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Working
Aboard a Cruise Ship
By G Podolsky MD
Cruise
ships are currently very popular ways to travel, especially in the
Caribbean with people imagining images of the 'Loveboat' or 'Titanic'.
The reality can be quite different. Travelers may forget that they
are no longer in Canadian or American waters and the rules and laws
on the ship can be very different. I had worked as Chief Medical
Officer for the Carnival Cruise line ships MS Tropicale and MS Jubillee.
And the following is a brief description of what working on a cruise
line was like for both travelers and doctors
Learning
Objectives:
1. Introduce clinicians to the on board environment aboard a Cruise
ship
2.
Learn the common and important illnesses and injuries to passengers
and crew at sea
3. Discuss Medical Officers role in Sanitation, Outbreaks and Occupational
needs of the cruise
4. Discuss Human Rights Issues aboard for Crew members and Passengers
Safety concerns
5. Advice for Family Medicine and Travel Medicine Professionals
to prepare their patients for cruise travel: pre-trip physicals,
immunization, chemoprophylaxis and education about inherent risks
of cruise travel and limits of resources
Introduction
I have included statements and from American College of Emergency
Physicians (ACEP) and the Centre for Disease Control (CDC) on their
guidelines towards Cruise Medicine.
Life aboard a Cruise Ship
I will discuss the basic operations of a cruise ship and explain
how the doctors and nurses fit into the hierarchy. Injuries and
illnesses that occur can be divided into those that will occur when
any large groups of people are congregated together as well as the
types of problems specific to a remote marine environment. Cruise
ships are a popular type of leisure travel with people having images
of the "Loveboat". The reality can be quite different. I have worked
as Chief Medical Officer on several large cruise ships. The following
is a brief description of the cruise environment.
Captain
The captain is the master of the ship and runs the ship according
to International Law and the rules of the cruise line. He is also
in charge of medical evacuations, not the physician who must convince
the Captain of the necessity of evacuation.
Staff Crew
The Staff Captain and his staff assist the Captain. It is the Staff
Captain who is in charge of disciplining all cruise ship employees.
The deck crews are also under the staff captain and perform
a variety of maintenance and repair work necessary for the ships
function
The Hotel Manager runs the 'Hotel' part of the ship, with
the Chief Purser and the rest of the pursers running the accommodations.
The Food and Beverage Manager also is responsible for the
catering and dining services aboard. Hygiene is a very crucial issue
and will be discussed later. There is an important coresponsibility
shared with the Chief Medical Officer for ensuring that the Ships
Sanitation record is clean.
The Chief Steward is responsible for the stewards, who run
guest services such as room service delivery and the cleaning of
rooms.
The Cruise Director is an important liaison with the passengers
and is in charge of the cruise staff. This includes the dancers
and shore excursions. This image is best exemplified as "Julie"
from the "LoveBoat" and of all the perceived stereotypes this is
the one that most holds true to the TV show.
The Casino Manager also has an important role as he oversees
the management of gambling a significant revenue for the ship.
Chief Engineer is responsible for the running of the engines
and other systems Other Separate Department heads include: the Chief
Radio Officer who was responsible for communications, Child Care
Director who manages all the day care staff, Beauty Salon
Manager, and the regular Shop Manager. The departments
work together to service the passengers. Every week the captain
holds a meeting, which all the major departments attend.
Security Chief is responsible for ensuring the safety of
the passengers and crew from each other and from external threats.
If there is an altercation aboard ship people were told not become
involved unless absolutely necessary and instead wait for security.
The
crew is truly international being from all over the world. We had
members from China, Philippines, Indonesia, Caribbean, South America,
Europe, and Australia. It may surprise people to know how little
English was spoken or understood. The Captain, Staff Captain and
the remaining Staff were all from Italy and few spoke English good
to well. I was told that our company only hires members of the Staff
department from Italy because of a prior agreement the company had
made with the Italian government. There was a big problem in communication
with the rest of the departments. Language was a major problem as
many senior officers could barely speak English. On routine day-to-day
events this was merely an inconvenience but during emergent and
urgent situations this as a major obstacle. When examining patients
I would always insist on an interpreter since communication became
too difficult. With enough effort I was always able to find an interpreter
which greatly facilitated understanding.
