Objective: No studies have been performed on cruising sailors who spend most of the year on offshore cruising sailboats. To gain a better understanding of this population, traumatic events occurring in this group of sailors were studied to define appropriate means of prevention.
Design, setting and patients: Primary care data were collected prospectively using a questionnaire during in-depth interviews by one of the authors (FM) of 100 cruising sailboat crews that called at Martinique between December 2001 and May 2002.
Main outcome measurements: In total, 56 injuries were reported: 20 involved the upper limb, 20 the lower limb, and 7 the head and neck. There were also 19 burns, 11 of which were photoinduced and 8 accidental. There were 16 skin infections, 3 of which were complicated by arthritis.
Results: After analysis, we found that most of these injuries could be prevented if the following recommendations were applied. Wearing shoes would avoid foot injuries. A hatch cover would effectively protect from cranial trauma caused by the boom. To protect from the sun, a bimini top (cover to shield the cockpit) would be most effective. A windlass would avoid hand injuries and acute lower back pain. Lastly, meticulous wound care until complete healing would prevent the common complications of skin superinfections.
Conclusions: Injuries to professional seafarers and ocean racers are well described, but the increasingly growing cruising sailor population has not been well studied. Development of easy and inexpensive worldwide network connection will allow better follow-up of this mobile population.
- sport traumatology
- sailing crew
- offshore cruising
- means of prevention
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With the development of the leisure society, an increasing number of people choose to sail to the Caribbean. This population has been growing since the 1960s, but has not previously been the subject of any medical study.
There is a wealth of published material about the medical care available aboard military, commercial, or fishing vessels,1–10 where medical follow-up is a priority concern. Over the past few years, offshore races have become time-limited media events, which have given rise to some very interesting studies.11–18 In contrast, the few publications that have dealt with pure pleasure sailing have only aimed at assisting the sailor in his role of “doctor”.19–22 We therefore aimed to study a sample of these boating people cruising in the Caribbean waters.
Between December 2001 and May 2002, every cruising sailboat arriving in Martinique was contacted by an investigator who was both a doctor and a cruising sailor (FM). The same questionnaire was filled in by all crew members during an interview of 1 hour. Only 2 of 102 captains declined to participate in the investigation.
Subjects had to fulfil two main inclusion criteria: to be a French-speaking subject, and to live aboard at least half of the year.
The collected data were entered into a spreadsheet (Excel; Microsoft Corp., Redmond, USA) for computer analysis.
Where do these sailboats come from?
Most of the crews (70%) were making an east–west transatlantic crossing, 12% had sailed on another ocean before returning to the Atlantic (round-the-world sailors), and the remaining 18% had had their sailboat ferried to the West Indies or had bought it there. Thus, 80% of sailors interviewed had made at least one transoceanic trip (fig 1).
Where are they going?
Of the 100 crews interviewed, 37 said that they intended to finish their transatlantic crossing within the year and then return to Europe, 27 crews were undertaking a round-the-world trip and had planned to sail to the Panama Canal to cross the Pacific Ocean, 26 crews had planned to sail among the Caribbean Islands, and 10 captains wanted to sell their boat after they had given up their projected trip.
Sailboat type, composition and size
In all, 90% of the vessels were single-hull sailboats, and 10% were catamarans, with 68% of the boats being made of polyester, 13% of steel, 12% of aluminum, 3% of epoxy wood and 2% of ferro-cement. All the boats had a size between 33 and 40 feet. Only 32% of the boats were < 10 years old; 5% of these were brand new.
A horseshoe buoy is mandatory on all boats, but the International Offshore Rule perch, which is far superior in many respects, was found in only 21% of the boats. Only 42% of the crews had an emergency beacon onboard. To contact a Maritime Medical Consultation Unit, which provides free medical advice by radio on a 24-h basis, a long-distance communication system is necessary. Only 48% of the boats studied were equipped with such a system: BLU (bande lateral unique; single lateral band) in 40% of the cases, iridium in 31%, and Inmarsat (www.inmarsat.com) in 29%.
