The medical kit I'm building for four kids offshore

Our second kid ran a 103°F fever the week we were reading through the DAN Diving and Boating First Aid manual for the fifth time. He was fine — a virus, three days of Tylenol, done. But my wife looked at me over the coffee pot and said, quietly, "This, but nine hundred miles from land."

That is the entire problem with building an offshore medical kit for a family. You are not preparing for the disasters you can visualize. You are preparing for the ordinary Tuesday that suddenly matters more because the ordinary Tuesday is happening on day fourteen of a Pacific crossing with a three-year-old and no ability to walk into an urgent care.

I have been assembling ours for eighteen months. I have talked with three ER physicians, an ISMED-affiliated pediatrician, a maritime physician at MedAire, and two families who have actually done this — one on a Lagoon 450 with kids the same ages as ours, one on an Outremer 5X. The kit is not done. I doubt it will ever be done. But the shape of it is now clear enough to write down, and I think that's useful because almost every family-cruising medical article I have read either (a) copy-pastes a generic first-aid list or (b) turns into a lecture about ordering a Ship's Medical Chest from the WHO and pretending the reader is a merchant captain. Neither is what a family of six leaving in a bluewater catamaran actually needs.

Here is what I've settled on so far.

Three layers, not one kit

The single biggest reframe was giving up on the idea of "the medical kit." What we're actually building is three separate systems that live in three different places on the boat and get used at different frequencies.

The first layer is the daily kit — a Pelican 1170 in the galley locker with the boring stuff you reach for every week. Band-Aids, sting relief, kids' chewable ibuprofen and acetaminophen, a decent thermometer (a Braun ThermoScan 7, because it wakes a sleeping kid less than a rectal probe and we've tested three), electrolyte packets, oral rehydration salts, saline nasal spray, kids' Zyrtec, aloe gel, Neosporin, hydrocortisone, a small suture-strip pack, and finger splints. Nothing exotic. It gets opened three times a week and needs to be findable in the dark.

The second layer is the offshore kit — a Pelican 1450 in the nav-station lazarette that gets pulled on passage and shore expeditions. This is where the antibiotics live, the wound-closure supplies live, the IV bag lives, the pediatric epinephrine autoinjectors live, and where the weight-based dosing chart is laminated to the inside of the lid. This is the kit I've spent the most money and thought on and it's the one that will matter if anything ever actually goes wrong.

The third layer is the abandon-ship kit — a small waterproof pouch inside the grab bag. Individually-dosed pediatric acetaminophen, a mylar blanket per person, sunscreen, two epi-pens, an inhaler, a small suture strip pack, and a laminated medical summary for each family member. That's it. The theory is that if we're in the raft you have hours to days, not weeks, so the point is to buy time for rescue rather than to run a clinic.

Splitting the kit this way solved my biggest anxiety, which was the fantasy that in an actual emergency I'd be able to dig through one giant Pelican and find the exact right thing. I wouldn't. My four-year-old could find the daily kit. My wife could find the offshore kit blindfolded. And the grab bag lives one arm's reach from the companionway.

The prescription piece is where families get stuck

You can buy a very good non-prescription kit off the shelf. Adventure Medical Kits' Marine 3000 is a defensible starting point and Bluewater Marine's kit is better if you can wait the eight weeks. The bill for either is under $600.

The prescription piece is the hard part, and it's where most family-cruising articles wave their hands and say "consult your doctor." Here's what I actually did.

I found a family-medicine doctor in Bend who has written maritime prescriptions before — this took three tries and a referral from another cruising family. She wrote scripts for a defined offshore kit against a signed protocol: broad-spectrum oral antibiotics (amoxicillin-clavulanate, azithromycin, cephalexin, ciprofloxacin, metronidazole), topical (mupirocin, silver sulfadiazine for burns), pediatric liquid antibiotics (amoxicillin suspension in dry powder form that reconstitutes with water — critical, because the pre-mixed liquid has a two-week shelf life), an EpiPen Jr two-pack, an albuterol inhaler with spacer, prednisolone oral, ondansetron ODT (the wafer form, because a kid who is actively vomiting cannot swallow a pill), diazepam for seizures, and a small quantity of injectable morphine with a signed use protocol.

Two things that surprised me. First, controlled substances are much less of a nightmare than the internet suggests if you have a physician willing to write the script and you're transporting them in original labeled containers with the prescription paperwork. The DEA's rules for personal-use maritime carriage are more permissive than for aviation, and most countries you'll clear into don't care as long as the volumes are personal-use and the paperwork exists. Second, the dry-powder pediatric antibiotic reconstitution question is the single most important thing on the whole list. Ready-to-use pediatric amoxicillin is a two-week product. Powder-form amoxicillin trihydrate is a two-year product. If you get sick 30 days into a passage, only one of those two options exists.

Total cost of the prescription kit — drugs plus refrigerator-storage insulin cooler (which I'm using for the injectables and one temperature-sensitive item my wife takes) — landed at $1,140. I expect to replace roughly $300 of that annually as things expire.

Dental is where I'd been shortcutting

Every long-time cruiser I talked to said the same thing about the medical kit: whatever you spend on general medical, you'll spend a quarter of it on dental and you will use the dental kit more than any other single component.

