Up, up and away
If you want to medically disembark a passenger from the ship there are three platforms to chose from. The easiest, and safest, is to wait until you come alongside in port an disembark them to a waiting ambulance. This works out well for patients with stable conditions such as a fractured neck of femur or a stroke. If you are close to land but the water is too shallow you could chose to disembark them by boat but transferring from one rocky platform to a smaller, rockier one can be dangerous. But unfortunately some passengers present with time critical surgical problems that are not going to get much better with intravenous antibiotics. If you are sailing around the coast of Alaska and have a patient present with a possible subarachnoid bleed then they need to be off the ship as quickly as possible. Contrary to what some passengers believe we have neither a CT scanner or an MRI on board.
The tranquil glacial waters mean the ship remains a (relatively) level platform for helicopter winch operations. As well as our regular cardiac arrest drills we also performed regular Heliops drills. Winch operations from land are pretty low risk when you compare them to winching a sick patient off a moving cruise liner. The benefits to the patient must outweigh the risks – to both the helicopter crew and the ship itself. Once the medical decision has been made and both coast guard and captain consent a complex team effort takes place to minimize risk. Deck hands and hotel staff clear away the deck chairs and towels and get rid of anything that may be swept up into the rotors. The swimming pool is dumped and empty martini glasses locked away. The engineering fire teams are fully kitted up with charged hoses and breathing apparatus on in case the helicopter comes down. The bosun has the fast response boat prepped and ready. Everyone is prepared for plan C.
The medical team are a small component of the team that facilitate the disembarkation of the time-critical neurosurgical patient.
The alternative is disembarking the patient by tender (those little orange lifeboats) to the nearest port followed by either rotary or fixed wing retrieval. In the developed world it is a straightforward process that just requires coordination with the retrieval service. In the less developed South Pacific it is a more complex operation.
Take Sydney* who suffered a VF arrest in the middle of a line dancing class. A couple of shocks and an ETT later he was safe enough to be transported down six decks to the medical centre. Recurrent runs of VT meant he needed a central line and an amiodarone infusion prior to transfer to a cath lab. The nearest ICU in the region was in Noumea, two days away by ship. With the help of the local port agent and a willing boat crew Sydney was transferred to the tender then endured a 20 minute boat journey to the nearest island, Poum. It was 500m carry up a gravel lined path to the helicopter landing zone in 30 degree heat for myself and a couple of crewmen. Once again preparation was the key – not heading out too early and running out of oxygen, fully charged pumps and a ready supply of drinking water. But you can only plan so much. A good retrievalist is able to cope with anything life throws at them.
Everyone knows the importance of a good handover Slightly more of a challenge when you have to conduct it in French!
*Not his real name
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