A 57-y-old sailor (Patient S) with a history of chronic lymphocytic leukemia departed from Hawaii on his sailboat. On the morning of his departure, he sustained a small laceration to his right foot while walking on the beach. During the next 1–2 d, this laceration became superficially infected. Four days after setting sail, a rogue wave hit the boat in bad weather, splitting the mainsail and damaging the ship's communication equipment. Over the next 3 d, Patient S experienced worsening of his wound infection to the point that by Day 7, when George Washington Maritime Medical Access was contacted to initiate medical management, Patient S had developed a full-fledged necrotizing fasciitis in his right lower extremity. Despite attempts to treat the infection while at sea, Patient S eventually required a complex medical evacuation from the middle of the Pacific Ocean.
Dr. Catherine Levitt: A 57-y-old sailor (Patient S) with a history of chronic lymphocytic leukemia departed on a sailboat from Hawaii following completion of the Pacific Cup Race. The crew consisted of Patient S (the captain), 2 novice sailors in their 20s, and a man in his 80s. The sailboat left Hawaii on the morning of July 25. Prior to this, Patient S sustained a small laceration to his right foot while walking on Waikiki Beach. This laceration became superficially infected 1–2 d after Patient S sustained the injury. Four days after setting sail, the vessel, a 37-ft Express, was 600 NM from Hawaii on its way back to San Francisco (Figure 1) when a rogue wave struck the vessel in bad weather. This resulted in damage to the mainsail and much of the ship's communication equipment. At about the same time, Patient S’s infected foot laceration took a turn for the worse over the course of the next 3 d.
Map of location of the patient's sailboat and other vessels at various time points during the return passage from Hawaii.
Dr. John Lafleur: Individuals making long-distance crossings are usually outfitted with redundant forms of communication equipment. What was the vessel equipped with, and how much was damaged?
Dr. Catherine Levitt: Communication equipment included 2 computers, a very high frequency radio with a range of ∼7–35 mi, a handheld very high frequency radio with a range of ∼2–5 mi, and an Iridium satellite phone. Although not all of the vessel's communication equipment was immediately destroyed, there was evolving water damage over the course of the next few days to the point that the sailboat's communication capabilities became limited to the Iridium GO!, with low bandwidth largely limiting voice communications but allowing for dependable Short Message Service (text) communications.
Dr. John Lafleur: How is communication at sea usually conducted?
Dr. Catherine Levitt: Marine communications between ships or with the shore are accomplished through shore stations and satellites using radio communication systems. These include ultra-high frequency, very high frequency, high frequency, and very low frequency transceivers. Satellite services need geostationary satellites to help transmit and receive signals, but their availability is not always guaranteed. Factors such as atmospheric conditions (eg, hail or storms), geographic obstructions (eg, elevated terrain or dense urban areas), and equipment malfunctions can disrupt signals. The Global Maritime Distress and Safety System is an internationally recognized distress and radio communication safety system that enables ship-to-shore and ship-to-ship communication using satellites and/or terrestrial radio systems with digital selective calling technology. Different radio communication systems are required depending on the area of operation of the vessel, and areas are broken down into 4 geographical regions depending on how far away they are from the coast. The further from the coast they are, the more long-range backup communication systems are needed.
Dr. John Lafleur: It seems that the vessel was partially incapacitated far from land, and Patient S had developed a severe soft tissue infection. What happened next?
EMT Kate Larsen: On August 2 (Day 7) during a window when the Iridium GO! became fully operational, communication was established with George Washington Maritime Medical Access (GWMMA), based in Washington, DC. This organization previously had been hired by the Pacific Cup Race organizers to provide telemedical support for the duration of the event. GWMMA's board-certified emergency medicine physicians provide 24/7 telemedical support to commercial and recreational vessels, aircraft, and remote teams worldwide. GWMMA's Worldwide Emergency Communications Center is staffed by EMTs around the clock; they can receive incoming communications through a variety of channels, including phone calls (usually from onboard satellite phones), email, and telemedical kits. When a vessel contacts GWMMA, the on-call emergency medicine physician determines the most appropriate course of action, taking into consideration the vessel's location, personnel with medical training, medications/medical supplies, and the estimated time of arrival at the next port of call or closest port. If deemed necessary, GWMMA coordinates with US or international coast guard services to arrange a medevac or vessel diversion.
