Medical Dispatches from the Whitbread Sailboat Race
How does a physician plan medical treatment for a dozen men who've just spent 3 weeks on a 64-ft boat sailing from New Zealand to Brazil?
Emergency physician Reynaldo (Rudi) Rodriguez, MD, who is working the Whitbread Round the World Race (https://www.whitbread.com), has volunteered to share the medical details of his experience on The Physician and Sportsmedicine Online. Rodriguez is team physician for two of the teams: Chessie Racing, of the United States, and Innovation Kvaerner, of Norway. Rodriguez hops a plane to meet the teams during each race stopover. He occasionally sees members from other teams and offers educational programs for the sailors who double as medics on their boats.
Check back here for Rodriguez' medical updates after each of the remaining legs of the race. The dates of his postings will depend on when the teams reach port and how busy he is during each stopover. The remaining stopover dates are:
A report from the conclusion of leg 7: Baltimore
by Reynaldo Rodriguez, MD (posted May 12, 1998)
Leg 7 race synopsis. Leg 7 from Ft Lauderdale to Baltimore's historic Fort McHenry National Monument was very short by Whitbread standards—only 870 nautical miles. All competitors completed the leg in 4 days. The course along the US coast, past Cape Hatteras and into the Chesapeake Bay, can be treacherous, and hundreds of ships have foundered in these waters. The Gulf Stream running north along the coast is one of the strongest currents in the world and can reach speeds of more than 5 knots. When the winds of a cold front or a storm low move south against current moving north, waves can become steep and violent—conditions most boaters try to avoid. The Whitbread racers have little choice and sought the Gulf Stream's conveyor belt advantage.
On the second day of the leg a cold front moved south and the fleet experienced adverse current and wind. One boat sailing close to the wind (wind angle of less than 45 degrees) had 28 knots of wind and 5.2 knots of current with significant waves. Mark Rudiger, the navigator of EF Language, described it well in an e-mail: "The waves are incredibly steep and short. Some of the drop-offs are so violent it sounds like breaking glass in a car accident. It seems like I have been in the air more than on my bunk when trying to sleep."
Medical incidents. For the first time in this race, seasickness (mal de mer) was frequent, despite habituation of the sailors. A few crew members requested pharmacologic intervention. The standard Whitbread medical kit is stocked with prochlorperazine suppositories or injections to be used every 12 hours for severe seasickness. Other treatments that can be used include:
Two seasickness medications that are not available in the US are cyclizine hydrochloride and cinnarizine.
The cases of seasickness resolved after the boats left the Gulf Stream to enter the Chesapeake Bay.
Musculoskeletal injuries. One of the more significant injuries of the race occurred this leg when Marco Constant of EF Language fell through the hatch and down the companionway (the steps down into the boat's interior) while trying to avoid a wave. He suffered a displaced, impacted fracture of the distal ulna and radius that required surgery and external fixation for stabilization. Constant refused helicopter evacuation citing the danger of a helicopter transfer and the time required to stop the boat and complete the transfer. The Swedish Match, a major competitor, was close by.
The most common overuse injuries and chronic musculoskeletal problems were shoulder impingement, elbow epicondylitis, and wrist tenosynovitis. Additionally, two sailors had prepatellar bursitis that required cephalosporin and nonsteroidal anti-inflammatory medications. One crew member has a symptomatic subluxing ulnar nerve that will require surgical repair after the race.
Infectious illnesses. During the Baltimore/Annapolis stopover, many of the sailors fought upper-respiratory illnesses that they had acquired during a 17-day stopover in Fort Lauderdale, Florida. Anecdotally, zinc supplements seemed to help. One crew member was hospitalized for atypical pneumonia and missed leg 7. At one point, local physicians suspected pulmonary tuberculosis, which would have been problematic for the crew members who had spent the last 8 months in close quarters. Curiously, all crew members had received at least one bacille Calmette-Guerin (BCG) injection in their home country.
A report from the conclusion of Leg 6: Ft Lauderdale, Florida
by Reynaldo Rodriguez, MD (posted April 13, 1998)
(Fort Lauderdale, Florida)—During the Sao Sebastiao stopover, the Whitbread Crews experienced unseasonably warm weather with the hottest temperature recorded for the area in the last 40 years. The crews modified their work schedules to cope with the extreme humidity and heat. Air conditioning was scarce, and swimming was the best way to cool off.
There were few medical problems during this stopover; however, there were concerns about the possibility of water- borne infections. Crew members took hand-washing precautions, fresh water rinses after swimming, and drank bottled water.
