From the Chair
By Arthur L. Diskin, MD, FACEP
As I assume the helm of this section (excuse the pun) and consider the section’s role in the development of our "subspecialty," I believe we are looking straight into the face of third-party accountability for our medical departments and shipboard infirmaries.
Many of our passengers have never seen an episode of The Love Boat and a significant number were born after it aired. The glamour and uniqueness of cruising has evolved into a standard American/European vacation and our passengers expect to take all the safety and security of home with them. The governments and governmental agencies that respond to the needs of their cruising citizens will continue to develop mechanisms to provide this sense of security. I believe medical services will fall squarely within the sights of these agencies in the next few years.
As an industry, we currently do little to quantify what we see on the ships and how we take care of it. We have no DAWN registry for overdoses, NERMI for MI or Trauma Boards. We do not apply the concept of Core Measures to what we see aboard the ships. We have no standards of demonstrating the application of Performance Improvement principles to infirmary or medical operations.
We have a choice. We can do this proactively as individual lines or the section can create measurement standards that can be recommended to demonstrate an on-going quality delivery of health care. Why shouldn't we "borrow" from existing literature – all ST elevation MI’s will be recognized and treated with thrombolytics within 30 minutes of arrival in the infirmary and treated with aspirin and beta blockers? Why shouldn't we borrow from the managed care literature to monitor the preventative care of our hypertensive and diabetic crew members? How do we demonstrate our accuracy rate for real time X-ray interpretation?
I would like to see the section become a repository for thoughts on this topic over the next year, as well as collect what the cruise lines are currently doing to demonstrate ongoing competency and quality care. Please forward me ideas to me. This should be one of the major topics of discussion at next year’s meeting; and, if agreed, we can move forward with the development of recommendations the following year.
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From the Editor
Cruise Ship Doctors and Nurses Do Not Require Experience in Acute Care Medicine
By Benjamin M Shore, DO, FAAP, FACEP
OK ... did I grab your attention? Oh, goodie. How I love to be controversial!
Fortunately, I am never controversial for the purpose of being argumentative. But as the newly appointed Chair-elect and Newsletter Editor, I love to deal with interesting topics and share challenges that we see from our unique perspective as cruise ship medical professionals.
I am so proud to be directly involved in cruise ship medicine since February 2002. And now, with this nifty pulpit which you have afforded me, we can have some very lively discussions in the months to come. But whether I succeed in my appointment is entirely up to you.
So in the months to come, I will solicit articles from everyone ... which will be of interest to everyone. In my view, this newsletter should not substitute for a medical journal. After all, we will not offer significant competition to the New England Journal of Medicine. However, we have a wonderfully diverse background of experiences, and I welcome all interesting medical cases, "tricks of the trade," or interesting experiences that you have encountered in your travels as a cruise ship medical professional that you wish to share with all of us in the field.
Under my dubious guidance, any topic which does not violate good taste and medical ethics is fair game. And so, I bring to you a glimpse of my first topic, and invite your comments: Cruise Ship Doctors Do Not Require Experience in Acute Care Medicine.
The public impression of cruise ship medicine was accurately captured by Bernie Kopell as Dr. Adam Bricker on the Love Boat. This "brilliant" show last aired in May 1986. As the archetypal cruise ship physician, Dr. Bricker ran the general practice office of the seas. He lent considerable advice to his lovelorn passengers and crew members each week aboard the Pacific Princess.
What a great practice he conducted. All that was required of him was his compassion, his sense of humor ... and, on rare occasion, his medical knowledge! I would like to believe that little has changed in these last 20 years. In fact, I would also like to believe that all lawsuits are meritorious, all plastic surgeries are medically necessary, and speeding tickets discourage speeding.
In 1919, a disillusioned young boy walked up to "Shoeless" Joe Jackson, one of the Chicago White Sox players who allegedly conspired to deliberately lose the World Series, and cried, "Say it ain't so, Joe!" I would love to tell you that "it ain't so." Unfortunately, anyone who has not been comatose for the past two decades knows it is so.
