Some special conditions/special considerations
It is the responsibility of the ship's doctor to assure that emergency procedures are clearly understood by all medical personnel. See also above: Availability of medical staff in port.
Before the doctor recommends a helicopter evacuation or a deviation of the ship's normal itinerary for purposes of medical evacuations of ill or injured passengers or crew, he is advised to first consult with the company’s medical department ashore.
(Adapted from information by Steve Williams, RN, CEN, CFRN, March 2009)
In the event that a guest or crew member becomes seriously ill or is injured, it may be necessary to evacuate them by helicopter. The decision to request a helicopter evacuation is a complex risk-benefit analysis, with the risk of transport being considered against the potential benefit of earlier care in a medical facility. While each case is unique due to the specific medical problems, on board medical expertise, location of the vessel, time to next port of call and available shore-side medical facilities, there are some general issues to consider in the decision-making process:
- Decreased ability to monitor during flight (noise, vibration).
- Restricted space, light and access; the patient is on the floor.
- Extreme difficulty in defibrillating or pacing.
- Extreme difficulty in airway management in a patient without a secure airway.
- Psychological trauma of conscious patient being hoisted off ship.
- Stretcher-bound patient must lie flat.
- Inability to allow next-of-kin to travel, unless patient is child.
Possible benefit outweighs risks of helicopter evacuation – Some examplesAcute arterial occlusion to an extremity, where early intervention could save a limb.
Suspected vascular emergency, such as thoracic or abdominal aneurysm.
- Trauma patient with injuries that require urgent surgical intervention.
- Unconscious patient, with secure airway, who may have intra-cerebral bleed or cerebral aneurysm.
- Acute surgical emergency where urgent surgical evaluation is indicated to prevent further deterioration, like suspected perforated bowel, active gastrointestinal or vaginal bleeding, and possible necrotizing fasciitis.
- Acute serious eye injury, like globe rupture from blunt trauma and foreign body penetration.
- Acute renal failure where dialysis is available at the receiving facility.
- Unstable fractures with vascular or neurological compromise.
- Hypovolemic shock where blood products are available at the receiving facility.
- Patient with acute myocardial infarction, who is not a candidate for thrombolytic therapy, or where thrombolytic therapy is not available, with active and continuing chest pain, and the receiving facility has the capability to provide cardiac catheterization and angioplasty.
- Patient body weight < 350 lbs (~160 kg).
Risks probably outweigh benefit of helicopter evacuation – Some examplesAcute myocardial infarction, when access to thrombolytics on vessel.
- Cardiogenic shock, or unstable cardiac rhythm.
- Acute respiratory failure in patient who has not been intubated and ventilated.
- Airway obstruction in non-intubated patient, like foreign body obstruction or oesphageal impaction.
- Active, premature labor, unless short journey to special care baby unit.
- Active psychiatric illness, psychosis or suicidal ideation.
- Overdose patient, unless only treatment is dialysis, or specific antidote is time sensitive and not available on board.
- Patient body weight> 350 lbs[jc2] (~160 kg).
Flight Surgeon’s Considerations
Once the ship's physician has decided that the patient requires evacuation by helicopter, contact the on-duty coast guard flight surgeon who will generally use five criteria to evaluate the request:
1. What does the patient have? (A best guess, based on the shipboard physician’s evaluation)
2. What does the patient need? (CT scan, neurosurgeon, general surgery, blood transfusion?)
3. When do they need it? (Only educated guess is required, but specifics are helpful, while “as soon as possible” is not)
4. Where can they get what they need? (The coast guard will always take to the closest, appropriate facility and their command center can confirm that the projected receiving facility can manage the patient.)
5. Can the coast guard meet the “window of opportunity”? (If the patient will not reach the receiving facility within the time-frame needed, there is no expectation of medical gain and only risk).
As a rule, do not request helicopter evacuation for a patient in cardiac or traumatic arrest.
