From the Chair: When Competitors Cooperate
Arthur L. Diskin, MD, FACEP
Sometimes it is just good business to work with the competition. We are in a unique position. The companies we work with or for are actively competing for market share and the passenger dollar in what has become a global market. Every purchase is looked at for Return on Investment – does it produce revenue, alternatively does it save money or meet a regulatory requirement? Medical diversions are judged not only on lives saved but fuel dollars spent.
However, within the scope of this competition rests opportunity. Passengers forget which ship had a Norovirus outbreak, where there was a sexual assault, or which ship stranded a passenger in a foreign port awaiting medical care. I have recently seen numerous opportunities for health care synergy and cooperation amongst the lines. There should be NO competition amongst the medical departments for cruise lines, unless it involves who will host the next conference on board. Several of the lines recently communicated about their experiences with a specific Turkish restaurant after our line had greater than 100 passengers take ill in what did not epidemiologically appear to be a Norovirus outbreak. We are all working toward establishing which restaurant alternatives are acceptable for our tours in this area. We have 5,000+ shore excursions and 363 ports – that scope is competitive – keeping our passengers healthy and avoiding any type of outbreak is not.
Legionella is a far greater concern of mine than Noro – it kills; though it is easily treated by macrolides in most individuals – if considered and diagnosed. If the incubation period links the pneumonia back to the ships, whether contracted on board or shoreside, we all know where blame will be cast. We must have an industry-wide validation of a single approach to removal of biofilm and appropriate measures for managing our spas and plumbing systems that the ships can hold out as evidence that we have done all we can to manage a ubiquitous organism in the shipboard environment.
Alleged sexual assault is a major problem on ships – alcohol and morning remorse aside – the major issue for us being how the alleged incident is handled. Sexual assault rests on the tripod of medical management, victim advocacy, and the collection of appropriate forensic evidence to allow the victim to pursue whatever legal recourse he/she wishes to pursue while maintaining patient confidentiality. The sharing of our plans and methodology for this has occurred and should continue to occur. There should be NO bad press about any cruise lines’ response to these incidents because the policies and procedures developed should not allow bad responses to occur.
There are many physicians attracted to the ship environment to practice for a variety of reasons. Unfortunately, not all are as qualified as their credentials may lead us to believe. Sometimes, it is just a personality issue and a change in lines or ships does the trick. However, the ability to call our colleagues and get an objective opinion of strengths, weaknesses, and competency is critical for our passengers.
These are just a few of the ways we are able to work together. We should all, whether medical directors or ship physicians constantly be on the lookout for additional synergistic opportunities. The next frontier, and one long overdue, is the development of a worldwide database of medical facilities and providers for our passengers and crew. We can no longer be at the mercy of the local port agents and medical providers to charge whatever they want and provide inconsistent levels of care with no understanding of the specific needs of our passengers and crew. Providing critical levels of business and defined expectations is good for everyone. I look forward to this occurring as soon as possible and I am glad to see we are moving in that direction. I am committed to sharing any information in this project with my colleagues.
As my tenure as the Chair of this section ends, I would like to thank the ACEP staff, especially Nancy Calaway, for their tremendous assistance over the last four years as your editor and Chair; and to the many members who have contributed articles and challenged us with their questions. I leave you in truly outstanding hands with Dr. Ben Shore. I wish him “smooth sailing” and much success.
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Don’t Miss This Year’s Section Annual Meeting
Please join us for the annual meeting of the ACEP Section on Cruise Ship and Maritime Medicine during Scientific Assembly in Chicago, IL.
Tuesday, October 28, 2009
11:30 am to 1:30 pm
McCormick Place convention center – North Building
Room N227B
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A Complicated “Twist of the Ankle”
Figure 1
Trimalleolar fracture with talus subluxation
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Figure 1A
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Post reduction views - Figure 2
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By Dr. Matthias Dahlmanns
MBChB. Dipl.P.E.C. S.A., M.D.Germany
History
A 25-year-old crew member with no medical history of note was walking back to his cabin on the crew deck corridor, where cleaning was in progress. He was wearing Cowboy boots, and while trying to open a heavy door, he slipped and fell, twisting his right ankle.
On Examination
The crew member was in excruciating pain because of his right ankle. His vital signs were stable and normal. Brief examination of other systems showed them to be normal. After the right boot was carefully cut and removed, his right ankle was severely deformed with bone crepitus on palpation. There were no open wounds. The neurovascular status of the right ankle and foot was intact.