The start of leg 6 promised to be interesting and possibly chaotic. Normal starts during the race feature a spectator-free starting box. A Whitbread 60 boat can rapidly accelerate to 20 mph under spinnaker (the usually large and colorful sail out front) and are limited to the channel by their 12 ft keels; involvement with spectator boats can be hazardous. The starting box in Brazil was crowded with thousands of spectator boats, many of which seemed overloaded. The racers had to pick safe routes through the crowds. Twenty six private helicopters hovered in what appeared to be random flight patterns and altitudes.
Though the Whitbread fleet made it to open seas without incident or injury, tension was significant. The Brazilian Navy had stated that any vessels involved in a collision would be impounded on the spot pending investigation.
Later that evening, the good fortune changed and severe weather moved through Sao Sebastiao with torrential rain, gale force winds, and flooding. In town, a local businessman died in a flood that washed him into the bay, while two more Brazilians died in motor vehicle accidents on nearby roads.
Leg 6 Race Synopsis. The 4,750 nautical mile course for leg 6 skirted the Brazilian coast, passed the Windward and Leeward Islands, sailed through the Bahamas and across the Gulf Stream into Fort Lauderdale, Florida. Conditions for Leg 6 were atypical; usually winds are variable along the Brazilian coast, fluky to nonexistent in the doldrums (a part of the ocean near the equator abounding in calms, squalls, and light shifting winds), and steady and moderate in trade winds above the equator. During the first week, offshore winds were significantly stronger than anticipated, reaching 30 knots. The doldrums proved to be virtually nonexistent, and the trade winds blew stronger than normal. Boat speeds were excellent and averaged over 10 knots. All of the nine competitors finished within 16 days—5 days ahead of schedule.
Morale should have been good on leg 6. Food supplies were adequate, the water-makers performed well, and there would be only 4,000 miles left after the finish of this leg. However, most of the sailors interviewed felt that Leg 6 was the worst leg of the race, and many felt it was some of the most uncomfortable sailing of their lives.
The cause of the misery: unbearable heat. As Dave Scott of Chessie Racing wrote in his e-mail during the leg, "This leg is the only one in the Whitbread where we start in a hot location, go to a hotter location, and finish in a hot place." Ocean waters during the leg reached 90°F, the below- deck temperature approached 110°F, and the decks were too hot for contact with bare skin. Sleep was virtually impossible during the day.
Incessant wetness because of high seas during the first 10 days of the leg turned the boats and crews into an excellent culture media, given the unavoidable poor hygiene and close contact. Brunel Sunergy reportedly harvested a crop of mushrooms in the galley.
Medical Incidents. Significant traumatic injuries were uncommon during leg 6, while skin conditions and infections were almost universal.
Infections and skin conditions encountered during Leg 6 included:
Skin infections affected more than 20% of the sailors on many of the boats and more than 50% on others. Environmental conditions alter skin resistance. Other causes of skin breakdown include the lack of hygiene, elevated colony counts, persistent wetness, constant wearing of foul weather gear during the first leg, and the resultant friction and occlusion of the skin.
Fungal Infections. Tinea pedis and tinea cruris afflicted a significant portion of Chessie's crew and also were the most common fungal infections through out the fleet. Prevention measures included drying and fresh air. Infections among Chessie racers were controlled by terbinafine cream and tablets. Other boats used Daktacort (Janssen Pharmaceutica, Ltd, Sandton, South Africa), an anti-fungal and steroid product supplied by the Whitbread race committee. Several athletes developed secondary bacterial infection or lymphangitis that required antibiotics. Crew members who received oral terbinafine hydrochloride for 3 weeks in Brazil for preexisting tinea pedis had no recurrence.
Bacterial Infections. Superficial abrasions and cuts healed very slowly, and antibiotic ointments seemed to help prevent deeper infections. Impetigo, with its honey-colored crusts occurred on exposed areas of the face and extremities. Two sailors developed bullous impetigo after arrival in Florida and required antistaphylococcal antibiotics.
A week out of Brazil, one of the more dramatic rashes occurred on both lower extremities of a Chessie Racing crew member, confining him to his bunk for 4 days. The rash began bilaterally at the top of his sea boots and rapidly spread proximally and distally from ankle to foot (figure 1). Like all Chessie crew members, the he had only had one pair of footwear and his boot tops chafed his legs. Chessie's medic Jerry Kirby contacted me by satellite phone; he described a beefy red, tender, and itchy rash with pitting edema and discrete "boils" and ulcers in various stages from knee to ankle. The onset was less than 36 hours and associated with subjective fever and bilateral adenopathy. Treatment with amoxicillin/clavulanate potassium, elevation, cleansing, and bed rest halted lesion advancement within 36 hours.