Blood Transfusion at Sea
Uncontrolled bleedings are rightly feared at sea. Blood banks ashore will not release blood unless there is a designated recipient. To obtain blood for transfusion is a major challenge, especially during long voyages outside helicopter range. Some ships have equipment for blood type confirmation and quick tests for HIV (but not for hepatitis). It must be stressed that blood transfusions should only be attempted as a last lifesaving effort. However, a search for potential donors should start long before the situation becomes critical. Do a public search among the passengers and crew for registered blood donors with recent donor cards. Search for the recipient’s blood type if it is known, otherwise for type O. Blood type O Rhesus negative is the universal blood donor type. Make certain that potential donors remain easily available until it is clear that their services will not be needed.
Accidents and Injuries
Every company has its own detailed instructions on how to deal with accidents, and the medical staff members are well advised to study them closely and follow them to the letter. Here is just some general information:
While passenger accidents happening aboard and during the ship’s shore excursions are of special interest to the company, it must by contract take care of all crew injuries and illnesses, even if they are a result of activities during authorizedshore leave.
The nurse or doctor must verbally notify the investigating (safety or security) officer immediately when they get notified that a passenger or a crew member is injured either on board or ashore. If possible, the investigator should be given the opportunity to inspect the scene as it was at the time of the accident before any cleaning or other tampering of potential evidence has been done. Thorough investigation of all accidents is necessary not only to prevent or prepare for litigation, but to make certain that there is no basis for a legal claim, and to prevent similar accidents from happening in the future.
While in the MC, the injured person should fill out a standard accident form (Passenger or Crew Accident Report)in own hand writing if possible and sign it. As a rule only a copy of this report can be given to the passenger or crew when requests for accident reports are made.
Because medical personnel are among the first to see a passenger or crew member after an accident, the doctor or nurse will be involved in obtaining information about the accident as part of the relevant history and the preparation of the ship’s accident/injury report. Record as much detail as possible for future reference, regardless of how minor the accident or resulting injuries may seem at the time, and do it immediately; don’t rely on memory. The time aspect (date and exact time) will often become an issue: when – and where – did the accident happen, when – and by whom - was the accident reported, when was the patient first seen by the nurse and by the doctor and when followed up? What, how and why should be recorded in the patient’s own words, preferably exact enough that quotation marks can be used. All details of injuries or illnesses, regardless of how small, must be accurately recorded during the first visit. Document also any contributory conditions, such as weight, alcohol, drugs, medical history, use of medicines, allergies, shoes worn, weather conditions (rough seas, rain, etc.), as well personal observations (smell of alcohol, suspected use of drugs, disabilities, etc.), performance of all relevant medical examinations and prescription, and administration of all treatment deemed necessary by the doctor. These details will be needed for the doctor’s accident report and also important if a claim is filed against the ship.
The doctor and nurse will render all necessary treatment and, will refer the patient ashore for further evaluation and treatment if this is necessary in the doctor’s opinion. All medical treatment will be properly documented together with all follow-up care in the appropriate medical log. The doctor and nurse must always remain cooperative and courteous, but never suggest to a passenger or crew any opinion or conclusion about fault. When accident care is given free of charge, this is to be considered a goodwill gesture from the company and is not to be taken as an admission of legal responsibility.
All cruise lines have strict policies against any kind of harassment. CLIA members have established a ‘Zero Tolerance Policy on Crime’ with guidelines for reporting allegations of serious crimes to appropriate law enforcement authorities. A serious crime is generally defined as a felony, which would include sexual contact with minors, or assault or sexual assault or battery. The staff captain is usually in charge of these investigations. All medical staff must familiarize themselves with the detailed company-specific guidelines regarding the MC’s role and be prepared to use the commercial rape kits recommended by ACEP. They have detailed check-lists for the medical team to secure legally valid evidence.
The doctor or nurse may be the first company representative to speak with the patient and must always show the patient and his/her family (companions) compassion and concern. Make them comfortable and keep in mind that health, safety and well-being of the patient are of primary concern. If the victim is female, conduct the interview in the presence of another female staff member and document her identity. If appropriate, recommend that the victim attends an assault treatment center as soon as possible.
