by Malcolm S. Sanders, MD
I had a friend who now hates me because I took him fishing in 5 to 7 foot seas. His emetic eruptions were so violent I feared he might rupture his esophagus (yes, this can really happen its called Boerhaave’s Syndrome). So… we turned the boat around. During lunch, which he couldn’t eat, he grabbed me by the shirt collar and assured me that “he was not OK” and then said something like “I’m gonna torch your boat to the waterline”. Oh, by the way, this guy practices medicine with me and took nothing before we shoved off, n-o-t-h-i-n-g.
There are no fool-proof tricks to completely eliminate motion sickness, but there are both time tested and new drugs that can dramatically reduce the likelihood of becoming severely ill. I have no financial ties or research funding from any of the companies that manufacture anti-nausea medications to which I will refer.
Another disclaimer, everyone has the potential for adverse reactions with both prescription and over the counter medications. Urinary retention, fever, malignant cardiac rhythms and horrible skin eruptions are just a few. Also, there are some individuals that should not take certain medications. For instance, men with benign prostatic hypertrophy should not take medications with anticholinergic effects (a lot of anti-nausea medicines) and people with pre-existing cardiac conduction abnormalities need to avoid the drugs that could potentially exacerbate their condition. It’s a royal pain in the neck, but do yourself a favor and go visit your physician. Don’t have one? Get one. You’ll be better off in the long run. Besides, this is a golden opportunity to get a prescription(s) for more potent medications that you can’t get over the counter. What ever you do, don’t just take a drug that someone hands you just because they say it works for seasickness. This could put you in the hospital, or worse.
Motion sickness and postoperative nausea and vomiting (PONV) frequently overlap. In my practice I will frequently treat patients that have problems with PONV with medications that work for seasickness if they have a history of motion related illness. Conversely, medications traditionally used for PONV can be exceptionally useful for those who tolerate ocean travel poorly.
Motion related illness is a spectrum that can span from mild nausea, like after you watch a Miley Cyrus performance to, “get me off this boat or kill me now”. The best strategies for avoiding seasickness should take place the night before the trip. Hydration, sleep and avoidance of alcohol help quite a bit. If you want to guarantee a miserable trip, get really sunburned and slam tequila shooters until 2 AM. Then, when you wake up consume the greasiest breakfast burrito you can find. For a pre-boat game plan look at Table 1.
The over the counter medications work well for a lot of folks. The two most common are dimenhydrinate (Dramamine) and meclizine (Bonine), both of which are antihistamines and theoretically stabilize the vestibular apparatus in the inner ear. Diphenhydramine (Benedryl) also works but has been marketed more for allergy symptoms. One of the drawbacks of using these medications is that if you wait until nausea strikes, it is usually too late, not to mention the fact that you likely will not be able to keep the tablets in your stomach for long. Ginger root has been reported to have antiemetic properties and anecdotally I think it does, although I have no idea why. The TV show “Myth Busters” stated that it works (“confirmed”). A commercial oral spray is on the market (Vitamotion-S). I frequently will order an extra portion of pickled ginger when I am out for sushi and take a couple of pieces the morning of my trip. Based on personal experience, I think it’s the real deal, no kidding! Wrist acupressure/magnets and electrical stimulation over the palmar surface of the wrist have been tried with mixed results. It probably works for some people but again, I have no clue as to the mechanism.
Beyond The OTC
Transdermal scopolamine, a prescription medication (Transderm Scop, also known as the patch) has been around for well over a decade and provides extended relief for nausea. This medication sticks to the skin behind the ear after you prep the skin with isopropyl alcohol. It too is an antihistamine and likely blocks vestibular output to higher centers in the brain which otherwise might result in nausea. It should be applied 4 hours before you get on the boat and can work for three days. If you inadvertently touch the edge of the circular patch and then touch your eye it can potentially result in blurry vision secondary to pupil dilatation (mydriasis) for the rest of the day. I actually had a patient who underwent thousands of dollars of testing because she had a dilated (blown) pupil from her scopolamine that looked like she was having a stroke.
Odansetron (Zofran), Granisatron (Kytril) and aprepitant (Emend) are oral medications that have been used extensively for PONV and chemotherapy induced nausea and likely work well for motion related symptoms. Like scopolamine, you will need a prescription to get a hold of these medications.
Individuals with cardiac conduction problems, specifically “long QT syndrome” should skip these medications. I like the solutab formula of odansetron because you don’t have to swallow them. It just dissolves on your tongue. This medication is great as a rescue for breakthrough nausea after you get sick.
Several prescription sedative medications like lorazepam (Ativan) and diazepam (Valium) can help with “mal de mer”, but they also make it exquisitely dangerous to be out on the water because of an altered level of consciousness. This might be appropriate in a closed cabin with adult supervision under a physician’s direction for severe protracted symptoms. If you have the resources (read “nurse”) an IV placement and a liter of normal saline or lactated ringers solution at this point can be heaven-sent, provided that your renal function is normal and you don’t have a history of congestive heart failure.
Where The Sun Don’t Shine
Prochlorperazine and promethazine (Compazine and Phenergan) are anti-nausea medications that are related to the phenothiazine antipsychotics. These drugs have been used for decades for both chemotherapy related nausea and PONV. The side effect profile is not trivial and again should be used as directed by your physician. The advantage or disadvantage (depending on how you look at it) is that these two medications come in suppository forms that can’t be “thrown up”.
I have a confession. Most of my friends believe that I am immune to seasickness, and this is not the case. The truth is that in moderate seas I am fine, but when things get messy, if I haven’t prepared myself, it doesn’t look pretty. Fortunately I usually come with all bases covered and after a day with rough seas, I’m bulletproof for subsequent trips.
When people ask me if I get sick at sea, I frequently repeat the 1907 Gilbert and Sullivan “Captain Corcoran’s Aria” from the musical “H.M.S. Pinafore”:
Captain: “Though related to a peer
I can hand, reef, and steer
And ship a salvagee;
I am never known to quail
At the fury of a gale,
And I am never, never sick at sea.
All: What never?
Captain: No never!
All: What never?
Captain: Well, hardly ever!
All: He’s hardly ever sick at sea!
Then give three cheers, and one cheer more
For the hardy captain of the Pinafore
Then give three cheers and one cheer more,
For the captain of the Pinafore! “
What to do if you know you might be prone to seasickness
1. The Night Before
- Have a light dinner
- Drink a liberal amount of non-alcoholic clear liquids
- Skip the parties and retire to bed early
2. The day of the trip
- Take your medications(s) and/or apply your scopolamine well in advance.
- Have a light breakfast and don’t drink the whole pot of coffee.
- You might try some ginger.
3. On The Boat
- Stay in the transom where there is less “rocking”.
- Avoid the side of the boat with the exhaust.
- Do not go below deck unless you absolutely have to.
- Let someone who won’t get sick tie your knots.
- Do not eat the sandwich you brought until you are in calm waters or back at the dock. Better yet, give it to the guy who might get sick and caught the biggest fish last year!
- If it’s OK with the captain, steer the boat and look at the horizon.
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