Investigations
AP and lateral X-rays of the right ankle showed a trimalleolar fracture with posterior subluxation of the talus. A spiral type “A” fibular fracture was present and there was avulsion of the medial malleolus (see Figure 1 and 1A).
Management
The fracture was reduced under analgesia, with correct orientation of all three fractures and the talus (see figure 2). A full above-knee plaster of Paris was applied. The patient was comfortable in the cast, requiring minimal analgesia. He was referred to an orthopedic specialist who confirmed the diagnosis and recommended open reduction and internal fixation of the ankle.
About the Author: Dr. Dahlmanns has been working for Norwegian Cruise Lines for nine years. He has been trained in Germany and South Africa in trauma surgery and general surgery, as well as emergency medicine and general medicine.
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First Impressions of X-Rays … Accurate or Not?
Dimitar Nechev, MD
Ships Doctor, Carnival Ecstasy
After a proper history and physical examination, a physician’s interpretation of test results is often the most important factor in arriving at a proper diagnosis. However, with every diagnostic test, a physician must appreciate how likely the test is to contribute to establishing the correct diagnosis, or how likely a misinterpretation might lead a physician off on a misdiagnosis … and possible further unnecessary testing and treatment.
It is commonly recognized that interpretative skills vary with the experience and training of the medical professional. And this is true especially when it comes to “analog” interpretations not represented by digital results. The plain X-ray image is one of the most common analog tests currently used in practice, and its proper interpretation is critically important to good patient outcome.
Factors that may bias the correct interpretation of analog test results are 1) a strong clinical bias toward certain diagnoses, 2) limited decision-making time, and 3) atypical or unfamiliar presentations and findings on X-rays.
Here are three examples of initially wrong X-ray interpretations, where clinical bias toward expected findings and atypical appearances on the X-rays might well have lead to misdiagnosis and subsequent mistreatment.
- This chest X-ray was taken from a patient who sustained chest trauma and presented in mild shortness of breath and pleuritic, right-sided chest pain (Image 1). There were no obvious signs of chest contusion. Some palpatory pain was present over the right anterior and upper ribs with no step deformities or crepitus. Lung auscultation was normal bilaterally, and saturation and vitals remained normal.
Image 1
Having the history in mind, a physician would like to be sure that there is no pneumothorax or hemothorax. Notice that the medial part of the right upper lung is clearly visible. Also, what appears to be a line of pleura can be plainly seen in the inferolateral right lung at the costophrenic angle. Thus, a physician might conclude that the X-ray reveals a small right pneumothorax.
However, more thorough examination of the upper portion of the image reveals that the clavicular lengths are asymmetric, indicating a significant left-ward rotation of the patient when positioned for this X-ray exposure.
Consistent with a continued stable clinical course, serial X-ray examination, properly centered, failed to confirm the originally suspected pneumothorax.
- This 24-year-old Indonesian patient presented with a chronic dry cough and some weight loss for the last few months. Although he did not report night-sweats or hemoptysis, his point of origin mandated that tuberculosis be considered in the differential diagnosis. His Mantoux test was positive, the significance of which was dubious, because he had earlier received BCG inoculation.
The chest X-ray interpretation was, therefore, critically important to assure the correct diagnosis and determine the cause of his symptoms (Image 2).
Image 2
On the only X-ray view obtained, there appeared to be an ovoid, cystic lesion with thin walls just above the right hilum. No air-fluid level was visible. It resembled an emptied abscess.
However, once the patient was sent for work-up by a pulmonologist, a CT scan of the lungs was found to be completely normal. This finding was attributed to a “play of the shadows,” which can be better appreciated on this enlarged image (Image 2A).
Image 2A
- A 68-year-old lady tripped and fell. She presented with right-sided hip pain, just 10 minutes before ship was to sail. As she was a bit demented, no accurate past medical history was obtainable.
On evaluation, she was limping, and demonstrated shortening of the right leg of about 3-4 cm with external rotation. There was no evidence of hematoma or deformities in the hip area. Moderate generalized tenderness was elicited to palpation. She had full range of motion in the hip joint with some pain on external rotation. Neurovascular status of the leg was normal, as were her vital signs.
