Practice makes perfect by Dr Andrew Tagg
If you are over 65 and have too many medical problems to be safe to fly then your only option for an overseas adventure might be going on a cruise. Every time we started a new journey I would look out of the clinic portholes and try and guess how many passengers would be trundling up the gangplank with their portable oxygen supply in tow. Often going on holiday also meant taking a break from your regular medications too. With a high pre-voyage levels of morbidity one would expect a high level of mortality on board. As Casey Parker (@broomedocs) said here, cruising is for “the newlywed, overfed and nearly dead.” Famous cases of death by misadventure notwithstanding we would be called to a cardiac arrest on every voyage. With time to first defibrillation being the most important predictor of survival we managed to achieve delivery of first shock within two minutes, comparable with the recommendations for in-hospital practice(1). How did we get so good? Practice.
The average cruise ship is over 1000ft long and 16 storeys high, with enough cabins for 3000 passengers and 1000 crew. In order to have comparable response times for reaching our patients we would perform weekly cardiac arrest drills. As the senior doctor I was charged with lugging our mannikin to any part of the ship and putting out the distress call at any time of day or night. The medical team would be expected to respond within two minutes no matter what they were doing. This high stakes game of hide-and-seek honed our algorithms but also pointed out any systems errors that needed addressing. How were we going to get the drowned man out of the pool? How were we going to provide dignity for a patient in the middle of the dance floor? Just how many flights of stairs did you have to run up when the lifts weren’t working? In one drill run by the UK coastguard that involved evacuation of the medical centre on a one doctor ship I had to run 75 flights.
As an officer on a ship you are rarely out of uniform when above stairs. A medical emergency is an exciting break from shuffleboard and line dancing for a lot of passengers and provides them with stories to tell when they get back home. Whilst I have performed countless RSI’s in theatre and in the ED there is a sense of added pressure when you are doing it in the atrium of the ship, with three decks of passengers watching on (some with video cameras), all whilst wearing the formal uniform of white jacket and black bow tie. The key is situational awareness, taking control of ones surroundings and relying on your team. Relentless drilling creates more than just a memory of cardiac arrest protocols, it leads you to consider points of entry and exit. It means you have learned to send one person up ahead with the red handbag (the always carried AED) whilst the second doctor grabs the Resus bag from the medical centre and the stretcher party trundles along with the Stryker trolley in their own time. It means you know the names of the security guards and can ask them to create some space and some privacy. It means you trust your nurses to run the arrest when you have to strip off your bow tie and get on with the skilled tasks. It means waiting till you are out of the public eye before you pull a “Benton” for another life saved!
Dr. Andrew Tagg left the shipboard life in 2009 to settle down and lose weight. He is currently an advanced trainee in EM working in Melbourne’s western suburbs. He still has the uniform. Contact him via Twitter @andrewjtagg
1. Chan, Paul S., et al. “Delayed time to defibrillation after in-hospital cardiac arrest.” New England Journal of Medicine 358.1 (2008): 9-17.