Digital images sent by e-mail from Chessie were fascinating and led to the working diagnosis of streptococcal ecthyma, a condition common among infantry soldiers fighting in the rice paddies of Vietnam, or staphylococcal furunculosis. One of EF Language's crew developed a similar rash that did not respond to amoxicillin/clavulanate potassium. The physician who saw the sailor on shore felt that the rash might have been caused by Aeromonas hydrophilia. The antibiotic was changed to levofloxacin, and the infection resolved over the next several days.
Of interest, during the Brazil stopover an Innovation Kvaerner crew member developed a erythematous macular rash after swimming in the bay. Although the patient was asymptomatic, the rash spread to the entire body. Amoxicillin/clavulanate potassium was prescribed, and the rash cleared within 36 hours. The rash appeared similar to "hot tub dermatitis" that can be caused by Pseudomonas aeruginosa overgrowth that occurs in warm water and is usually self limited. Afterward, the boat's skipper asked his crew to stop swimming during the remainder of the stopover and instituted regular fresh water rinses of themselves and their undergarments. They seemed to have fewer problems with skin infections than the other syndicates.
Sailors on Brunel Sunergy, in addition to skin infections, experienced acute gastroenteritis after several days off shore. At various times, 6 of the 12 crew members suffered nausea, vomiting, abdominal cramps, and diarrhea that confined them to their bunks. Symptoms abated 2 days after crew members began taking ciprofloxacin hydrochloride.
Spotty botty. An additional interesting dermatologic condition prevalent on leg 6 was an entity known by numerous colorful names—spotty botty, gunwale bum, skipper's seat, or barnacle butt. The condition begins on the buttocks after 2 to 3 days at sea and is caused by wetness, pressure, friction, and heat (figure 2). Symptoms range from itching to significant pain. The lesions look like "pimples" surrounded by redness.
The eruptions may be a folliculitis similar to acne mechanica (1,2) or bikini bottom (3,4). Unlike acne vulgaris, however, spotty botty occurs solely on the buttocks and, unlike bikini bottom, spotty botty lesions resolve without systemic antibiotics. The condition responds well to reversal of predisposing causes—dryness, fresh air, good hygiene, and sunshine are effective. When predisposing conditions can not be avoided, palliative treatments are used with variable success. Medicated Vaseline, lanolin, antibiotic ointments, powders, and Bag Balm (Dairy Association, Inc, Lydonville, Vermont) are said to help. Bag balm is an antiseptic ointment used by dairy farmers for chapped udders in their herds. Sudocrem (Tosara Products, Ltd, Liverpool, England) an English antibacterial cream, is one of the most popular treatments among the crew. It contains zinc oxide 15-25%, anhydrous wool fat 4%, benzyl benzoate 1.0%, benzyl cinnamate 1.5%, and benzyl alcohol 0.39%. It is usually used to treat "nappy rash"—better known to us as diaper rash.
Musculoskeletal injuries. The forces of the wind, water, and the boat caused the typical and common sprains, strains, and bruises, but incapacitating injuries were rare. One sailor was thrown 15 across the cockpit by the force of a spinnaker sheet and suffered a clinical 5th metatarsal fracture and a large gastrocnemius hematoma that required therapy on shore to regain full range of motion. A Chessie Racing crew member suffered a crush injury with nail avulsion, nail bed laceration, and an open distal phalanx fracture.
Looking ahead. During the last 8 months, each leg has had its unique set of circumstances and medical problems. Leg 6 problems were primarily determined by environmental factors. At this point, the crews are manifesting signs of the long competition. Many feel their strength and endurance have remained below prerace levels. Most have not regained the weight they have lost, and studies under way by Stefan Branth, MD, from University of Uppsala in Sweden indicate that lean muscle mass has been lost and body fat levels have increased during the course of the race. Although only 4,000 miles remain, these considerations may be significant because the race is still very close for all positions except first place. With three legs remaining, EF Language, from Sweden, leads the race and is 115 points ahead of the second place boat. The leg across the Atlantic should be physically demanding and will challenge the strength and endurance of the athletes.
A report from the conclusion of Leg 5: Sao Sebastiao, Brazil
by Reynaldo Rodriguez, MD (posted March 18, 1998)
(Sao Sebastiao, Brazil)—This small coastal town of 40,000 permanent residents is nestled in the rain forest of surrounding mountains that tower over the bay. Sao Sebastiao is 2 1/2 hours from the large metropolitan center of Sao Paulo. The two-lane serpentine road that connects the two cities often seems to be hung from the side of the mountain. Carnival was ending as the first of the racers entered the port.