In addition to the doctor’s and nurse’s medical function, they are also the company’s‘ambassadors’. The patient may look to them for continuing support and be inclined to tell them things which may help in her treatment (both physical and psychological) and which may relate to the incident itself. Be available and visit or call the patient (and/or the family) periodically during the remainder of the voyage. Document all visits and attempted visits.
Passenger Referral Ashore
A primary purpose of the ship's MC is to make medical services available to passengers for common medical problems and, in emergency cases, to stabilize the patient until s/he can be referred to a health care facility ashore. In most cases, a shore-side specialist has far greater resources and facilities available for diagnosis and treatment than can possibly be made available on a ship. Whenever possible, the doctor should not let the ship leave port with a passenger that may need emergency or general hospitalization ashore.
If the patient refuses to leave the ship or refuses to stay at the hospital ashore and returns to the ship, the doctor should discuss the situation as soon as possible with the MCA or Master. He should have the patient sign an illness ‘Letter of Indemnity’ indicating that the passenger is continuing the cruise against the advice of the ship's doctor (see:Legal Aspects, above). If the passenger refuses to sign any forms, indicate that where the signature should be and in the patient log. Also get the names and signed statements of any medical staff or other employees who heard the passenger disregard the advice of the doctor.
Most ships' MCs are not equipped or intended for invasive surgery. Even if the ship's doctor is a surgeon, the patient should be referred ashore for surgical procedures (i.e. appendectomy), unless he determines that it is necessary to preserve life to do emergency surgery on board[jc3] .When the ship is far from the nearest port and outside helicopter range, conservative approaches that are not acceptable ashore may have to be used.
Crew Referrals to Medical Specialists ashore
Crew referrals to medical service ashore are necessary when the ship’s doctor feels that the ship’s resources are insufficient. The ships’ insurance covers medical referrals for crew, but experienced cruise doctors try to avoid port consultations whenever possible as they are generally time-consuming, inconvenient, costly and often useless because of language barriers and limited port time. Referrals to dentists may represent an exception, since the ships’ MCs are only expected to handle simple dental emergencies and temporary repair.
Referrals for Dentistry ashore
Dental treatment performed aboard is free of charge for crew members, but they have to pay for dentistry ashore, except for basic dental examinations, X-rays and tooth extractions, as well as for treatment for work-related dental injuries. Therefore, many crew members choose to wait until they can see their own dentist at home, but their decision may depend on numerous factors, like symptom control, general fear of dentists, damage visibility, vanity, income level, remaining contract length, availability of a dentist in the next port within the possible time frame, possible language barrier, estimated cost of the dental procedure, reputation of the port dentist’s skill and friendliness, etc. This ‘wait-and-see’ attitude is often encouraged by the ship’s medical staff members, who have seen that many port referrals cause frustration and anger, as prices for emergency port dentistry are uncontrolled and often (too) high, communication poor, the time in port too short and follow-up often impossible.
An adverse effect of the insurance practice of covering extractions, but not maintenance, is that low-wage crew members often insist on extracting a painful, but salvageable tooth.
Another problem arising from this insurance policy occurs when a low-wage crew is referred to a modern dentist who refuses to sacrifice the tooth and instead, believing that the cost is covered by the ship, starts high-priced root canal work that has to be followed up and finished by expensive dentists in other ports.
Passengers with toothache may be disappointed not to get expert help on board, but because they are usually aboard for much shorter time than the crew, the referral rate of passengers to port dentists are lower than those of crew.
A few cruise lines actually have had programs of full service dentistry aboard, provided by shore-side companies. However, after initial enthusiasm, the programs seem to have folded. One problem was lack of guaranteed cabin space for the dentist during fully booked cruises.
So how can dental conditions at sea be improved? Doctors performing pre- and re-employment seafarer examinations are by international law required to examine the dental state of the crew and should ensure that dental problems are solved before sign-on.