Dr. John Lafleur: How was Patient S doing when contact was initially made with GWMMA?
Dr. Catherine Levitt: Patient S was afebrile, and his pain score was 3 of 10. Sensation was intact, and no odor or pus was detected. He was having serous drainage from the shin with pitting edema and redness with areas of dark discoloration and sloughing skin (Figure 2). Recommendations made by the GWMMA physician included application of a wound dressing twice a day with a topical antibiotic and medications for symptomatic relief. Systemic antibiotics were recommended at the time of initial contact, but the sailboat's medical kit contained no antibiotics other than triple antibiotic ointment. This circumstance was subsequently communicated by Patient S to the race coordinators, who arranged to divert another race participant returning to the continental United States to deliver their antibiotics to the stricken mariner. While awaiting the rendevouz with the second boat, GWMMA had limited information about Patient S due to continued communication challenges despite various measures undertaken by the vessel's crew to remedy the situation. These measures included adjusting antennas, attempting to dry moist electronic components, and searching for replacement parts among the vessel's extensive replacement equipment.
Image of right lower leg infection sent via email on August 2 to George Washington Maritime Medical Access.
Dr. Catherine Levitt: What concerns did the GWMMA physician have at this point?
Dr. John Lafleur: Lacerations in marine environments are always concerning.1 Wound infections caused by marine bacteria can occur in healthy individuals. Some marine bacteria are aggressive, potentially fatal, and require rapid treatment. Along with usual skin flora, lacerations in marine environments can become infected by Pseudomonas, various Vibrio spp, Aeromonas hydrophilia, Mycobacterium marinum, and Erysipelothrix rhusiopathiae.1 Sailors are also at an increased risk for injuries particularly to their hands and feet due to tripping, falling, getting hit, or handling lines. Given these risks, first aid kits2 on boats going offshore should include antimicrobial agents. Among those recommended for marine-related skin infections are doxycycline and fluoroquinolones.
EMT Kate Larsen: How long did it take for the second vessel to arrive and deliver the antibiotics?
Dr. Catherine Levitt: It took 2 d. By August 4, shortly after midnight (Day 9), the antibiotics were successfully delivered (Figure 1). During that day, however, following 2 doses of trimethoprim-sulfamethoxazole and 3 of cephalexin, Patient S's condition worsened. At this point, Patient S was experiencing pressure in the right knee with a pain score of 7 of 10 and significant swelling from the knee down. He developed a low-grade fever, chills, sweats, and red-hot skin over the right lower leg. His wound had become malodorous and had begun to drain pus. These findings were communicated to GWMMA's on-call physician. In light of the patient's deteriorating condition, the decision was made by GWMMA to attempt evacuation.
Dr. John Lafleur: What resources need to be mobilized to evacuate a sailor? Are there criteria that must be met for this to happen?
EMT Kate Larsen: There are roughly 13 rescue coordination centers (RCCs) for the US Coast Guard that serve 9 separate districts at sea throughout US coastal waters. In this case, the ship was situated between two RCCs, and ultimate ownership of the medical evacuation was given to RCC Alameda, which leads responses for shipboard emergencies from California, Nevada, Arizona, and Utah. This was due to the proximity of the ship and its final destination of San Francisco.
Approximately 19% of rescue missions in the maritime environment include the need for at-sea evacuations due to a lack of onboard medical resources, limited communication capabilities, environmental conditions, and typically remote locations.3 Roughly 47% of rescues involve vessel deviation or pier-side transport at the next available port. Nonetheless, most medical evacuations at sea are facilitated by helicopter transport.3 The Coast Guard has the final say when considering vessels within its jurisdiction and sometimes will deny the request if the patient's clinical condition does not risk life, limb, or sight or if the risks to rescuers are too great (often due to sea or weather conditions).
Dr. John Lafleur: How was the evacuation accomplished?
Dr. Catherine Levitt: GWMMA clinicians discussed the patient's deteriorating condition with Alameda Coast Guard 11th District. The Coast Guard, in turn, alerted the Air Force RCC for pararescue response. An oil and chemical tanker (FPMC 35) on its way to Panama was identified by the Coast Guard as the only large vessel in the surrounding area. The Coast Guard communicated with FPMC 35 through Inmarsat-C Station, giving the GPS coordinates of the sailboat and requesting diversion to provide assistance. While the commercial ship was enroute, the Air National Guard began planning a complex pararescue response.
