Emergency medicine on the high seas
Dennis Djogovic, MD
Emergency Medicine Resident, University of Alberta, Edmonton, Alta.
The boy could not have been older than seven. As he held out the book and pen, I had to smile. The self-consciousness I felt earlier that evening, while putting on my formal whites, melted away. I had never been asked for my autograph before.*
I was approaching the 4th year of my emergency medicine residency, and looking forward to using some elective time to pursue a totally unique medical experience. Five months later, I found myself as one of two physicians on a Caribbean cruise ship. Blue seas, bluer skies, margaritas by the pool; it seemed like a dream. But reality came quickly.
I entered the exam room to meet my first patient. He was a sullen 7-year-old with sunken eyes and a bald head -- both consequences of chemotherapy for rhabdomyosarcoma. His Dad described the fever he had recorded shortly before, but history and physical revealed no localized infection. Could we get a CBC and differential to rule out neutropenia? Unfortunately, we cannot get a differential on the white count. How about a urinalysis? The little boy can't pee right now, and is deathly afraid of a catheter. Is there anything on chest x-ray? I struggled to achieve the right penetration, but the series of x-rays I produced looked more like a Rorschach test. With much trepidation, I did something we seldom do in tertiary emergency departments: I discharged the boy and asked him to see me again the next day. Later that evening, I passed by the pool and saw my patient, running like mad and screaming through a huge grin. Dad caught my eye and flashed me a "thumbs up." A heavy weight lifted off my shoulders.
There I was, 5 hours from land, rolling through rough seas, with a big inferolateral MI staring me in the face.
My most challenging moment came in the form of an 02:30-hr page from the duty nurse, who was seeing a patient with 10/10 chest pain. Ten minutes later he was in the clinic -- pale, diaphoretic, bradycardic and hypotensive. An ECG showed ST elevation in leads II, III, aVF, V5 and V6. There I was, 5 hours from land, rolling through rough seas, with a big inferolateral MI staring me in the face. Despite being mobilized from our sleep, we managed to thrombolyse our patient in 35 minutes, only 5 minutes from making the Heart and Stroke Foundation proud. Forty-five minutes later, our patient's pain had completely resolved. His ECG, now free of ST changes, was a sight for tired eyes.
Working on a cruise ship opened my eyes to the difficulty in practising acute care medicine with limited resources and personnel. It also showed me that a cruise medicine elective could provide first-hand experience with two key aspects of emergency medical services: patient transport and disaster planning.
Should a patient need a higher level of care, there are few choices for emergency disembarkation. On a ship with no helipad, helicopter evacuation is difficult. It requires the helicopter to match the speed of the ship and, while hovering four stories above the highest deck, lowering an evacuation basket to lift the patient. The other options are to have the captain increase the ship's speed toward the intended destination, or possibly to divert course to a closer one, through less familiar ocean topography. Neither is attractive or easy; both pose challenges for the bridge and endanger all aboard.
It is far from the lush tropical "elective holiday that one might envision. ... The responsibilities assigned to the resident are immense because no one on the ship thinks of you as anything less than a fully licensed physician, ...
Disaster planning for 3500+ people is not straightforward. However, the weekly mock drills for medical emergency, man overboard, raft survival and ship evacuation were impressive and incorporated all on board, from dishwasher to guest to executive officer. Perhaps, one day, a similar level of disaster preparedness will become as routine in our own institutions.
A cruise medicine elective is a relevant and rewarding experience for any EM resident who would like to pursue experiences outside the traditional ED. The American College of Emergency Physicians has a Section on Cruise Ship and Maritime Medicine that can be contacted for more information (www.acep.org/1,4254,0.html). The benefits of completing such a rotation are numerous. It is far from the lush tropical "elective holiday" that one might envision. Working, interacting, relaxing and studying within the limited confines of a ship's quarters are challenging and taxing, and bring forward images of being perpetually "in house." The responsibilities assigned to the resident are immense because no one on the ship thinks of you as anything less than a fully licensed physician, therefore responsible for the health and safety of all on board, as any other senior officer. The variety of patients and problems, and the immense danger of waiting too long to declare the status of a potentially critical patient push the resident to hone that ever important skill of rapidly and confidently determining "who is sick, who is not," and often doing so without any investigations. These skills are essential and transferable to a career in the ED.
Infectious outbreak recognition and isolation, random crew drug testing, and 24-hour first responder status are other elements of the cruise ship experience. But most rewarding were the social exposures: 2700 guests notwithstanding, the 950+ crew formed a unique international community that welcomed me wholeheartedly. People from all corners of the earth could be found on this seemingly small vessel, making it seem much smaller than when I first boarded.
*I took the book and pen from the young boy. I thought of all my experiences and then I wrote. "Dear Tommy, Hope you had a great cruise. I know I did. -- Dr. Dennis."