The other day I found a treasure chest of medical research spot on for amateur ocean racers. Researchers of Cambridge University Department of Neurology conducted extensive studies during BT Global Challenge Race 1996-1997 to quantify the incidence and type of medical problem arising during an amateur circumnavigation yacht race. The research paper was published on 2002 in British Journal of Sports Medicine and it is freely available on their archives. Ten years have passed since its publication, but the results can be still taken as a good indication of the type of illness and injury amateur racers may encounter over extensive periods at sea.
The intent of this post is to discuss and reflect medical research results published in a professional medical journal, so please don’t panic if you’re joining an amateur ocean yacht race and worried about your health and safety. As Ocean Volvo Race organisers note in their race rules, ocean going boat racing is hazardous activity by nature, and anyone participating in it should recognise the risk involved. The sea is the same for professionals and amateurs alike, therefore risks need to be acknowledged so that they can be efficiently managed by training and preparation. Please notice that I am not a medical professional (just a humble designer), and therefore I have no credibility or authority what so ever in the health care industry.
Research background
Over 300 amateur sailors participated in the BT Global Challenge Race 1996-1997, where they sailed around the world in 14 identical yachts. The survey by C.J.S. Price, T.J.W. Spalding & C McKenzie set out to quantify the incidence and type of medical problem arising during an amateur circumnavigation yacht race. The data was collected and reported in a confidential medical log by an appointed medic on each boat. All incidences were reported without exclusions. A total average circumnavigation time at sea was 170 days, representing 2380 crew days. From a total of 365 participants, 283 male and 82 female, 140 circumnavigated and the remaining 225 completed between one and five legs of the race. Prior to the race each crew member had to provide a written report from the general practitioner or hospital consultant certifying that they were medically fit to participate. All crew had gone through core sail training before the race, and subsequently trained with individual professional skippers who remained solely responsible for training and safety throughout the race.
Injury vs. illness
A total of 685 cases were reported during six months at sea, of which 43.6% were injuries and 56.4% were illnesses. Authors casually report:
No deaths were recorded, which, in the context of duration and weather conditions encountered, indicated a level of commitment to safety from both organizers and crew.
Thank goodness for that. There were three evacuations, which were all surgical emergencies – a case of haematuria (red blood cells in urine), malaena stool (black, “tarry” feces that are associated with gastrointestinal hemorrhage) and acute appendicitis (subsequently confirmed and appendix removed). Authors point out that two of these evacuations were necessary because of undisclosed information requested in the medical questionnaires completed before the race (crew probably told selectively about their medical conditions), and the third evacuation was for a newly developed diagnosis of appendicitis. This indicates that highly motivated crew may obscure or not relate medical information to the race organiser prior to the race (and suffer the consequences later when things get hairy).
Bruising and burns: breakdown of the injuries
Injuries were the single largest category of incidents totaling 43.6% (299/685) of all cases. Legs 2 and 4 were spent mostly in Southern Ocean where the sea conditions were the roughest, and for that reason these two legs had significantly higher rate of injury than other legs of the race. Across the whole race there was a trend towards higher injury at the beginning than the end of each leg, which suggests learning effect. Variations of weather could have also contributed to this trend. From amateur sailor perspective this makes perfectly sense. Low sailing experience + low confidence + high wind strength + confused sea state = high risk of injury.
The largest category of injuries were abrasions and contusions, totalling 36.1% of the all injuries. Second largest category was burns at 15.7%, which included thermal, rope and sun burn. Fractures made up 11% of the injuries, and they were all closed. During BT Global Challenge 96-97 the crew broke their ribs, clavicles, wrists and tibial plateaus. After being immobilised, these injuries were analgased using medication on board. Lacerations also comprised 11% of the injuries, which boat medics sutured, especially in wet and cold conditions. Damage to cartilage, ligament or tendon made up 9% of the injuries. Head injuries were quite common with 6.7% of the injuries, but no loss of consciousness was documented. Miscellaneous injuries featured foreign body, dislocation, blunt abdominal trauma, effusion/bursitis and crush injuries, totaling 8.4% of all injuries. The authors speculated that a number of factors may have contributed to the relatively high number of injuries, for example the amateur nature of the race (relative inexperience), relatively high incidence of disability aboard one of the boats, night and rough sea conditions. Amateur racers tend to get more serious injuries than professional racing sailors, and based on studies on Whitbread Round the World Yacht Race 97-98, the authors suspect that this difference may be because of enhanced balance, optimal physical fitness and sharper instinctive type reflexes of the professional racing sailors.