Although there are many female captains in offshore sailing races, all the captains in our study were men. Over half (52%0 were >49 years old (fig 2). The trained first-aider was a woman in 49 cases, and a man in 51 cases. Only 16 boats had a medical or paramedical professional on board.
Retired people made up the largest socioprofessional category of the captains (fig 3). Most (87%) of the captains had >2 years’ sailing experience (fig 4). Regarding crew composition (fig 5), 45% of the crews were couples, 16% of whom had children sailing with them, and 15% were solo sailors.
Injuries and illnesses identified
As our investigation method is based on a non-biased questionnaire answered some time after the events had taken place, the number of injuries reported and described is very likely underestimated. Minor trauma or mild skin infections are often forgotten in a few weeks, so that only the serious traumatic events that required significant treatments are mentioned.
In all, 56 injuries were reported. Pelvic trauma was rare; the one case reported was a sacrococcygeal trauma from a fall due to rolling. The head and neck were involved in seven cases (13%), including one eyeball bruise caused by the genoa sheet clew during shivering. There were two wounds of the superciliary arch: one was sustained during a fall in the companionway, and the other one when a winch handle kicked back.
The boom was responsible for four cranial traumas three of which were due to involuntary jibing. There were eight chest traumas (14%): six ribcage bruises and two rib fractures. All resulted from loss of balance due to a sudden shift of the boat, with the sailor falling either in the companionway or in the cockpit.
There were 20 upper limb injuries (35%), 70% of which involved the hand: injury from knife when cleaning fish (3 injuries), anchor chain at the windlass (2), winch rope or pulley rope (2), accidental closure of a deck cover (1 ), rope (1 ), and bladed weapon attack (1 ).
There were eight cases of contusion, sprain or fracture, seven of which were sustained during a fall either in the companionway, in the cockpit or on a deck cover that had been left open, and one due to crushing between the winch and the sheet.
There were 20 lower limb injuries (35%), 3 of which were bruises on the thigh. The ankle or the foot was involved in the remaining 17 cases, 13 of which were toe sprains or fractures due to bare feet hitting deck equipment.
Methods of sun protection were generally used on the boats: sunglasses and hats were worn by 80% of the crews, and sun cream by 70%. Most (60%) of the boats had a bimini top (a removable canvas top that shades the cockpit), and 70% of the boats were equipped with a companionway sea hood. However, even with all these means of protection, 19 burns were reported, 11 of which were photoinduced (that is, directly attributable to solar radiation, including 5 first-degree and second-degree burns). There were also six cases of actinodermatitis (inflammation of the skin produced by exposure to sunlight).
Additionally, there were eight accidental burns: four caused by ropes, three by scalding hot fluids and one by a marine animal.
Acute rheumatoid pathologies
There were three cases of sciatic pain with neurological signs, seven of acute lower back pain, one of gout in the great toe, three of septic knee arthritis secondary to an untreated boil in the anterior aspect of the knee, and four of microtrauma (two of “winch elbow” and two of rotator cuff syndrome in former athletes (one gymnast and one kayakist in their 50s)) in sole sailors, which severely interfered with the manoeuvres on board.
Sixteen staphylococcus-induced skin infections were reported, including three boils in the anterior aspect of the knee, which resulted in septic arthritis, as described above.
Vuksanovic and Goethe10 showed that merchant seamen and fishermen aged <25 years have the highest frequency of accidents at sea, and that there are significantly more injuries during the first voyages. Lethuiller15 analysed the 1984 Transat des Alizés sailing race, and reported that trauma is more common among amateurs than among professional seamen; the latter make very few mistakes. With amateurs, a “learning effect” was found by Price et al,17 who noted that injuries are less common in the last third compared with the first third of a race.
All the round-the-world captains in our study were alone on their boat and had the lowest number of traumas compared with the other two groups. It therefore seems that sailing experience is an influential factor in preventing trauma.
Places of risk on board
The deck was the most common place where trauma occurred, owing to factors such as mobility, speed and being on a wet and slippery surface with many obstacles (table 5).
The anatomical regions involved in marine trauma have been classified by increasing order of frequency as the pelvis/abdomen (2%), head/neck (13%), chest (14%), upper limbs (35%) and lower limbs (35%).