A cracked filling, a popped-off crown, a lost temporary — these things happen. They happen more when you're eating dried mango and hard bread for weeks. They happen to adults, they happen to kids, and no adult can rig a spinnaker with an exposed nerve.

The offshore dental kit I ended up with:

• Cavit temporary filling material (two tubes; it's the most forgiving)
• IRM (intermediate restorative material) for slightly more durable repairs
• Coe-Pak periodontal dressing for gum injuries
• Temporary crown cement (I chose Recapit for its ease of use)
• Dental wax
• A small dental mirror, explorer, and cotton pliers
• 4x4 gauze and cotton rolls
• Chlorhexidine rinse
• A laminated one-page guide with photos

I spent $180 on it, watched two evenings of Dr. Jim Sturm's Where There Is No Dentist video series on YouTube, and asked my dentist to walk me through how to seat a temporary crown at my last cleaning. That's it. If your dentist won't do this, find one who will — a cruising dentist is worth their weight.

Telemedicine is the multiplier

The kit is useless without someone to tell you what to do with it. There are three services worth considering.

MedAire MedLink is the most serious option. It's what most commercial ships and megayachts use. You get 24/7 access to emergency physicians via satphone, they'll walk you through anything from wound closure to a heart-attack protocol, and they can arrange evacuation. It's not cheap — the family package I was quoted runs about $1,200 a year — but the physicians on the line have decades of maritime medicine experience specifically, and they are the ones who will authorize you to open the schedule II box.

GWU Maritime Medical Access is roughly half the cost and roughly the same clinical quality. Same 24/7 physician access, similar protocols, less polished user experience.

DAN Boater Advantage at around $110 a year for a family is worth having regardless — it's oriented toward diving medicine but includes medical consultation and evacuation-assistance benefits.

I'm carrying MedAire and DAN. MedAire is for the clinical call — the moment when you need a physician to tell you whether a two-year-old's abdominal pain is a virus or an appendix. DAN is for the logistics call — when you know what you need, you just need help getting there.

Insurance won't cover most of what you think

Regular travel medical insurance almost never covers offshore rescues from a private vessel. Global Rescue and Medjet Assist both write policies that specifically cover evacuation from a vessel at sea; both are around $1,000 to $1,500 a year for a family. Read the actual policy: distance-from-shore caps, "if commercially reachable" clauses, and named-storm exclusions are real. Our five-year plan includes cyclone-season transits (Panama to French Polynesia is fine; French Polynesia to New Zealand is fine; the pinch points are Fiji-to-New-Zealand and the Indian Ocean south transit). At least two policies I looked at exclude both.

The realistic cost of a helicopter evacuation from mid-Pacific is between $50,000 and $250,000 depending on how far offshore, and the evacuation itself is only step one — the receiving hospital in Tahiti or Nuku Hiva is another line item, and a medical repatriation home from there on an air-ambulance is $75,000 to $150,000 more. Global Rescue's premium plan covers all of it. So does DAN's top tier. Both are worth reading in full before you sign.

What I overbought and what I skipped

I overbought on suture supplies. I bought three sizes of monofilament, two sizes of chromic gut, and a real needle driver. In reality, I'm not going to suture anything short of a limb-threatening injury; steri-strips and Dermabond hold most cruising injuries closed just fine. If I had it back, I'd keep one suture pack for the emergency case and use the $140 on more Dermabond and more butterfly closures.

I skipped IV fluids initially and then went back and added a single 1L bag of normal saline plus a start kit. The talk track was severe dehydration in a small kid, which is the single scariest common scenario. Setting an IV is not something I'm going to teach myself on YouTube for real — but a MedAire physician can talk you through it, and having the supplies to attempt it under their guidance is worth the eighty dollars.

I skipped a portable defibrillator (Philips HeartStart runs about $1,600) after a long conversation with the MedAire physician. Their read: on a boat with no crew members over 45 with no known cardiac history, the marginal life-safety per dollar is much higher applied elsewhere. When we cruise with older guests, that math changes.

The other thing I skipped and now regret: I did not buy a good otoscope. Kids get ear infections. On a boat that will pitch and roll for three weeks at a stretch, kids get more ear infections. A $60 Welch Allyn pocket otoscope and one hour of YouTube gets you to "I can see fluid behind the drum, let's start amoxicillin" instead of the much worse "I have no idea and the child is screaming."

That's tomorrow's Amazon order.

What I'm still working on

Three open questions I haven't fully solved.

One: refrigeration reliability for the insulin cooler if we lose ship's power for more than 48 hours. I have a plan (a small backup cooler with ice packs pre-frozen in the freezer) but the failure mode is a compressor death during a passage. Working on it.

Two: which two crew members do the medical training. Right now it's me and my wife, both taking the Wilderness Medical Associates Wilderness First Responder course this fall. The stronger version is one of us doing WFR and one doing WEMT. That's another $1,800 and a month of nights, so it will happen after we take delivery of the boat, not before.

Three: how to explain to a four-year-old what the ondansetron wafer is for at four in the morning in a squall without terrifying her. Turns out the answer is "special candy" and to practice the routine on land first. Kids on boats requires more theater than I expected.

If you're doing this for your family and you want to compare notes, I read every email. What did you overspend on. What did you skip that you now wish you hadn't. What's on your list that I've missed. I'll fold it into the next revision — this piece will get rewritten when we're actually offshore and the theoretical kit meets the actual ocean, and probably again a year after that.