Danger areas on an ocean going race yacht are foredeck, galley, winches and helm. Generally helm is not considered as a high risk position on round the cans racing and onshore races, as mentioned in another excellent paper about epidemiology of injuries and illnesses in America’s Cup yacht racing (published 2006). However in offshore races helm is exposed to elements and suffers from high speed volumes of spray while making considerable physical effort steering the boat in heavy seas. There is correlation between the type of injury and a position on the boat in match racing such as America’s Cup, but the results cannot be directly applied to amateur ocean racing (different level of sailing experience, length and intensity of the race and weather conditions). However it might be interesting to know that sailing injuries sustained by professionals were impact with boat hardware (15%), specific overuse (5%), pulling/lifting sails (5%), sustained posture (3%) and grinding (2%). Rest of their injuries were training injuries (34%), combination of sailing and training injuries (24%) and other (13%). I’ll get back to this research in more detail some later day, there’s lots of good information to digest. Until then: Bowmen – mind everything on the foredeck, grinders – watch those arm joints, helmsmen and trimmers – rest your necks!
Means to reduce risk of injury
- Thermal burns: waterproof clothing should be worn in the galley while cooking.
- Sun burn: Wear high SPF sun cream and clothes that have been specifically treated for UV protection. Avoid direct sunshine where possible. (This point is a combination from various sources, not only the research paper.)
- Rope burns: Wear sailing gloves when handling rope under high tension, e.g. when trimming spinnaker. Authors point out that the gloves designed to give maximum dexterity provide inadequate protection against cold. (And there are Clipper skippers who swear by name of fleece lined marigolds when helming in cold weather – they are gloves that professional fishermen use.)
- Wear knee pads. Bursitis in the lower limb may be prevented by additional padding within foul weather salopettes.
- People with pre-existing joint problems: Wear supports to prevent further injury. In the BT Challenge 96-97 the main problems in the lower limb were knee injuries comprised of ligament, cartilage, or cruciate damage, and authors suspect that some of these injuries in participants with pre-existing joint problems may have been prevented with knee supports.
- Head injuries: Watch out for moving spars, the boom, spinnaker or jockey poles, flagging clews or other loose parts. Authors suggest wearing protective headgear where necessary. Stay away from Milton-Keynes!
Tummy trouble and spotty bottoms: breakdown of illnesses
Stomach and intestine problems (gastrointestinal and renal tract) were the largest contributor making up 22.5% of all illnesses, including the three surgical emergencies which were all evacuated during the races. Cases under this category were gatroenteritis (inflammation of the stomach and intestines, typically resulting from bacterial toxins or viral infection and causing vomiting and diarrhea), indigestion and gastritis (inflammation of the lining of the stomach). Additionally there were cases of constipation, perianal pain / haemmorrhoids, urinary tract infections, inguinal hernias, one complication of previous abdominal surgery and non-specific abdominal pain. One boat had an epidemy of gastroenteris, most likely caused by contamination of their water supply.
Dermatological conditions (21.2%) were boils, “gunwale” bottom and eczema, all which were treated with basic hygiene methods (which are often lacking on boats), oral antibiotics, and/or topical steroid ointment. (For the curious readers: Gunwale bottom, aka gunwale bum, spotty body, spotty botty, yotty botty, barnacle butt, skipper’s seat etc. is a rash on the rump caused by spending too much time in wet foul weather gear and sitting on a wet deck.) Skin conditions were very common, and most likely a result of a combination of heat, damp, salt encrustation (in wrist and neck seals of foul weather gear) and oilskin chaffing. Lack of fresh water facilities (one shower a week), crowding and lack of personal hygiene were contributing to the problem.