Dr. John Lafleur: Where was the Air National Guard located? What type of training does its staff have?
EMT Kate Larsen: The Air Force RCC engaged the 129th Rescue Wing, a unit of the Air National Guard based at Moffett Airfield in Sunnyvale, California. The 129th Rescue Wing specializes in long-range and combat search and rescue. Given that the sailboat was beyond helicopter range (and therefore the patient could not be hoisted off the boat and flown to shore), a pararescue response involving pararescuers flying out on a longer-range fixed-wing aircraft and parachuting into the patient's vicinity was the only way of providing lifesaving medical care to him.
Dr. Catherine Levitt: At around 0200 on Day 10, the sailboat was approached by FPMC 35, and the tanker's crew dropped a rope ladder over the side.4 The patient reported that the crew on deck spoke primarily Chinese, which made understanding their instructions difficult. He decided to wrap a line hurled from the deck of FPMC 35 around himself twice and jumped from the sailboat and was successfully pulled onto the ladder and lifted onto the ship (Figure 3). Twelve hours after his transfer onto the larger vessel, an Air Force C-130 fixed-wing aircraft from the 129th Rescue Wing arrived overhead. Due to sea conditions and challenges with the tanker's small launch, only 2 pararescuers (originally 4 were planned) parachuted out of the aircraft (Figure 4). They were then picked up by the tanker's launch, which subsequently hoisted them aboard with their extensive collection of medical gear. Connecting the tanker's hoist to the launch also was complicated by a large ocean swell and a weak engine as the small boat strained under the weight of the personnel and medical equipment it carried.5 Once aboard, the pararescuers began attending to the patient, focusing on wound debridement. He was given intramuscular ceftriaxone and oral doxycycline—and pain control. After initial stabilization, the 2 pararescuers worked in shifts to provide around-the-clock patient care.
Patient climbing a rope ladder onto the deck of FPMC 35 on August 5.
Pararescuers preparing to parachute from within the hold of a C-130 aircraft into the seas next to the tanker FPMC 35 about 12 h after transfer of the patient early in the morning on August 5.
As FPMC 35 proceeded toward San Francisco, the pararescuers determined that the patient's condition warranted steps to reduce the time to definitive surgical care. The decision was made to intercept the tanker with helicopters and airlift the patient to land. Once FPMC 35 came within 400 mi of shore, 2 Pave Hawk helicopters and a C-130 aircraft flew out to intercept the vessel.
Dr. John Lafleur: Why were 2 helicopters deployed? What is the range of this type of helicopter?
Dr. Catherine Levitt: Two helicopters were sent to ensure that the mission could be completed successfully should one or the other of them develop problems during the flight. The aerial refueling of this kind of helicopter by a C-130 allows for an extended range, which makes them ideal for long-range missions. Without midair refueling, Pave helicopters can fly <600 mi on a single tank of gas. After the 3 aircraft arrived at FPMC 35, one of the Pave Hawk helicopters hovered over the ship and hoisted the patient onto the helicopter followed by the 2 pararescurers. They then returned to shore and met an awaiting ambulance that transported the patient to Stanford Medical Center.
Dr. John Lafleur: This is an incredible story and rescue. What were the findings of the Stanford physicians?
EMT Kate Larsen: The patient arrived at Stanford Medical Center on Day 12, 2 d after his initial transfer to the tanker. At the time of Emergency Department presentation, Patient S’s vital signs were stable; he was noted by the emergency physician to have a large necrotic wound on the distal aspect of his right leg with significant tissue loss over the medial malleolus and bone exposure (Figure 5). A computed tomography angiogram of the lower extremity showed a right medial malleolar soft tissue wound with extensive subcutaneous edema tracking up to the level of the midthigh and several foci of gas immediately deep to the soft tissue defect, which may be the result of an exposed wound with a gas-producing infection such as necrotizing fasciitis (Figure 6). Initial labs values showed a leukocytosis of 41.5 cells/microliter and elevated inflammatory markers (ie, erythrocyte sedimentation rate of 75 mm·h–1 and a C-reactive protein level of 21.9 mg·L–1).