Today's cruise ship medical professional must deal with many pressing issues -- preparing sanitation reports to the CDC Vessel Sanitation Program and Division of Global Migration, providing specialty-level medical care that often surpasses the care available at lesser-equipped shore-side facilities, and anticipating the needs of guests and crew members on a floating city of more than 3,000 people for fear of running short of critical supplies beyond the limits of delivery. All this, while coping with the public relations demands of a consumer-oriented business!
This is no longer a job for the generalist hoping to spend a few last months of practice as a floating, vacationing semi-retiree. This is no longer a job suited to the novice who has had little practical experience, hoping to acquire on-the-job experience until choosing a life-long professional direction. Rather, this is a job for Superman ... or Superwoman, as the case may be!
And so, we now come full circle. My premise was, indeed, purely controversial. I have little doubt that the demands of a modern-day cruise ship medical center require the services of full-time, committed medical professionals who have broad experience in delivering quality, acute medical care, exceptional public relations skills, and a commitment to maintaining public health aboard our ever-larger vessels.
And it is only fitting that the medical directors of all of the major cruise lines have adopted ACEP guidelines and seek experienced, seasoned medical professionals to staff their medical centers aboard their vessels. It is fitting that these respected travel businesses seek committed doctors and nurses who have chosen cruise ship medicine as a career.
I am proud to be a member of this privileged group. I look forward to your communications in the year to come.
Warm professional regards,
Dr. Ben Shore
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Presumed "Gastritis" -- Pitfalls and Differential Diagnosis of Epigastic Pain/Nausea and Vomiting
By Matthias Dahlmanns, MD
All too often, physicians are confronted with patients complaining of nausea and vomiting, with or without epigastric symptoms. This especially holds true for doctors working on cruise ships. When the seas are rough and the ship is "rocking and rolling," such symptoms are common, and we tend to delegate the initial assessment and treatment of the patient to our nurse, telling her to give him "a shot" for motion sickness. Most of the time we are right, but what happens if we are NOT?
These two cases from our ship’s practice occurred within one week of each other. They are brief clinical descriptions, intended to keep us vigilant of possible pitfalls in the differential diagnosis of patients presenting with non-specific epigastric symptoms.
CASE 1
History:
A 70-year-old Hispanic female presented to our ship’s medical center, complaining of upper abdominal discomfort, nausea and vomiting, bloating and constipation. She had a history of hiatus hernia and Type 1 diabetes mellitus. The night before, she had eaten spicy food, to which she attributed her symptoms. Communication was conducted through an interpreter.
Past History:
- Coronary artery disease with a three artery bypass graft six years earlier and a coronary arterial stent placed one month prior.
- Hiatus hernia.
- Insulin dependant diabetes
Regular Medications:
Clopidogrel, verapamil, lisinopril, Crestor, Lexapro, Humulin R and L.
On examination:
The patient appeared in severe abdominal discomfort. The mucus membranes and skin were dry. No jaundice, anemia or cyanosis noted. Temperature: 36.3 C. Pupils: equal and reactive, no focal signs. Respiration: clear lung fields, Saturation 96% at room air. CVS: BP 108/51 Pulse 60/min, regular, no chest pain. No signs of CHF. Abdomen: obese, soft with epigastric tenderness and normal bowel sounds. Neurological: slow but responsive and initially oriented to person time and place. GCS: 15/15 (E4, V5, M6).
Assessment and Management:
The patient was admitted to our medical center with the initial diagnosis of gastritis/dyspepsia, dehydration and possibly poorly controlled diabetes mellitus. An intravenous infusion of normal saline 0.9% was started, and she was given Buscopan, metoclopramide, and cimetidine intravenously, and Mylanta by mouth.
Further tests showed:
- ECG with possible signs of lateral ischemia in V4, 5 and 6. No signs of acute MI. Cardiac status panel: myoglobin, troponin 1, CK-MB negative.
- Blood sugar: 550 mg/dl.
- Urine for urinalysis could not be obtained.
The patient settled down briefly on the above treatment. After additional questioning, however, it became clear that her glucose had been uncontrolled for several weeks prior to joining the ship.