The Medical Department
Depending on the size of the ship, there are one or more doctor(s)
and at least 2 nurses. Medical staff may be from anywhere in the
world but generally speak English. There has been criticism in the
past about the composition and training of medical staff as not
all are board certified. Although the American College of Emergency
Physicians (ACEP) has made guidelines (See Appendix 1) the cruise
ship industry is not under obligation to follow these and ships
are not monitored nor inspected by ACEP.
The infirmary is open during regular office hours for both passengers
and crew, and is open 24 hours for emergencies. Each ship's infirmary
has different capabilities, but generally includes IV fluids, splints,
ACLS medications and a defibrillator. (Appendix 1)
Medical
staff can perform minor procedures, treat accidents, dispense medications
and begin treatment for cardiac problems. Most ships have the capabilities
to communicate with backup experts on shore. Our ship had a satellite
phone to communicate with a Miami Emergency Physician to provide
Medical backup advice. This is useful for both medical and legal
considerations. In general the consulting physician would generally
agree with me that an evacuation was advisable in situations that
I deemed to be emergent.. This was exceptionally useful when I had
to advise patients to be evacuated, since both the patients and
Cruise Officers did not want to organize an evacuation. Infirmary
beds are available for quarantine or for observation of ill patients.
Passengers are responsible for infirmary costs, and these can be
significant. Medical insurance with evacuation coverage is strongly
recommended. Prices for medications are usually higher when compared
with home. On our ship minor medications -analgesics, cough and
flu meds and anti-nauseates were for purchase in the gift store
by passengers. Anyone requiring an assessment or refill was required
to see a physician.
Treating Passengers
Vaccinations for Cruise Ships
Immunizations
are recommended for both the port destinations as well as for the
ship itself. For short cruises a booster tetanus, diphtheria, and
polio, hepatitis A, typhoid, influenza and possible hepatitis B
(for those exposed to high risk situations) is recommended. Outbreaks
of influenza, rubella and other diseases occur on cruises 31-33.
Ports of call may be in developing countries, and people often eat
on shore so vaccinations must also cover the itinerary. Also, the
ship's food handlers come from many developing countries and sanitation
is not always optimal. I was a little upset when I found a gnawed
toothpick in my salad one night. Passengers usually embark on day
trips to shore and are usually back ashore before nightfall. They
usually will not require antimalarial medications. They may be exposed
to insect borne diseases like yellow fever and dengue fever among
others. This is something we did not directly address with passengers,
as they should receive this type of advice with their pre trip check
up.
We had 2 crewmembers with chickenpox during our voyages while I
was working. Passengers and crew should be confirmed to be immune
before joining the ship. Adults who come from equatorial countries
are apt to be susceptible since not all adults may be assumed to
have had varicella infections previously. Our crew members had to
be carefully quarantined, which is not simple aboard ship. The hotel
manager had to carefully search the ship for empty beds and crew
were quarantined with room service for the duration of their contagiousness.
Pregnant women should be confirmed to be immune to rubella and varicella
before they travel since many outbreaks have occurred.
Yellow Fever Immunization
Yellow fever immunization for cruise ship travelers is controversial.
Yellow fever vaccination is firstly recommended for anyone at risk
for significant exposure to yellow fever. This may occur through
daytime exposure to infected Aedes egytii mosquitoes. The vaccine
had previously been thought to be very safe but recent concerns
about viscerotropic side effects causing symptoms similar to actual
yellow fever have been observed in patients immunized for yellow
fever. These patients have been older so those who are over 65 or
immunocompromised are thought to be more susceptible to these side
effects. It is recommended that yellow fever vaccination be used
with caution in high-risk individuals although even apparently healthy
young people can also become very sick..
Yellow fever vaccination is also required by certain countries for
entry from travelers who are entering from countries where yellow
fever is present or the possibility of yellow fever exists (yellow
fever endemic areas). This is to protect that country from any imported
yellow fever virus being introduced into their mosquitoes so that
an urban cycle of yellow fever does not start. For reference of
each country's yellow fever requirements the CDC provides updated
information1. Some cruise itineraries take place through yellow
fever endemic countries and ports of call may include cities where
travelers may do a shore leave. Yellow fever may not exist in the
port but in the surrounding countryside, which, although travel
to is unlikely, is still accessible by day-trippers. Balancing out
the needs of the passengers to fulfill their entry requirements
may be difficult. Yellow fever waivers are given for true medical
contraindications and will allow people with egg allergies and immunocompromised
statuses to travel but waivers should not be abused since these
very individuals who have their yellow card waived can also become
the perfect vehicle to spread yellow fever.