The quality of the medical resources and care here is rare for a race stopover. The immediate health needs and the demanding schedule of the Whitbread race would have overwhelmed the small local hospital. Fortunately, staff from Hospital Israelita Albert Einstein in Sao Paulo set up an emergency clinic in the Whitbread "village". (Many Brazilians consider Albert Einstein one of the finest hospitals in South America.) The clinic is open 24 hours a day, and a helicopter and ambulance are on site if hospital transport is needed. The clinic was open for the arrival of every yacht, including those that arrived in the early morning.
Leg 5 Race Synopsis Leg 5 was a long and difficult. The Southern Ocean often had constant winds of 38-42 knots and heavy seas of 20 to 40 ft. The yachts raced in conditions that most amateur sailors would just be trying to survive. The conditions battered the boats: two lost their masts, and one may have hit a small iceberg. The first boat (EF Language, Sweden) crossed the finish line of leg 5 in 23 days. Over the next 4 days, she was followed by Brunel Sunergy (Netherlands), Chessie Racing (USA), Swedish Match (Sweden), Merit Cup (Monaco), Toshiba (USA), Innovation Kvaerner (Norway). Silk Cut (UK) retired from the leg because of technical problems. The final boat, EF Education (an all-female Swedish crew) is expected to finish in 40 days. She was also dismasted and had an emergency stop to install a new mast.
Medical Incidents The constant heavy seas took their toll on the crews, as well; however, significant injuries were infrequent. The motion of a 64-ft yacht in unpredictable seas resulted in daily contusions, hematomas, sprains and strains. Treatment consisted of continued activity and a course of NSAIDs. One crew member suffered a clinical rib fracture, but it didn't disable him.
Lacerations. Medics on board two of the boats put their wound closure training to use; they closed two large lacerations with staples. Both injuries occurred in rough conditions that would have made suturing technically difficult.
Josh Belsky, bowman on the EF Language, was thrown off the boom of the mainsail onto a stanchions in 25 plus knots of wind. He sustained a 10-cm laceration to his calf that extended into the gastrocnemius. The medic cleaned the wound with 1% betadine solution, closed it with 10 staples, and started him on amoxicillin-clavulanate potassium for the rest of the leg.
On arrival, his sutures were removed. A 2-cm area of the wound had inverted during stapling, and despite a large organizing hematoma, there was no evidence of deep infection. Routine wound care was continued, and he underwent physical therapy for minimal loss of knee extension and foot dorsiflexion. He anticipates starting leg 6 of the race on March 14 in good condition.
Greg Gendell of Chessie Racing did not fare as well. He suffered a 12-cm laceration of his anterior tibia when a wave swept him off the bow into a piece of metal. Because of marked sleep deprivation and cold conditions, he did not realize his injury until he was preparing for his next watch more than 4 hours later when gear failure and heavy seas required every available hand. The medic quickly irrigated the wound, closed it with staples, started Gendell on amoxicillin-clavulanate potassium, and sent him back on board in his foul weather gear. The staples failed, and the medic packed and cleaned the wound daily.
On arrival, 2 weeks after injury, his wound appeared clean. I debrided the wound, started him on cefadroxil monohydrate, and sent him home to Annapolis to receive aggressive wound management in time to start the next leg. Gendell is undergoing hyperbaric oxygen therapy twice a day. His wound shows no culture growth, and delayed closure was successful. After 6 months and 15,000 miles on Chessie Racing, he is considered essential to the campaign.
Dehydration. While traumatic injuries were uncommon, technical problems with water makers on Swedish Match and Chessie caused both crews to ration water and collect rainwater. (Cold weather conditions can cause the water makers to malfunction.) Swedish Match seemed to suffer the most. The crew was restricted to 2 to 2 1/2 cups of water a day for 2 weeks. Complaints of dizziness, thirst, lethargy, and myalgia were common. However, the marked weakness and loss of efficiency while racing was considered the biggest problem.
Fortunately, as water and ambient temperature increased toward the end of leg 5, water production increased also. Although the crew appeared emaciated on arrival, their primary concern was "disappointment" at their fourth-place finish. (Interestingly, Brazilian health authorities required that all of Swedish Match's crew receive Yellow Fever immunizations before they were allowed on land.) Once on land, basic labs were taken, and the crew was finally able to relax after 26 days and nights at sea.
On board Chessie, the situation was not quite so grim. They were able to repair their water maker after receiving parts from the US delivered off the coast of Cape Horn during an emergency stop.
Inadequate nutrition was also a concern for both boats. Without water to rehydrate the freeze-dried provisions, the crews were reduced to eating dry cereal, olive oil, candy bars, and other non-freeze-dried foods. Body fat compositions of 8% to 9% were common prior to the start of the race and still, several of the sailors lost more than 6 kg of weight. Weakness remained a problem for many to the finish.