Shortly afterward the patient became stuporous, with hypoxia, bradycardia, and cardiovascular collapse requiring assisted ventilation and aggressive fluid resuscitation including inotrops. After stabilizing her in our medical center, she was transferred to a shore-side facility for further management in ICU.
Secondary Diagnosis:
Non-ketotic hyperosmolar diabetic coma, with severe dehydration and cardiovascular collapse.
CASE 2
History:
A 34-year-old man of Chinese decent. Communication through an interpreter. No medical history of note. No regular medication.
He apparently became acutely ill after joining the ship. He presented to our ship’s medical center at 5:30 am, with a history of prolonged vomiting (about 30 times), nausea and abdominal discomfort for the past two days. He also reported some weakness/dizziness and cramping of both hands and feet. His vital signs were normal, and he was afebrile. He presented with a soft abdomen and normal bowel sounds. Initial diagnosis was motion sickness and acute gastritis. He was treated as an ‘outpatient’ with metoclopramide, Bentyl, and omeprazole. The patient, however, presented again about five hours later with continuing symptoms of weakness, nausea and muscle cramps. He reported some improvement of his abdominal pain. After additional detailed questioning, he also reported weakness, disorientation and frequency of urination over the past weeks while at home.
On examination:
Young adult, slim in stature, complaining of weakness, dizziness, spasm of wrists and fingers of both hands. Dehydration mild to moderate with dry mucus membranes. Temperature 37.2 C. Respiration: clear. CVS: BP110/70, Pulse 90/min, regular, no chest pain. Abdomen: soft, mild epigastric tenderness, no guarding, normal bowel sounds. Neurological: oriented to person, place and time. Cranial nerves normal. Pupils equal and reactive. No focal signs, however spasm and paresthesia of both hands. Other systems normal.
Assessment and Management:
The patient was admitted to our medical center, an intravenous line with normal saline 0.9% was started, he was monitored, and further tests were conducted:
- Blood sugar: 408 mg/dl (double checked peripheral and venous sample).
- Potassium: 3.97 mmol/l.
- Hemoglobin: 12.5 g/dl.
- Urinalysis: 4+ glucose, 4+ ketones, 3+ blood.
The patient received further intravenous fluids with potassium during the next three hours. He was given an initial bolus of 10 units of Humulin R. Prior to leaving by ambulance to the next shore-side hospital, he was stable and feeling better, his blood sugar had come down to 268 mg/dl and he had a good urine output of 150 ml/hour.
Secondary diagnosis:
Newly diagnosed acute diabetic ketoacidosis (DKA), with uncontrolled hyperglycemia, dehydration and electrolyte imbalance.
DISCUSSION
Diabetic ketoacidosis (DKA) and nonketotic hyperosmolar state (NKHS) are acute complications of diabetes. Both disorders are associated with absolute or relative insulin deficiency, volume depletion, and altered mental state. Diabetic ketoacidosis (DKA) requires prompt diagnosis and all patients with dehydration, altered mental state, respiratory difficulty should be tested for capillary blood glucose (CBG) and urinary ketones. Hyperosmolar non-ketotic state complicates elderly Type 2 diabetes and is often triggered by poor diabetic control and/or underlying infections, most commonly respiratory tract infections.
Table 1. Clinical Presentation
Table 2. Laboratory Values
Table 3. Differential Diagnosis of Epigastric Pain
Management
The details of the management of a diabetic coma are not the subject of this brief clinical review. In summary, there are three important and common components in the management of diabetic ketoacidosis (DKA) and diabetic non-ketotic hyperosmolar state (NKHS):
- Fluid replacement.
- Correction of hyperglycemia and electrolyte imbalance.
- Treatment of underlying medical conditions.
The major difference between the two types of diabetic coma is that in non-ketotic coma, fluid requirements tend to be substantially higher than in diabetic ketoacidosis. In NKHS, fluid deficits average about 22% of total body water, or about 8 liters, while in DKA, fluids deficits are typically closer to 5 liters. Initial fluid resuscitation and replacement are of utmost importance and should be addressed primarily. Mortality rates of hyperosmolar non-ketotic coma approaches 20-40% and are significantly higher than in DKA because of concomitant disease, complications, and old age.