Common medical problems aboard ship for Passengers
With a large passenger count and a crew almost as large basically
anything can happen aboard. Clinicians may expect to see anything,
as passengers will often minimize their illnesses despite what their
tickets warn against. Peake34reports a breakdown of common complaints
aboard which reflects a distribution similar to an urgent care facility.
Table
1.Breakdown of Infirmary visits by Main Diagnosis 34
| Principal
Diagnosis |
Visits
to infirmaries |
% Distribution |
| All Patient
visits |
17147 |
100 |
| Neoplasm
related |
15 |
.2 |
| Endocrine/Immune
|
56 |
.8 |
| Mental
Illness |
51 |
.7 |
| Nervous
System |
653 |
9.1 |
| Circulatory
|
239 |
3.3 |
| Respiratory
|
2077 |
29.1 |
| Digestive
|
635 |
8.9 |
| Genitourinary
|
230 |
3.2 |
| Skin |
182 |
2.5 |
| Musculoskeletal |
224 |
3.1 |
| Injury
related (total) |
1299 |
18.2 |
| Other non
specified |
893 |
12.5 |
Traveler's
diarrhea
This condition can generally be averted by careful attention to
what you eat, especially on shore. The cruise doctor is responsible
for doing a weekly "diarrhea log" of all affected passengers and
crew. If the ship has an incidence of 3%, it is considered significant
and must be submitted to the CDC. They generally investigate
large outbreaks. Part of the assessment of cruise ship hygiene depends
on the regular submission of the weekly diarrhea log and failing
to comply will cost points off the ships rating, so this is done
scrupulously and is one of the major duties of the ships doctor.
Sea Sickness.
It usually takes a few days to get your "sea legs". Avoiding excessive
alcohol and sunburn, helps prevent dehydration. Medications such
as Gravol, Meclizine, and Phenergan, all help in controlling symptoms
(during the first few days). Injections of Phenergan are available
and are usually effective. Pregnant women may have prescriptions
from their own doctors (for Gravol or Diclectin) or may try ginger.
To avoid seasickness it is recommended to stay in the middle of
the ship, near the center of gravity where there is less sway).
Avoid reading. If above deck, focus on far away objects. Sea bands
to provide acupressure to prevent and alleviate seasickness were
very popular although there was very little evidence that they helped
anyone.
Sexually Transmitted Diseases (STDs)
Many of the crew, especially officers are openly promiscuous with
passengers47-48. The crew appeared to have little knowledge of STD
prevention, which is very worrisome considering the prevalence of
HIV in many parts of the world. Many crew members had multiple partners
and some had literally a 'girlfriend in every port'. The crew is
not regularly tested for STD's. Both male and female crew members
will be fired if they are found in any passengers' cabin, unless
they are working there. Occasionally there are charges of rape or
other forms of assaults against crew or other passengers. Such incidences
can generally be avoided by using one's common sense. If there is
an occurrence, seek out a security officer and they will deal with
the dispute.
Disabilities
Cabins specifically designated for people with disabilities are
not always available. One of our passengers, a 21-year woman with
metastatic spinal cancer, had requested such a cabin and became
severely injured when a malfunctioning door crashed into her, further
limiting her mobility. Although the cabin was designated as "handicap
accessible," it had not been properly maintained as such and the
stewards responsible for this cabin did not have the proper training
to do so. Many special themed cruises are available. Among these
are dialysis cruises with specialized medical care.
Accidents
Incidents whether on or off the ship, should be reported and documented
by the ship's security staff as well as medical personnel. Most
injuries are simple and similar those in an urgent care clinics34.
As mentioned above, simple fights break out. X-rays were unavailable
on board but available at all ports if required for non-urgent problems.
Some accidents were from stumbles and falls. After a fall in a previously
safe part of the ship the Captain's staff would post another ubiquitous
"Watch your step" sign near the offending area so as to limit future
liability. There were a small minority of accidents brought to our
attention by "career passengers" which were people who had sustained
previous falls on prior cruises and would again attempt to get future
free trips. These passengers were always examined for free and a
detailed report was forwarded to security. The hotel manager would
then decide if any compensation was appropriate.
One passenger, very soberly, told me that 'something should be
done' to prevent future injuries where she fell where she had in
fact rubbed her elbow against a perfectly flat, blunt wall on a
long corridor
I did see one bad case of jellyfish envenomation although we
did not identify the species. Hazards like marine animal encounters
and SCUBA related problems are possible since many vacationers also
embark on a variety of activities at port50-52.