With a working diagnosis of right hip fracture, the X-ray was reviewed for signs of trochanteric, inter-trochanteric, or femoral neck fracture. Shenton’s lines were found to be intact, and the lengths of both femoral necks were equal.
It was obvious that the hip joint space on the right was diminished, there were deformities of the pubic rami, and the right obturator foramen appeared narrower. The diagnosis of acetabular fracture with central dislocation and fracture of the pubic rami was entertained (Image 3).
Image 3
The patient though was suspiciously well and stable, and a much clearer image was obtained (Image 3A).
Image 3A
With this image, lumbar scoliosis was readily visible, as well rotational pelvic deformity. The simphysis was displaced to the right, the curve of arcuate lines was asymmetrical, and the right ilio-sacral and femoro-acetabular joints were obliterated.
It was now clear that this patient suffered from pre-existing lumbar scoliosis, pelvic rotational deformity, and apparent shortening of the right leg, which could be easily mistakenly for a hip fracture under the less than careful X-ray interpretation.
After viewing these images, I hope that you will agree that the proper interpretation of the plain X-ray image, one of our most common analog tests in use, is critically important to good patient outcome.
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Unusually Large Rescue at Sea
Philip E. Henderson, MD, FACEP, FAAFP
Senior Ship’s Physician, M/S Carnival Liberty
Sixty miles off the coast of Cuba at 10 am, the M/S Carnival Liberty, carrying 3,500 passengers and 1,200 crew members, stopped abruptly.
A powerless 27-foot boat drifted nearby, packed with 44 passengers. Some of those passengers later told us 51 sailed from Haiti for an island only four hours away, and therefore carried no food or water. There was no sleeping room on board the overloaded boat -- only sitting and standing room. They told of drifting at the mercy of winds and waves for 15 days in hot sun, cold nights, and storms after their boat's motor stopped. Of the boat’s captain, who attempted to swim to shore to get help and was never seen again. Of throwing six bodies overboard after they died from dehydration.
One of our ship’s life boats was quickly lowered and sent to their rescue, along with a doctor and nurse to perform a primary triage. The medical team rapidly began assessing the condition of each passenger. A number was taped to each passenger's chest, and they were sorted into two groups. Five Haitians were found to be in critical condition from dehydration and they were the first to be taken aboard. The critical patients were swiftly moved to the medical center, where IVs were started and quick physicals performed.
The remaining women boarded our cruise ship next, followed by the men. Pursers met them and recorded their names to match the numbers. Adhesive wrist bands with computer generated names and numbers were then applied to all.
The less critically ill were moved to the crew's recreational area. There they were hydrated with both water and weak juices containing added salt, and offered rice and other foods. They were given fresh clothes, mattresses, and blankets. For security reasons, except for showers, they were kept together.
The ship’s two doctors and four nurses mobilized the medical center for a secondary triage of all 44 passengers, starting with the 5 critically ill patients. One nurse took vitals, while another entered medical history information into a computer database. Searching for infectious diseases, two nurses processed digital chest X-rays on all 44 victims. One doctor did rapid physical examinations, while the other interpreted films and performed final dispensation. Within five hours, we had created an individual medical record for each Haitian.
Most of the Haitians suffered from moderate to severe dehydration and were very thin. Some were cachectic. All were exfoliating and caked with salt. Many had skin ulcers and abrasions, especially around the buttocks and groin, from their prolonged ordeal of sitting. Yet they responded quickly to liquids and food.
After learning of the rescue, the Coast Guard mobilized the cutter, Venturist. Flying in via a helicopter, a capable physician assistant joined the cutter, which rendezvoused with our ship nine hours after the initial rescue. All of the Haitians boarded Coast Guard zodiacs for a trip to the cutter and the voyage back to Haiti. We gave individual medical records and digital X-rays to the Coast Guard. Despite these efforts, however, we later learned that one woman collapsed and died the following day.
The ship’s passengers found the event and drama quite fascinating, and gave both cheers and good-luck shouts to the Haitians as they disembarked.
Our ship arrived several hours late the next morning in Miami.
So what did I learn?
I was very impressed with how well the entire crew, including, but not limited to, the ship’s command, hotel management, security, deck crew, and medical team, can respond to an emergency. I also greatly appreciate the professional and rapid response of our USCG.
And although grateful for the many that were saved, I am left with remorse for the eight who died.
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