There was a subtle electric click as the overhead tannoy crackled into life. I was already half in my scrubs before it summoned me to the medical centre. CPR was in progress on a pale and flabby middle aged man. He was naked from the waist down, having just been dragged off the toilet, with a blood stained sheet protecting his shriveling dignity. The acrid smell of malaena assaulted my nostrils as I directed the team as if we were performing our weekly drills. A single round of compressions and adrenaline was enough to bring our patient round…for now…but what he really needed was blood.
When I tell people that I used to be a doctor on a cruise ship they generally have two frames of reference. They think either of “The Love Boat” or the adventures of the put upon SImon Sparrow in “Doctor at Sea.” They think of the crisp white uniforms and dining at the Captains’ table. They think of gastro outbreaks and mal de mer. What they don’t think of is acute medicine. In the almost five years I spent sailing the oceans I treated passengers aged from 2 to 102. I dealt with all stages of life, from conception through to death. I dealt with ectopic pregnancies and suicides as well as things that no text book could prepare me for (piranha bites anyone?).
I have worked on ships of all sizes. There were those that were small enough to pass up the Amazon and those that were floating Caribbean hotels. I was the doctor for a drifting rural community of between 1000 and 4500 people, the majority with the average age between 65 and 75 and the attendant medical problems that come with seniority. I wasn’t alone in my practice though. Helping me on the smaller ships were often a couple of excellent nurses whereas the bigger vessels had a complement of two doctors and four nurses for a population that changed almost weekly.
Working at sea taught me skills I use every day in the emergency department – team leadership, crisis management, communication and customer service. Most of all it taught me how to work with limited resources.
Think through what you do in the ED when someone comes in with a big PR bleed. What tests do you order? How much blood do you request from the blood bank? What’s your disposition for the patient? Now think how you would deal with an exsanguinating post-arrest patient two days from the nearest land when you don’t stock blood?
The first thing you do is delegate. With four nurses and two doctors on board someone is going to have to go back to bed to be able to work the day shift as you have a long couple of days ahead of you. There is no chance to divert the ship or speed up your arrival time. One of your nurses and the other doctor start doing the standard post arrest care – obtaining a second IV line, running off an ECG, taking bloods for an haemoglobin as well as a group. They hand them over to the second nurse who is in the onboard laboratory running the tests, confirming the results of the Eldon card with you and preparing for the next stage.
Whilst cruise ships do not stock blood it is only a phone call away. After a brief telephone conference with the captain and senior purser (think hotel manager) a call is put out for any passengers with compatible blood to present themselves to one of the restaurants. Why passengers? Well, theoretically they are less likely to have picked something up on their last run ashore than the crew. Eight likely donors show up as a result of your early morning wake up call. Once the situation has been explained to them the third nurse takes a sample of donor blood and screens it – confirming group as well as HIV and hepatitis status.
By the time an hour and a half has passed you are already transfusing the first bag of still warm whole blood into your patient. By three hours you have four units in hand should he bleed again. You are still two days away from land, remember?
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