Both cases demonstrate the importance of a detailed history and physical examination. Clear communication collected from the patient and/or relatives are key in this process. A good history alone often enough points us in the right direction and gives us valuable diagnostic clues, which then only have to be confirmed by our examination.
If the patient presents repeatedly or does not improve on our initial treatment, we have to become vigilant, questioning and reassessing our initial diagnosis, and start from the beginning.
We may get a "second chance," but rarely a third one.
References:
- Powers A. Harrison’s Principles of Internal Medicine 15th ed. 333. Diabetes Mellitus.
- Alberti KG, Zimmet PZ: Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: Diagnosis and classification of diabetes, provisional report of a WHO Consultation. Diabet Med 15:539, 1997.
- Arieff A. Diabetic Comas – Ketoacidaosis, Non-ketotic hyperosmolar Coma and lactic acidosis, chapter 11.
- Umpierrez GE et al: Review: Diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic syndrome. Am J Med Sci 311:225, 1996.
- Mukherjee AK, Chowdhury MB, Journal of Indian Medical Association, 2006 May;104(5):244-6, 248.
- W.Berger, Schweizer Rundschau Med.Prax. 1997 Feb. 18; 86(8):308-13
About the Author:Dr. Dahlmanns has trained and worked for many years in emergency medicine, internal medicine and surgery in Cape Town, South Africa. He has been working with NCL since January 1999.
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Just Another Sprained Wrist?
By Robert L. Simich, DO
Ship Physician, Norwegian Cruise Lines
While sightseeing in St. Thomas during a Caribbean cruise aboard Norwegian Cruise Lines MV Norwegian Spirit, this 62-year-old Caucasian male passenger slipped and fell. He landed on his outstretched, non-dominant right hand. Twenty hours post injury, the passenger presented to the Spirit's medical center for examination.
Physical examination revealed a swollen painful right wrist and hand. NVS was intact, and there were no ecchymosis, abrasions, or deformity. There was voluntary splinting with limited range of motion.
X-rays were taken of the hand and wrist in AP, lateral, and oblique view.
X-ray AP
|
X-ray lateral
|
X-ray oblique
|
What is Your Diagnosis ?
ANSWER:
X-ray examination revealed a 3 mm x 1 mm fleck of avulsed bone dorsal to the proximal carpal row, visible only on the lateral view. "This small avulsion fracture is often the only radiographic sign of a triquetral fracture." (Fracture Management for Primary Care, 2d Edition, Saunders, 2003, p 105.) Though much attention is paid to scaphoid fractures, a triqueteral fracture is the second most common carpal fracture.
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P.U.H.A. in STYLE
The stretcher team on the Pride of Hawaii takes a break and shows off their T-shirts. Written on the front – "P.U.H.A. in STYLE," referring to the popular paramedic term "pick up, haul ass."
Photo submitted by J. Renee' Reed, RN.
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Reintroducing U.S. CDC Quarantine Stations: Background and Reporting Requirements
By Kiren Mitruka, MD
Background
The Division of Global Migration and Quarantine at the Centers for Disease Control and Prevention (CDC) in Atlanta currently oversees 18 quarantine stations at major U.S. international airports and land border crossings. Each quarantine station has responsibility for communicable disease surveillance and response at all ports in an assigned geographic area (see figure 1).
CDC significantly reduced the number of U.S. quarantine stations in the 1970s -- from 55 to 8 -- after the eradication of smallpox. Infectious diseases were thought to have been conquered, and the focus of the remaining quarantine stations changed from routine public health inspection to program management and problem intervention.
The 21st century brought new challenges to public health with a new set of infectious diseases. In 2003, SARS spread quickly around the world through migrating populations, and other emerging infectious diseases, such as West Nile, anthrax, and monkeypox surfaced. Additionally, the threat of bioterrorism and pandemic influenza has grown, raising concerns about the international spread of infectious diseases via travel.