Types of injury and illness
Head and neck trauma
In the meta-analysis of publications about trauma aboard vessels, performed by Goethe and Vuksanovic2, the estimated rate of head/neck involvement was 13%. Our results are very close to those from merchant marine or commercial fishing.1–3 6 10
In our study, as in that of Price et al,17 a moving spar such as the boom was implicated in all cranial trauma. Accidents typically occur when there is a combination of a helm error and jibing while the victim is returning from the cabin.
Two of four boats had a boom guy (also known as a preventer; a line to prevent such swings) that broke when the accident occurred. None of the involved boats had a companionway sea hood. It seems that this hood, which forces the sailor to bend down to take the staircase to the cabin protects from the boom much more effectively than a boom guy, which may break during a gybe in the trade wind area.
In the meta-analysis by Goethe and Vuksanovic,2 ribcage injuries accounted for 11% of all traumatic accidents. Trauma occurs when a crew member is carrying an object up to the cockpit. If a rolling motion occurs, the body rotates about a single vertical axis, and the person is unable to grab for support because of the occupied hand. Therefore, a companionway protected by two side walls is much safer than a simple narrow ladder as the person can lean against a wall to free one hand while keeping three support points.
Upper limb trauma
Our results are closer to those reported in studies involving fishermen than in studies involving merchant seamen,2 9 14 15 probably due to the small size of the boats and to the similarities between manual work on a sailboat and on a fishing boat.
On “live aboard” sailboats,11 13 15 hand injuries are generally caused by deck equipment containing a mobile part (pinch points). Therefore, it is recommended to keep body parts away from equipment such as pulleys, winches, windlasses, trolleys, propellers and motorised deck covers, As the forces generated by these devices are comparable with those of engines, remote control is strongly advised.
The fishing technique of “trolling” in the trade wind area is very productive but it is also a source of injuries. Pulling a large fish aboard a sailboat that is not intended for this purpose may be challenging and is an emotional experience. Cleaning of fish by an inexperienced individual using undersized tools in poor condition was the cause of the most severe injuries that were reported to us. These deep lesions may involve tendons or neurovascular structures that cannot be surgically managed on board, and may severely compromise the safety of the crew. The best “treatment” is prevention—that is, wearing sturdy gloves from the moment the fish is handled to the moment the cutting is finished. The use of a strong sharp knife with a sheath is also recommended.
Lower limb trauma
Previous studies conducted on injuries occurring on commercial or fishing vessels1–10 have shown that the lower limb is much less subject to trauma than the upper limb; the incidence of upper limb trauma is approximately 33% higher than that of lower limb trauma. Merchant seamen and fishermen generally wear safety shoes or boots, which has resulted in the taking of the incidence of lower limb trauma in seamen down to that seen in farmers.16
Our results show that lower limb trauma is as common as upper limb trauma. Analysis of the circumstances of injuries showed that 15 out of 20 reported injuries were due to direct contact with some component of the deck equipment. In 13 cases, only the foot was affected. If all toe wounds, sprains and fractures resulting from direct contact with a fixed component of the deck are considered, it seems that >50% of the lower limb trauma reported to us could have been avoided by simply wearing shoes on the boat.
In our study, photoinduced conditions made up 28% of those reported. This is likely to be an underestimate; sunburn is viewed as the normal process of adaptation of European people to the Tropics rather than a true medical problem. As confirmation of this, after a transatlantic sailboat race, Nicol5 only mentioned in his follow-up report incidences of sunburn that had been complicated by shock.
