bloody stools is an emergency. Give nothing to eat or drink, give analgesia on advice, and arrange evacuation. Do not give laxatives.

Burns, scalds and environmental injury

Burns: cool for 20 minutes under running cool water, remove rings and watches, cover loosely with cling film or a non-stick dressing. Large burns, burns of the face, hands or genitals, and any burn with breathing difficulty need TMAS at once. Prevent shock with fluids.
Hypothermia: shelter, remove wet clothes, insulate (including from the cold deck), warm drinks if conscious, handle gently. Severe cases may need hospital care.
Heat exhaustion and heat stroke: in the tropics, rapid pulse, headache, cramps and weakness can progress to confusion and a temperature above 40 C (heat stroke, a life-threatening emergency): cool by any means (wet sheets, fanning, ice packs), give fluids, and call TMAS.
Sunburn and dehydration: prevent with shade, hats, high-factor sunscreen and regular drinks.
Marine stings and bites: rinse jellyfish stings with seawater (or vinegar for box jellyfish), do not rub; for fish spines, immerse in hot water (as hot as bearable, for 30 to 90 minutes) to relieve pain. Ciguatera fish poisoning from large reef fish can cause vomiting, tingling and temperature reversal: ask locally which fish are safe.
Fish hooks: push the point through and cut off the barb, or use the "string pull" method; clean and dress.

Fractures, head and spinal injuries

Immobilise the injury in the position found, splint above and below the break, check circulation beyond the splint, and treat for shock. An open fracture needs a clean dressing and antibiotics on advice. For suspected spinal injury on a small boat, minimise movement; if you must move the casualty, log-roll with the head and neck supported. A casualty who was knocked out, vomits repeatedly, has a worsening headache or drowsiness, or fluid from the nose or ear after a head injury needs urgent advice.

Drowning and near-drowning

A casualty recovered from the water, even if apparently recovered, may develop delayed breathing problems from water in the lungs. Keep them under observation for at least 24 hours and discuss with TMAS.

Cardiopulmonary Resuscitation at Sea

CPR is the same as ashore, but the circumstances make it harder. On a heeling or moving boat, lay the casualty on the cabin sole or cockpit floor, wedge yourself, and call for help from other crew immediately.

Check for danger, response and normal breathing (no more than 10 seconds).
Call a Mayday or Pan-Pan (on DSC, then voice) and ask another crew member to do so, and to fetch the defibrillator if carried.
Begin 30 chest compressions at 100 to 120 per minute, 5 to 6 cm deep, on the lower half of the breastbone, then 2 rescue breaths (use a pocket mask) if trained and willing. For a drowned casualty give 5 initial rescue breaths first.
If an AED is carried, switch it on and follow its prompts; dry the chest first.
Change the person doing compressions every 2 minutes. On a small crew, you may be exhausted in 10 minutes: this is why you ask TMAS early about when to stop.
Stopping is a decision made with TMAS: usually when the casualty recovers, when a professional takes over, or when all rescuers are exhausted, or after prolonged efforts without response.

Worked Example: Chest Pain on Day 14

A 58-year-old man on a 2,800-mile crossing has felt tight central chest pain for 25 minutes, with sweating, nausea and pain down the left arm. He takes blood-pressure tablets and has no allergy.

Danger and response: he is awake and alert. Sit him in a half-sitting position with his back against the cabin side, and ask a crew member to start a chart.
Vital signs: pulse 96 and regular, breathing 22, BP 142/88, SpO2 95 percent, temperature 36.8 C.
Treat: aspirin 300 mg chewed (no allergy), reassurance, loosen clothing. GTN spray is not in his kit and he has none of his own.
Call: DSC distress is not needed yet; make an urgent Pan-Pan Medico call, or phone MRCC Falmouth by satellite phone and ask for the TMAS doctor. Give an SBAR: "I have a 58-year-old male with 25 minutes of central crushing chest pain, history of hypertension, no allergy, 2,800 miles from landfall; request advice and evacuation options."
Advice: the doctor asks for repeat observations every 15 minutes, a second aspirin dose is not needed, keep him still, nothing to eat, and the MRCC begins to look for a nearby ship via AMVER.
Monitor: if the pain eases within an hour and observations stay stable, the plan may be to divert at a gentle speed towards the nearest port while continuing to report. If the pain returns, pulse becomes irregular or he collapses, start CPR and use the AED.

The principle: the skipper treats the immediate problem, calls early, follows advice, and keeps records. It is not the skipper's job to diagnose.

Preparing a Crew Medical Pack Before Departure

A crew medical form for every person, filled in before sailing, including conditions, medication, allergies, blood group, previous surgery and a named next of kin.
A pre-voyage review with each person who has a chronic condition (diabetes, asthma, epilepsy, heart disease, anticoagulants). Agree what they will carry and what the skipper needs to know.
At least two crew who have completed a first aid course; ideally the skipper has the MCA or RYA Sea Survival and a medical care course.
Dental, eye and travel-health checks completed.
A laminated action card next to the radio with the TMAS contact route, satellite phone numbers, and the SBAR template.
A medical log on a clipboard in the chart table: observations, drugs given, times, and the TMAS doctor's name.