To prevent the importation and spread of disease into the United States, CDC has revived its quarantine program. It is expanding the number of its quarantine stations, as well as the capabilities and skills of their staff. Since 2003, CDC has opened 10 new quarantine stations and enhanced the training and response capability of public health officers by staffing stations with epidemiologists and physicians.
Reporting
CDC quarantine stations conduct syndromic surveillance for communicable diseases and, under federal quarantine regulations, require reporting of certain febrile illnesses and death. The applicable regulation (42 CFR 71.21[a]) states that "the master of a ship destined for a U.S. port shall report immediately to the quarantine station at or nearest the port at which the ship will arrive, the occurrence, on board, of any death or any ill person among passengers or crew (including those who have disembarked or have been removed) during the 15-day period preceding the date of expected arrival or during the period since departure from a U.S. port (whichever period of time is shorter)."
A person is defined as being ill, and the occurrence must be reported, if signs include any of the following:
- Fever (a measured temperature of 100° F [37.8° C] or greater) lasting more than 48 hours; or
- Fever of any duration plus any one of the following symptoms:
- rash,
- swelling of the lymph glands, or
- jaundice (yellowing of skin or eyes)
The federal quarantine regulations are being revised to broaden the reporting requirements to include certain febrile neurologic, respiratory, and hemorrhagic syndromes. Therefore, in addition to the required reporting criteria noted above, CDC requests that ships report the following conditions, which may also indicate a serious, communicable disease:
Fever of any duration plus any one of the following conditions:
- difficulty breathing or suspected/confirmed pneumonia,
- cough for more than 2 weeks or cough with bloody sputum,
- headache with neck stiffness,
- reduced level of consciousness, or
- unexplained bleeding.
Cases of diarrhea are also required to be reported in accordance with federal regulations, and cruise ships should continue to report such cases to the CDC Vessel Sanitation Program. To make a report of other febrile illnesses and death, the ship or its agent should contact the quarantine station at or nearest the port of arrival.
CDC quarantine stations, their contact information, and areas of jurisdiction are found at http://www.cdc.gov/ncidod/dq/quarantine_stations.htm. If contact cannot be made with the nearest station, please call the CDC Quarantine Duty Officer on call at 866-694-4867. CDC Quarantine Division staff will make a public health assessment of the illness in conjunction with the subject-matter experts at CDC and provide guidance to the ship on appropriate control measures to minimize the risk of spread of illness and contribute to a healthy cruise environment.
Author’s Acknowledgment: Donald Meadows, MA, Editor/Writer on contract with CDC’s Division of Global Migration and Quarantine, Quarantine and Border Health Services Branch, in Atlanta.
About the Author:Dr. Mitruka is the Medical Officer for the Centers for Disease Control and Prevention, Miami Quarantine Station, Division of Global Migration and Quarantine.
Figure 1 — CDC’s 18 quarantine stations, as of 2006. The shaded areas indicate the jurisdictions of each station.
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How (Not) to Apply for a Medical Position on a Cruise Ship
By Eilif Dahl, MD
You don’t have to be particularly superstitious, or demand solid evidence, to accept that you suffer from very bad luck to be run over by 13 steamrollers.
Another self-evident fact: If at first you don’t succeed, skydiving is not for you. And if you decide to do it anyway, don’t blame the pilot if you didn’t bother bringing a parachute, or check in advance if it was properly packed.
To apply for a job is a little like skydiving -- if your application is not good enough, you will not get to second base, the interview. (That is, unless the company is desperate for help, in which case you should think twice about that job anyway.) The job application is your first, and therefore a crucial, test. Having read a large number of applications from well-intentioned medical professionals who want to work on cruise ships, I know that there is ample room for improvement.
Here are some tips if you consider working as a ship’s doctor or nurse:
- Your application should show that you have some familiarity with cruise medicine and life on passenger vessels. It doesn’t help much to write that "I love the ocean and spend most of my free time on my 45-foot sailboat." It might actually be better to put "I enjoy dancing with little old, blue-haired ladies." Then we might be able to use you aboard – as an unpaid dance host. If you are recently retired and look forward to travel and relaxation, don’t apply to be the doctor on a large, busy cruise ship; buy a ticket instead, and have the time of your life.