The Whitbread Round the World Race could be described as the Olympics of ocean sailing. The race, which started in 1973-1974, is held every 4 years. This season's event started in Southhampton, England, on September 21, 1997 and will end in the same place about May 24, 1998. The race consists of nine legs; stopovers include Cape Town, South Africa; Fremantle, Australia; Sydney, Australia; Auckland, New Zealand; Sao Sebastiao, Brazil; Ft Lauderdale, Florida; Annapolis/Baltimore, Maryland; La Rochelle, France; and Southhampton, England. There were 10 teams, one dropped out because it lost its financial support. The boats are 64-ft high-performance sailing vessels that can reach sustained speeds of 20 knots.
Q & A with Rudi Rodriguez, MD
What's your medical background?
I was an emergency medicine resident at the University of California, San Francisco, from 1978 to 1980. I was a full time emergency medicine physician from 1980 to 1996. I recently finished a primary care sports medicine fellowship at University of California, San Diego, with Mark D. Bracker, MD, and E. Lee Rice, DO.
How did you get involved with the Whitbread race?
I lived in Annapolis briefly, and Chessie Racing is from that area. I'm also acquainted with Jim Allsopp, head of marketing for North Sails and a member of the Chessie Racing Management committee. I initially became involved after reviewing the team's fitness program and making recommendations. After that, my role developed into medical director and team physician.
Where are you now?
In Sao Sebastiao, Brazil. The boats have just finished a brutal 6,670 nautical miles through the Southern Ocean from Auckland.
How do the teams medically prepare for the race?
The rules of racing stipulate that each yacht have at least two crew members (medics) trained in:
Each yacht is also required to carry an extensive first aid kit provided by the Whitbread Race Committee. The crews can also contact race headquarters for medical specialist advice. Though the race committee recommends that either a physician or a registered nurse be onboard, only Swedish Match has a physician, Roger Nilson, an orthopedist. EF Education has two registered nurses on its crew.
Each medic has the ability and equipment to suture wounds. Although the sail makers on board were ready to try, the inexperience of most of the medics with suturing and the storm conditions that usually accompany a laceration made repairing a large wound at sea a daunting proposition.
Medics on Chessie Racing had already been trained to use surgical staplers and carried one in their medical kit. During the stopover in Cape Town, South Africa, the rest of the fleet was introduced to staplers in preparation for leg 2 in the rough waters of the Southern Ocean.
In Australia, the Johnson & Johnson company Ethicon provided the Whitbread fleet with the new skin adhesive that they market, Dermabond. The company also sponsored a formal training lab for the medics in the use of staplers and Dermabond.
How do elite sailors train?
The quest for top performance and every competitive advantage starts before the teams set sail: Many incorporate formal physical and fitness programs into their race preparations. Fitness and flexibility regimens, in fact, are incorporated into routine team activities during the nine stopovers and are directed at maintaining the highest level of efficiency, rehabilitation, and injury prevention.
Chessie Racing's prerace preparation included identifying problem areas during the preparticipation evaluation and aggressive management of those problems. Overuse injuries of the upper extremities were common as were complaints of back pain and stiffness. Standard therapies proved effective. Medial and lateral elbow epicondylitis and wrist tenosynovitis. Back strengthening, chiropractic care, and improved hip and hamstring flexibility have kept Chessie crew functioning at a high level.What nutrition issues affect the sailors?
Obsession with weight reduction during the Whitbread race is well established. To make boats lighter, sailors have been known to take drastic measures, such as cutting toothbrushes in half and carrying only 6 titanium spoons with two spares to feed a 12-man crew. Body fat compositions of 8% to 9% are common prior to the start of the race.
Racers carry little if any water. They depend on reverse osmosis water makers that are powered by a diesel auxiliary engine. Hand-powered emergency water makers can't provide adequate amounts for basic needs.
Nutrition has been a vital concern during this race. In past races, it was common to jettison food to try to improve boat speed. Lightweight freeze-dried food is universally used during this race.
Swedish research during the 1993-1994 racing season established that calorie requirements for Whitbread sailors are between 4,500 and 5,000 calories per crew member. Each team has devised its own program with different calorie intakes and vitamin and mineral supplements. Nutritionists, dietitians, and physicians have been involved in the planning or each team. Olive oil has gained almost uniform acceptance as a dietary staple due to its high calorie density, its taste when added to freeze dried food, and its apparent ability to aid GI transit. Food may be rationed, the sailors may complain about it, but it is rarely thrown overboard any longer.