A, Last day aboard the sailboat. B, Arrival at hospital. C, Healing. D, Skin graft after 2 wk. E, Present day.
Computed tomography of the patient's lower extremities on arrival at the hospital.
Dr. John Lafleur: What were the next steps in treatment? Was the infecting organism identified?6
Dr. Catherine Levitt: Patient S's leg was operatively debrided; extensive necrotic tissue with subcutaneous air was noted. He required repeat operative treatment 4 times over the following week for additional debridement and wound vac placement. He was empirically started on tazobactam-piperacillin (subsequently switched to penicillin) and clindamycin—cultures taken during surgery grew Streptococcus pyogenes.
Dr. John Lafleur: This appears to be a case of monomicrobial necrotizing soft tissue infection secondary to a group A streptococcal organism. Can you discuss the frequency of monomicrobial versus polymicrobial necrotizing soft tissue infection and the indications for surgical debridement?
Dr. Catherine Levitt: These often-devastating infections are divided into the following categories: Type 1, polymicrobial; Type 2, monomicrobial (often group A strep.); Type 3, marine gram-negative bacteria; and Type 4, fungal.7 Monomicrobial infection may be more common and more severe than polymicrobial infection.6 It is somewhat surprising that Patient S was not infected with marine flora. Monomicrobial infections of this type tend to affect immunocompromised hosts—our patient's chronic lymphocytic leukemia may have played a role in this. Necrotizing soft tissue infections are life-threatening infections of tissue and fascia with necrosis of the overlying skin,8 and they have been reported after prolonged marine exposure under stressful conditions.9 Patient S's soft tissue infection grew out S pyogenes in culture, which is commonly seen in bacterial fasciitis and myonecrosis and may resemble gas gangrene.10 Evidence of advanced disease includes crepitus, bullae, paresthesia, and necrosis. In the extremities, this type of infection may progress to compartment syndrome.11 Crepitus and gas were seen in the patient's foot, suggestive of advanced infection. Infection with S pyogenes is more commonly found in immunocompromised individuals, such as those with diabetes, or malignancy.11 Successful management of this particular infection requires prompt recognition, aggressive debridement (and amputation, if necessary), and intravenous antibiotics.10 Antibiotic therapy without surgical debridement is ineffective and has almost 100% mortality.12
A scoring system (the Laboratory Risk Indicator for Necrotizing Fasciitis Score [LRINEC]) has been developed to help clinicians determine the likelihood that a soft tissue infection is a necrotizing infection, and it takes into account the white blood cell count and hemoglobin, sodium, glucose, creatinine, and C-reactive protein concentrations.8 LRINEC scores >6 have a sensitivity of ∼90% and a specificity of ∼95%, a positive predictive value of 92%, and a negative predictive value of 95%.8,13 Patient S had a LRINEC score of 9 on arrival to the Emergency Department, therefore appropriately raising the clinician's suspicion for a necrotizing infection of his right lower extremity.
EMT Kate Larsen: What was the outcome for this patient?
Dr. Catherine Levitt: Patient S was discharged 3 wk after admission, and 33 d after the initial injury, with the wound vac still in place after completing his course of intravenous antibiotics. He also underwent an outpatient skin graft procedure on the day of discharge. His wound vac was removed within 1 wk of discharge, and he continued to heal well per outpatient plastic surgery follow-up. He started physical therapy and had a full recovery of function of his right leg.
Dr. John Lafleur: In wrapping up this case discussion, it is important to note that skin wounds in an austere environment pose significant challenges. Goals for treatment include minimizing risk of infection and disability and implementing definitive care when possible.14,15 For most skin wounds, irrigation with at least 1 L may help decrease the risk of infection, with tap water demonstrating equivalent incidence of infection to sterile saline.14 Potable water (eg, filtered, boiled, or chemically treated water—rather than untreated water from an open source) is preferred in the austere setting if it is available for irrigation. Additives such as povidone-iodine or chlorhexidine should be avoided because they cause damage to the tissue and affect wound healing.14,15 It is estimated that despite proper wound care, there is still a 1 to 12% risk of infection that will likely require the use of empirical antibiotics, and it is suspected that most of these wounds are polymicrobial.14 Although no definitive guidelines exist, in a wilderness or austere setting, individuals who have wounds/infections with concerning progression after administration of antibiotics or systemic signs of toxicity should be evacuated.14
Conclusion
This case demonstrated that long-distance maritime voyages carry significant risk, particularly in the case of individuals with preexisting conditions. This case highlights the importance of adequate redundancies in communications equipment as well as the need to travel with more comprehensive medical supplies in austere settings. The complex evacuation described involved selflessness and bravery on the part of many, including the pilots, pararescuers, and crews of vessels that diverted to provide assistance to a stricken mariner. In the case of FPMC 35, this diversion caused delays to the huge ship's route and operations, but the crew and company emphasized the high priority placed on saving lives at sea.