Ent/flu/respiratory cases made up 18.9% of cases, and most of them were upper respiratory tract infections. Additionally there were cases of middle ear infection and earwax. Seasickness accounted for 15.5% cases, and authors suspected that this category was probably underestimated and hence mild symptoms were not reported or considered as a medical case. It was observed that most crew acclimatised to motion within 72 hours. Seasick crew has higher risk of dehydration, hypothermia and possible injury. Female crew and those who had migraine at sea were more likely to get seasick. Seasickness and hypothermia often go hand in hand, however no cases of significant hypothermia were reported. Authors suspect that mild hypothermia went unreported based on verbal reports from crew members. Each crew member was provided with a set of Gore-tex offshore foul weather gear, but informal reports suggested that it was not sufficient to maintain dryness in heavy weather, especially in the foredeck. (Clipper participants should notice that the brand of the BT Challenge gear is not mentioned. Also the data is from year 1996 – technical clothing must have advanced since then. It is recommended by Henri Lloyd and Clipper race organisers that the round the world crew would bring a second set of foul weather gear.)
Neurological problems (4.4%) were mainly headaches including migrane, one posterior interosseus nerve lesion (that is a nerve in the forearm) from a flogging sheet while tacking – this patient was unable to complete the race. Additionally there was a case of benign positional vertigo following head injury and one collapse of unknown cause, which was several months later diagnosed as intracerebral pathology. One psychiatric case of “deck fright” emerged following a heavy storm in the Southern Ocean, which was characterized by fear of being on deck especially at night. This case was treated with a short course of diazepam and gradual reintroduction of general boat duties. This crew member left the yacht at the next port. Psychological cases were very rare, and therefore it is impossible to draw conclusions about the correlation of weather, personality and a presence of a sympathetic medic. Authors acknolwedge that symptoms such as fatigue may be a manifestation of psychosomatic illness, and that in contrast with professional sailors, amateur crew members may have had differing attitudes and responses to certain situations at sea.
Dental problems (4.1%) were mostly related to gingivitis (inflamed gum) or decay. Dental injuries were temporarily repaired using filler. Eye complications (3.6%) were infectious conjunctivitis (infection of the outermost layer of the eye and the inner surface of the eyelids), issues caused by contact lenses, dry eyes and styes. Crew reported sore eyes caused by high velocity salt spray, particularly when helming. The remaining miscellaneous cases (9.3%) included malignant melanoma, idiopathic oedema (fluid retention with unknown cause), drug reaction, phlebitis (vein inflammation) and four amputation stump/sinus infections on the boat with disabled crew.
How to be healthier on board
- Wear effective sunglasses to protect eyes.
- Helmsmen require visors or goggles for protection from high velocity spray.
- Visit a dentist before embarking to an ocean race. Or if you prefer, we can administer temporary fillers with clove oil and chewing gum! (That’s a hot tip from a dentist who used to serve in the army.)
- Reduce risk of hypothermia by wearing appropriate clothing and layering system for protection against cold and wet.
- Drink enough liquids to avoid dehydration, especially in hot weather, when seasick or hit by a stomach bug.
- Take multivitamin tablets with minerals in them. Extra nutrition is required on board to supplement dry and tin food. Water makers produce clean sweet water that does not have the same minerals that the shore water filtered through sediments, therefore mineral supplements are required to maintain general well-being. (This tip is from Clipper race skipper.)
- Sleep when you can. Downtime of sick and injured crew places strain on fit members especially in heavy weather. This may lead to fatigue and ultimately exhaustion. It is extremely important that every crew member will get enough rest, but ultimately it is down to skippers how they manage watches and make sure that every crew member has equal opportunity to recover.
- Take care of your personal hygiene. Use wet wipes when showers get scarce, and keep your nether regions dry and clean! (One professional sailor has mentioned talcum powder as one method of keeping skin dry. It works the same for buttocks and feet.)
- Female crew needs to plan how to manage periods over the course of the race. This is entirely personal topic directly linked to one’s medical issues, strength of the period flow etc, therefore general advice is difficult to give (and even irresponsible). Please consult your general practitioner! Some female crew may be happy to do nothing and just deal with menstruation as it happens naturally. Some female crew of BT Global Challenge 96-97 opted for continuous use of the contraceptive pill, hence suppressing the normal menstrual flow for each leg of the race. My GP has mentioned coil as an option for women who have given birth, and also some contraceptive pills that suppress periods for 3 months at a time. As said – consult your own GP!
- Be healthy already when you get on board. Stress-free individuals in good physical shape are more resistant to ailments such as common cold.
Further reading for inquisitive minds
Further research, thoughts, comments anyone?