Pregnancy, Maternity and Children – Cruise Line Policies
It is the responsibility of each female crewmember to officially inform the ship’s physician as soon as they become aware of their pregnancy. The ship’s physician should then monitor her to ensure she is assessed by a port of call obstetrician/gynecologist of her choice. Companies’ agreement with the International Transport Federation ensures that if the crewmember refuses to see a port of call obstetrician/gynecologist or she is denied permission to sail, she should be signed off the ship with two months of regular pay and an airline ticket home - with documented instructions to see a obstetrician/gynecologist immediately.
Complications at any time during pregnancy, in particular miscarriages and ectopic pregnancies, are always more dramatic at sea and therefore dreaded by the medical staff, especially on cruises to remote areas where shore-side medical facilities and blood transfusions are not available.
An expert panel of medical cruise representatives supported by CLIA suggested in 2006 that passengers and crew should be prohibited from sailing if they will have entered the 24th week(or later) of pregnancy at any time during the cruise. The main reason was that medical facilities available on cruise ships are not suitable for, neither are ship’s doctors expected to be trained in, neonatal care. Moreover, a septic work-up on a febrile infant requires pediatric equipment beyond the capability of cruise ships. Therefore, most representatives also felt that children should not be permitted to sail prior to 12 weeks of age on the first day of cruise. However, they found it reasonable that certain lines may extend this minimum age based on other risks (e.g. longer, or more remote cruise itineraries) where appropriate back-up facilities are deemed inaccessible.
Furthermore, there are good medico-legal reasons for a 24th gestation week pregnancy time limit. Before last trimester the fetus cannot be considered viable outside the uterus without specialist intervention; a neonate born before 24 weeks on a cruise ship can hardly be expected to live.
n addition, if a woman is hospitalized ashore for pregnancy complications, she may not be able to get home. Some airlines require health certificates from all passengers traveling beyond their seventh month of pregnancy. She will need a certificate from a physician stating that it is safe for her to travel by air, and she might not be able to get that until well after delivery. It is usually considered safe to travel by air 1-2 weeks after uneventful vaginal delivery, but in case of complications air travel to get home may have to be indefinitely delayed. Besides, diplomatic complications may prolong repatriation if a baby is born in international waters on a vessel registered in a country different from the one where mother and child are urgently disembarked post partum. Lack of passport and visa for the child may make it very difficult to transit some countries, like USA, to get home.
Most major cruise lines now adhere to the 24th week rule for pregnancy.
Oxygen – dependent Passengers
Passengers who may need oxygen during a cruise are considered medically unfit for traveling. For safety reasons liquid or gas oxygen tanks are usually not permitted in any staterooms or public area, nor is the ship able to store portable oxygen tanks for passengers who may need oxygen during shore excursions.
Oxygen concentrators may be used on most ships provided that the passenger bring their own or make direct arrangement with an independent medical contractor who agrees to undertake all required arrangements without involving the MC and its staff. Such a contractor must assume complete medical responsibility.
The concentrator-dependent passenger and the traveling companion must be completely familiar with the operation of the concentrator. They must agree in advance to leave the ship immediately if they cannot operate the concentrator, should the equipment, at any time during their voyage malfunction, or if the passengers develop symptoms or complications that may require medical assistance.
Concentrator-dependent passengers must be aware of the fact that the ships are often in areas where evacuation to modern medical facilities ashore may not be possible for days, and that the MC aboard is neither equipped nor staffed to handle emergencies related to the above.
Dialysis at Sea
Many ships will accept passengers with kidney failure that require continuous ambulatory peritoneal dialysis as long as they bring all necessary equipment aboard and are capable of doing all procedures themselves (self-administration).
If physician-assisted hemodialysis is required, some companies will assist commercial providers perform hemodialysis programs at sea if the latter take all medical and legal responsibilities and do not involve the ship’s regular medical staff in the procedures.