Medication Safety at Sea

Always ask about allergies first, and check the casualty's own medication for interactions.
Paracetamol: adult dose 1 g every 4 to 6 hours, maximum 4 g in 24 hours. Ibuprofen: 400 mg three times a day with food, avoided in asthma, stomach ulcer, kidney disease and dehydration. Do not give aspirin to children.
Antibiotic stewardship: antibiotics are not for colds or minor wounds that heal well. Start on TMAS advice, complete the full course, record each dose, and watch for allergic reaction (rash, swelling, wheeze), diarrhoea or vomiting.
Opioids and other controlled drugs: carry only if legally allowed and the skipper holds the right paperwork; store locked, with a register of every dose and a witness signature. Some countries ban their import at all, so check before you cross a border.
Keep a written administration log with date, time, patient, drug, dose, route, who gave it, and the effect.
Never give a drug you do not understand: ask TMAS to confirm the dose and route by voice, and write it down.

Evacuation Procedures

Helicopter evacuation

Helicopters from the Coastguard or a military service can reach perhaps 150 to 300 miles from the coast, depending on the type. For a lift, the MRCC will brief you by radio. In general:

Have a summary of the casualty (name, age, condition, drugs, passport and crew list) in a waterproof pouch with the casualty.
Clear the deck, and stow loose gear, sail covers, flags and any free halyards. Lower sails or sail on a steady course, with the wind about 30 degrees on the bow (follow the pilot's request).
Do not touch the winch wire until it has earthed in the sea or on the deck (static electricity).
Do not secure the wire to the boat. Follow the winchman's instructions.
The casualty wears a lifejacket, with a head covering and warm clothes.

Ship transfer

If no helicopter is within range, the RCC may divert a merchant ship. The transfer is made by boat or by lifting a casualty, and is difficult in a seaway. It is the ship's master who decides on the method. Prepare fenders and lines, a lee for the ship, and lifejackets for everyone. A yacht should never come close alongside a large ship in a seaway without a clear plan agreed by radio.

If a crew member dies

This is rare, but the skipper must know what to do: record the time, circumstances and any treatment given, inform the MRCC and the next of kin through them, protect the body from heat and keep it for authorities if the vessel can reach a port within a reasonable time. Burial at sea is a serious decision and must be discussed with the authorities and the family. Support the crew: grief and shock are real problems.

Treat Aboard, Divert or Evacuate?

The skipper makes the final decision, but always with TMAS advice. The diagram below summarises the criteria.

Medical evacuation decision criteria: evacuate now for uncontrolled bleeding, chest pain, stroke, severe head injury, unresponsive anaphylaxis, open fractures or when TMAS recommends; monitor and treat when stable; decision factors and coordination flow

Seek evacuation or urgent diversion for:

uncontrolled bleeding;
chest pain suggesting a heart attack;
stroke symptoms (face drooping, arm weakness, speech difficulty);
severe head injury or reduced consciousness;
anaphylaxis not responding to adrenaline;
open fractures or crush injuries;
suspected appendicitis or other acute abdominal emergency;
any case where the TMAS doctor recommends it.

Monitor and treat aboard where vital signs are stable, bleeding is controlled, minor fractures are splinted, infection is responding to antibiotics, or seasickness and dental pain are controlled, with regular TMAS follow-up.

The decision depends on four factors together: the severity of the condition, the distance to a port with suitable care, the weather, and the crew's capacity to sail the boat and care for the patient.

Mid-ocean "evacuation" usually means transfer to a merchant ship diverted by the RCC (via AMVER or similar), which is itself hazardous in a seaway, or a long diversion. Helicopters only reach within a few hundred miles of land. The coordination flow is: TMAS recommends, skipper decides, MRCC/RCC organises the SAR response, and the crew continues supportive care until handover.

Worked Example: An Infected Hand Mid-Atlantic

Day 9 of a crossing, 1,100 miles from Antigua. A crew member cut his hand on a hose clip three days ago. This morning the hand is red and swollen, there is pus, and he has a temperature of 38.7°C. A red streak runs up the forearm.

Assess: pulse 104, breathing 20, BP 128/80, temperature 38.7°C, SpO2 97%, alert. Mark the edge of the redness and note the time.
Immediate care: irrigate the wound thoroughly with sterile water from a syringe, apply a clean dressing, elevate the arm in a sling, give paracetamol.
Call TMAS via Iridium to MRCC Falmouth: SBAR report, list of antibiotics aboard, allergies (none).
Advice: start a course of co-amoxiclav at the dose specified, re-irrigate and redress twice a day, record temperature 4-hourly, report again in 12 hours or immediately if the redness spreads past the elbow or he becomes confused or breathless.
Record: administration log and observations chart.
Decision: within 24 hours temperature falls and the redness recedes. Continue to Antigua with daily TMAS updates. Had it worsened, the plan was to divert towards the nearest island and ask the MRCC about a ship transfer.