Multiple modes of onboard communication proved to be essential in this case. Ultimately, the sailboat's Iridium GO! could send only text and emails, and this was the sole means of communication available after various other communication modalities became inoperable. As a result of the Pacific Race organizers having contracted with a professional medical oversight group, the patient had access to physicians familiar with the inner workings of maritime medicine and a knowledge of complex evacuations.
Footnotes
Author Contribution(s)
Catherine V. Levitt: Investigation; Writing – original draft; Writing – review & editing.
Kate Larsen: Resources; Visualization; Writing – original draft; Writing – review & editing.
John E. Lafleur: Conceptualization; Supervision; Writing – original draft; Writing – review & editing.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
References
1.
OliverJD. Wound infections caused by Vibrio vulnificus and other marine bacteria. Epidemiol Infect. 2005;133(3):383–391.
2.
ForyckaJWojtowiczJKolodziejczykKLesmanJMostowyM. Observational study of self-reported offshore sailing-related injuries in a wide range of amateur and professional sailors. Wilderness Environ Med. 2023;34(4):473–482.
3.
DillardJSMaynardWKashyapR. The epidemiology of maritime patients requiring medical evacuation: a literature review. Cureus. 2023;15(11):e49606.
4.
MoradzadehM. Details From Medical Evacuation of Pacific Cup Captain.Latitude38. Published online August 2022. Accessed May 1, 2024. https://www.latitude38.com/lectronic/details-medical-evacuation-pacific-cup-captain/
5.
RozaD. Air Force rescuers just flew hundreds of miles over the Pacific to save a patient on an oil tanker. Task Purpose. Published online August 15, 2022. Accessed May 1, 2024. https://taskandpurpose.com/news/air-force-pararescue-jumper-mission/
6.
NaamanyEShiberSDuskin-BitanH, Yahav D, Bishara J, Sagy I, et al.Polymicrobial and monomicrobial necrotizing soft tissue infections: comparison of clinical, laboratory, radiological, and pathological hallmarks and prognosis: a retrospective analysis. Trauma Surg Acute Care Open. 2021;6(1):e000745.
7.
SkredeSBruunTRathEOppegaardO. Microbiological etiology of necrotizing soft tissue infections. In: Norrby-TeglundASvenssonMSkredeS, eds. Necrotizing Soft Tissue Infections. Vol. 1294. Advances in Experimental Medicine and Biology. Springer International; 2020:53–71.
8.
Mehraban FarPRulloJKratkyV. Use of telemedicine in the management of life-threatening periorbital necrotizing fasciitis in a remote community. CJEM. 2020;22(1):118–120.
9.
SimonFGautretPNicolasXAussetPDe PinaJJDemortièreE. Crossing the Gulf of Aden: cutaneous infections in African migrant shipwreck survivors. Travel Med Infect Dis. 2013;11(6):431–434.
10.
ProkuskiL. Treatment of acute infection. J Am Acad Orthop Surg. 2006;14(auppl):S101–S104.
11.
Centers for Disease Control and Prevention. Necrotizing Fasciitis. Published online March 1, 2024. accessed May 1, 2024. https://www.cdc.gov/group-a-strep/about/necrotizing-fasciitis.html
WongCHKhinLWHengKSTanKCLowCO. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004;32(7):1535–1541.
14.
QuinnRHWedmoreIJohnsonEL, Islas AA, Anglim A, Zafren K, et al.Wilderness Medical Society practice guidelines for basic wound management in the austere environment: 2014 update. Wilderness Environ Med. 2014;25(suppl 4):S118–S133.
15.
SpanoSJDimockB. They had me in stitches: a Grand Canyon river guide’s case report and a review of wilderness wound management literature. Wilderness Environ Med. 2014;25(2):182–189.