Assaults
There are many recorded assaults on both guests and crew members
by both passengers and crew. The cruise ship is looked on as a finite
area and security is ever present. Crewmembers are instructed not
to get involved in altercations and simply observe until security
officers arrive.
When I first worked for the cruise line altercations between
young men were common over women. Our cruise line made a very clever
change to their rules, which made theses types of fights less common.
It was observed that fights often occurred as groups of men came
aboard to meet college spring break coeds. The company changed its
admission rules that limited anyone under the age of 21 from coming
aboard unless they had a chaperone over the age of 25 years. This
prevented groups coming aboard with one member over 21 acting as
the chaperone.16
One big fight turned into a riot after two groups fought over one
girl on the lido deck three o'clock in the morning. One man had
extensive lacerations that were caused when another broke a beer
bottle over his head and another individual had a broken nose. Blood
had been smeared across the entire lido deck as drunken bystanders
had spread the blood in a panic. Clearly from eyewitnesses and the
amount of damage done, security was unable to deal with the situation.
I treated several of the major participants but those with minor
injuries typically did not present to the infirmerary. A security
officer gave the men their reports and both men were told to take
their grievances to a civil court in Florida if they wanted to litigate
against each other.
Working with Shore Doctors in Foreign Countries
Ships try to maintain list of doctors at ports of call that seem
to provide reasonable treatment. But sometimes patients chose their
own doctors, with variable results. For example, we visited one
practitioner to whom we had been referring crew to and found him
and his facility acceptable but some patients returned with expensive
prescriptions for multivitamins or very poor advice. When interacting
with shore doctors its best to work with people you know best. Often
the local Embassy of your country can provide a list of practitioners
in the area and while they may not specifically endorse any they
can tell you about recent complaints. The international society
of travel medicine also has a listing of travel clinics worldwide
but not every country is represented54.
We used a local Dentist in Mazatlan to replace fillings for crew.
I was curious to visit so I inspected it once. The Dentist was very
apprehensive about his attention to sterility. Although it was not
my intention to grade him I found his office very professional and
clean with a working autoclave.
Man Overboard
People do go overboard and it is important to know the proper ways
to respond to emergencies. Passengers are shown the proper safety
measures and responses when boarding and while participating in
lifeboat drills. For man overboard situations, witnesses should
point at the spot where the person was last seen while someone runs
to stop the boat. By maintaining a bearing it becomes easier to
find the lost person.
"One of the passengers had been standing on the upper rails,
urinating while intoxicated, and fell into the sea. Many cruise
ships and rescuers were diverted to that area. Roughly 12 hours
later, he washed up on shore alive and well! Back on his ship everyone
who had been mourning him, now wanted to kill him for ruining their
cruise!"
Table
2. The Vessel Samaritan Program Covers
Score
is out of 100 and focuses on ship's water supply
(storage, distribution, protected and disinfected)
Ships spa and pools (filtration and disinfections)
Ship's
food (storage, protection, service potential for food and water
contaminates)
Practices
and personal hygiene of employees
General
cleanliness and physical condition of the ship (includes absence
of insects and rodents)
Ships
training programs in general environment and public health practices
Occupational
and Family Medicine Aboard for Crew Members
There is a good proportion of occupational medicine among the
crew, especially musculoskeletal overuse problems59. If a crewmember
is very sick the medical staff may recommend evacuation. For less
urgent problems consultation with portside consultants in the
USA and in other countries can be made while a ship is in port.
This included referrals to dentists, physiotherapists, internists
and sub specialists and gynecologists. Interestingly cruise physicians
were forbidden to do gynecology exams on female crew except in
emergencies. No reasons were given for this but undoubtedly reflect
prior boundary issues in the past. The general crew was multinational
and made up of members of all 6 continents and many had variable
states of health care, some of them claimed to never having seen
a doctor in their life. Members from developed countries had claimed
to have a pre-crew physical as well as an HIV test. I myself had
no physical or confirmation of prior vaccinations done.
All crewmembers were compelled to complete a Panamanian physical
on the ship that I worked on which was registered in Panama. This
consisted of a simple history and physical checklist and cursory
review of systems to satisfy the Panamanian authorities. All crew
had to pay $50 US for this procedure. This examination had very
low predictive value in determining any type of illness and was
more of a financial incentive than anything else. Most of the
crew despite coming from poor backgrounds are hardworking and
honest. The deck hands may work more than 12 hours a day at less
than minimum wage and are often treated poorly by other staff
and passengers. They often depend on tips from customers yet may
do very well from the tips they make relative to working in their
native countries.