Common Mistakes

Waiting too long to call TMAS, often from embarrassment or a wish not to bother anyone.
Calling without vital signs, or with no record of what drugs have been given.
Inadequate wound cleaning: a dab of antiseptic instead of thorough irrigation.
Expired or heat-damaged drugs, or no list of what is aboard.
Crew members' own medication in one place only, or not enough of it.
Treating anything beyond your training (suturing, IV, extraction) without a doctor's direction.
Ignoring mental health until there is a crisis.
Under-estimating seasickness as a cause of serious dehydration.
Giving a drug without checking allergies or the casualty's own medication.
Failing to take vital signs more than once, and so missing a worsening trend.
Forgetting that one crew member may be the skipper's only help: if the skipper becomes the casualty, the crew must know how to use the radio, the medical kit and the boat.
Neglecting the carers: the person looking after a casualty for days also needs rest, food and watch relief.

Exam Tips

Present the answer as a logical sequence: assess, stabilise, call, treat, monitor, decide.
Name the kit contents by category, and say that the standard to follow is the MCA Category A list.
Quote SBAR and the contents of the call (vital signs, history, drugs given).
Mention prevention (fit crew, dental check, medical forms, safe working) and a crew medical information sheet.
Say that you call TMAS early and follow the advice.
Know the limits of your training: say you would not attempt invasive procedures unless trained and directed by a doctor.

Summary

On an ocean passage the skipper must stabilise, treat, monitor and decide for days or weeks. Prevention and training matter most.
Carry a medical kit to the Category A standard, well organised, with expiry dates visible, a list, an administration log and a regular audit.
TMAS gives free 24-hour medical advice (UK via HM Coastguard). Prepare vital signs and history, use SBAR, follow the advice and record everything.
Irrigate wounds thoroughly and start antibiotics early on advice; spreading redness, red streaks or fever over 38.5°C need urgent TMAS contact.
Manage dental pain with temporary fillings, clove oil and analgesics; seasickness with early prevention and non-oral routes once vomiting.
Recognise and respond to psychological distress; escalate any risk of self-harm.
Evacuation decisions weigh severity, distance, weather and crew capacity: TMAS recommends, skipper decides, RCC coordinates.

Check Your Understanding

Name four extra medical responsibilities an ocean skipper has compared with a coastal skipper.

Answer: Any four of: stabilising casualties for days rather than hours; giving prescription medication; monitoring and recording vital signs over time; coordinating telemedical consultations; deciding whether to continue, divert or seek evacuation; managing psychological crises.

How does a UK yacht obtain TMAS advice, and what does it cost?

Answer: By contacting HM Coastguard (an MRCC, for example MRCC Falmouth by satellite phone or via a coast station on HF), who connects the yacht to the duty TMAS doctor. It is free and available 24 hours a day.

What vital signs should you record before calling TMAS?

Answer: Pulse rate, breathing rate, blood pressure, temperature, oxygen saturation and level of consciousness, with times, ideally two sets to show the trend.

What does SBAR stand for?

Answer: Situation, Background, Assessment, Request.

What is the most important single step in treating a contaminated wound at sea?

Answer: Thorough irrigation with large volumes of clean water or saline under pressure from a syringe, to remove debris and bacteria.

Which signs in a wound infection call for urgent TMAS contact?

Answer: Spreading redness, red streaks running up the limb, a temperature above 38.5°C, or the patient becoming generally unwell.

A crew member has lost a filling and is in severe pain. What can you do?

Answer: Dry the cavity and pack it with temporary filling material; apply clove oil locally; give regular paracetamol and ibuprofen; seek TMAS advice on antibiotics if there are signs of an abscess.

Why may seasickness tablets stop working once a person is vomiting, and what alternatives exist?

Answer: Tablets swallowed are vomited before they are absorbed. Alternatives include buccal tablets dissolved against the gum, suppositories, skin patches and injections, used on medical advice, plus small frequent sips of oral rehydration solution.

List four conditions that normally justify evacuation or urgent diversion.

Answer: Any four of: uncontrolled bleeding; chest pain suggesting a heart attack; stroke symptoms; severe head injury or reduced consciousness; anaphylaxis not responding to adrenaline; open fracture or crush injury; suspected acute abdomen; TMAS doctor recommending evacuation.

What four factors does the skipper weigh in deciding whether to evacuate?

Answer: The severity of the condition, the distance to a port with suitable care, the weather, and the crew's capacity to sail the boat and look after the patient.

A crew member has crushing central chest pain with sweating and nausea. What are your first actions?

Answer: Sit the casualty in a comfortable half-sitting position, keep them calm, check airway, breathing and circulation, record vital signs, give aspirin 300 mg chewed if not allergic (and GTN if prescribed and blood pressure is above 90), call TMAS at once, and prepare for CPR and evacuation or diversion.

Describe the first-line treatment for anaphylaxis aboard.

Answer: Intramuscular adrenaline (an auto-injector or 0.5 mL of 1 in 1,000 into the outer thigh for an adult), repeated after 5 minutes if there is no improvement; lay the casualty flat with legs raised, call TMAS, and monitor for at least 24 hours because symptoms may return.

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