We mentioned earlier that most crews had been very careful to use sun protection methods. Almost 70% of the boats were equipped with a companionway sea hood, and 80% of the subjects said that they always wore sunglasses and a hat when sailing. It must be kept in mind that in the Tropics, the sun is a constant enemy. When at sea, high-protection sunscreen is recommended even for pleasure sailors who have been living in tropical areas for several years.22
It is in the kitchen that the most severe burns occur. A stove on board is gimbaled, but it swings with the motion of the boat, which results in dishes falling off the stove, or the cook’s body coming into contact with the burning hot oven.11 13 20 Whenever the motions of the boat make it necessary to hold the handrail, the cook should wear waterproof trousers bloused over boots, and only the cook should carry hot dishes and fluids.20 23
Rope burns have been reported in a few studies relating to offshore races12 15 20 as being due to a basic reflex of trying to hold a cable that has been accidentally released. Gloves are definitely an efficient protection for the regatta sailor, but it would be illusory to think that ocean-going pleasure sailors will accept constant wear of protective gloves. On the other hand, being aware that a sail is not a simple piece of material but a real engine that is capable of moving several tons is very important to make sailors understand how dangerous it can be to grab the drive belt.
Acute sciatic and acute low back pain
In this study, three cases of acute sciatic pain were reported. In one case, this was caused by a fall in the cockpit; in the other two cases, it occurred after raising the anchor. Adding these two cases to the seven cases of acute low back pain gives a total of nine accidents resulting from hauling up the chain and anchor.
All cases were found in small boats without a windlass, and all traumas were sustained when the subject was pulling while standing upright, with the full weight of the chain being held by the lumbar spine in hyperflexion.
To avoid this injury we suggest sitting on the deck with feet resting safely on the pulpit and the lumbar spine locked in extension. This position would be better to prevent back injury, as in this position, the trunk safely swings backward and the sailor can raise the anchor without any risk of spinal damage.
All seamen who had been sailing in tropical areas for >1 year insisted on the importance of wound management. Any skin lesion, even mild, must be disinfected immediately and then regularly until complete healing, to avoid deep infection, as occurred in three subjects who developed septic knee arthritis secondary to an untreated boil in the anterior knee.
Telemedicine would be ideal to follow up this constantly moving population. Remote medical monitoring has been used for offshore races27 and scientific vessels,27 However, pleasure sailboats cannot use telemedicine unless they have a connection to a network. In our study, only 48% of the boats had this type of equipment. In addition, before departure, all crew must contact the Maritime Medical Consultation Unit to have a personal medical file created so that the correct advice can be given should consultation be necessary. Development of such systems is highly desirable.
Although numerous epidemiological data have been published on merchant seamen, fishermen, navy personnel and sailors taking part in offshore races, to date, no medical data have been available for offshore cruising, and yet this population has been growing since the 1960s. Analysis of the collected data allowed determination of the causes of traumatic injuries and suggested appropriate means of prevention, as follows.
(1) Adequate technical training should be given on use of winches, pulleys and cables that are part of the “transmission system” of the sailboat and are under tension.
(2) There should be a companionway sea hood on every boat as the best protection against a swinging boom.
(3) There should be a bimini top to protect from the sun even at sea.
(4) A windlass, even a mechanical one, should be used to make anchor raising easier. If no windlass is available, sitting on the deck with feet resting safely on the pulpit and the lumbar spine locked in extension is a safer position.
(5) Crew should ensure that they always keep three support points to avoid pendular movements when walking on the deck or in the cockpit.
(6) Shoes should always be worn on deck.
(7) Sturdy gloves and an appropriate cutting tool should be used when cleaning fish.
(8) The chest and lower limbs of the cook should be protected by wearing waterproof overalls.
(9) Daily treatment of skin wounds is essential until complete healing.
If the above precautions were routinely taken on cruising sailboats, a great number of traumas would be avoided. As proof of this, the incidence of trauma in round-the-world sailors is very low. Sailing so many miles across the open ocean provides extensive experience of the sea, which explains why this group of sailors had the lowest incidence of traumatic complications in the whole study.
What is already known on this topic
There is a wealth of published material about medical care aboard military, commercial, or fishing and offshore races sailing boats.
In contrast, the few publications dealing with pure pleasure offshore sailing have been aimed only at assisting the sailor in the role of “doctor”,
No publications are available regarding cruising sailors who spend most of the year on offshore cruising sailboats.
What this study adds
With the development of leisure society, an increasing number of people choose to sail to the Caribbean.
This population has been growing since the 1960s, but has never, to our knowledge been the subject of any medical study.
This publication is the first to study this mobile population.
Traumatic events and causes in this population were studied to define appropriate means of prevention.
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