- Have at least the minimum qualifications, as outlined in Health Care Guidelines for Cruise Ship Medical Facilities. "Medical staff should undergo a credentialing process to verify the following qualifications:
- Current physician or registered nurse licensure
- Three years of post-graduate / post-registration clinical practice in general and emergency medicine or board certification in Emergency Medicine or Family Practice or Internal Medicine
- Competent skill level in advanced life support and cardiac care.
- Physicians with minor surgical skills (i.e. suturing, incision and drainage of abscesses, etc)
- Fluent in the official language of the cruise line, the ship and that of most passengers"
So if you are just out of medical school, get the necessary practice experience and documentation before you apply. And those out of depth in a parking lot puddle should forget about an ocean-going career.
- Put some effort into the appearance of your application. Surprisingly, even doctors with impeccable medical credentials submit applications with numerous spelling errors and poor grammar. The medical consultant will wonder, "If you don’t bother to use a simple spelling and grammar program, will you check medical references if in doubt about a diagnosis or a treatment?"
Documentation on board is crucial ("If you didn’t document it, you didn’t do it!") To defend a medical case in a court of law is unpleasant, even when it was correctly handled. It becomes a nightmare if the record looks like it was written by a preschooler.
Here is a recent e-mail exchange that may illustrate some of my points --
"Hy, My name is NN, I am from (X country) and I am generalist doctor. I am looking for a job as doctor or nurse on a ship. I will attach my C.V. and I hope you will give me an answer. Dr. NN"
His CV showed that he was 26 years old and had worked only a few moths after graduating from medical school - as "probation doctor." However, as my company had no openings, I answered truthfully that I was sorry to disappoint him as all positions were taken.
His prompt comeback --
"Thanks for reply! i am sure that my nationality means a lot in your answer. Have a good day!"
I couldn’t resist --
"Dear Dr. NN; Certainly an unexpected, but interesting response. Why would you think that? Do you know something I have missed? Sincerely…"
He answered --
"Sorry! I was angry and furious because a lot of companies are looking for nurse or doctors, but when i told them that i am from (X), their answer is: sorry, we are looking for somebody who has finished the studies in usa or Canada. I am angry because the medicine, the anatomy, the diseases are the same in my country. They don't say that i have not enough experience, or something else. why don't they try me?
I think my biggest defect is that i was born in (X)! Ok, forget it! It was a bad day for me and i has ischarge on you! . My mistake! Sorry again! You was in the wrong place in the wrong time! I hope you will understeand that and you will forgive me! I wish you a good day! Dr NN"
My reaction --
"Cruise medicine is serious business and one of the most challenging areas in international medicine today. You might have confused nationality with license; most cruise passengers are American, and some companies or the ships' flag state - for good medical and legal reasons - require a US or Canadian license. If you don't have one, you simply can't work. It's like driving a car: Without a license, nobody cares how well you drive. If the police find you behind the wheel, you may even get arrested.
For minimum medical cruise staff requirements, you might want to consult the web sites of American College of Emergency Physicians and International Council for Cruise Lines
Furthermore, I am surprised at your statement: Why don't they try me? Well, they all already have: When you apply for any job, the very first and basic test is your application. If not even that is up to the expected standard, no sane company would risk giving the applicant a second chance. By the way, my medical cruise staff members never have a bad day. If they ever had one and reacted in your fashion to anybody aboard, guests or crew, their next day would be worse, as they would be off the ship and on their way home.
Sincerely, …"
Yes, a rather arrogant response from my side, but hopefully of some help for future applications. Also, applicants should be aware that a pompous reply may be an additional test -- if you can’t handle the consultant’s patronizing attitude, you will certainly and quickly get into trouble with cruise ship patients.
How did I get into cruise medicine? Well, I was 26 years old, had just finished my internship, and wanted to have a good time partying in the sun for a while before looking for a real job…
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This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.