Case Study: Luis, the Ideal Worker
I had noticed that one of the older cooks aboard had been particularly
subdued and pleasant to everyone. He had attended the clinic with
a translator because he only spoke Spanish. A week later, the
Food and Beverage Manager had praised him on what a great worker
he had been and all he ever did was get up and go to work and
then go back to sleep causing no problems and always being reliable.
This sounded very suspicious to me and I couldn't t stop thinking
about it. I remembered that one entry in his chart had mentioned
he was on digoxin and I started to think- if I had been there
for weeks who else could have given him any? I immediately called
him in and found that he hadn't taken either his digoxin or lasix
for a few months and was fluid overloaded with CHF. After resuming
his medication after a week he had a normal affect and even took
to wearing a print Hawaiian shirt apart from his Cook's uniform
during his time off.
Significant Injuries Requiring Evacuations
Medical evacuations are indicated for patients who are very ill,
badly injured or in need of immediate treatment. But evacuation
is not always practical, and always very expensive. The Captain
and Chief Medical Officer will make arrangements to evacuate patients
to the nearest appropriate hospital. The ship's doctor can only
recommend evacuations, not order them, but no reasonable captain
would go against their doctor's medical opinion. Some of the medical
emergencies we encountered included myocardial infarcts; strokes,
deep vein thrombosis, and open fractures.
The U.S. Coast Guard will evacuate passengers from ships that
are within 100 miles of the U.S. coast. Many cruises, obviously,
travel much further than that. And there are watershed areas where
there is about one to one and a half days between ports. When
passing through these watersheds, evacuation becomes difficult
for many reasons, including: logistics, many passengers/patients
are reluctant to leave the ship; and changing course if necessary,
angers lots of passengers. Sometimes the ship is reversed to the
last port or sped up past its cruising speed. Although in the
Caribbean the arrival time between islands is usually given as
a day, it can usually be accomplished in a few hours. This is
not widely done, in part because the company benefits more from
keeping the passengers in international waters longer so they
can gamble more in the casinos.
Transport time for sick patients will vary according to where
in the cruise the event takes place..One study showed a main time
from the physician calling for an evacuation to arrival at hospital
was 16.6 hours60,61. Each cruise has a preplanned course that
gives in a set pattern. On ocean going cruises with sea days there
are certain known "watershed areas" of where access for help or
speedy evacuation will be very difficult. One hotel manager had
confided with me that this is specific information they keep from
the new doctors so as not to worry them. If a passenger has an
incident while traveling away from a port of call and with no
significant air evacuation available, this will obviously cause
a delay in patient transfer.
Some urgent emergency situations that had occurred for me are:
Deep vein thrombosis in the deep blue sea A young woman
with a prior pulmonary embolism from a deep vein thrombosis presented
to our infirmary in the middle of the Gulf of Mexico with symptoms
of her previous deep vein thrombosis. After consulting with a
physician in Miami and the patient, we agreed to initiate a heparin
infusion empirically and take blood to establish a baseline PT,
PTT. The woman had an uneventful transfer to Tampa.
Open fracture On a cruise out of Grand Cayman a deckhand
had crushed his index finger with an open wound. Although not
life threatening, an open dirty wound could not wait for air next
port of call and I advised evacuation. In this instance the ship
had to be turned around back to the Grand Cayman. The staff was
very unhappy with my decision and I was shown a bill for all the
"wasted fuel" that my diversion has caused by one of the junior
engineers.
Second open Fracture from doing the Jitterbug While leaving
Tampa an elderly couple had been dancing the jitter bug and the
lady had sustained an open fracture of her right wrist. A small
cube of wrist bone was actually located on the dance floor. I
had wanted to attempt to identify it but it was thrown out like
waste before I could secure it. Since the cruise was still in
American water I had assumed that it would be an easy evacuation.
Initially the cruise was only two hours out of port heading for
the Caribbean at 900 pm. The coast guard was contacted and despite
our Captain's protests that I just put a cast on it until we get
to Grand Cayman I understood that we would get an evacuation.
After three hours of waiting I found the Captain had changed the
plan to meet a coast guard ship in 15 hours. I spoke with the
coast guard again this time impressing that this woman had at
least a limb threatening injury and given her diabetes and past
medical health a risk for sepsis. The coast guard agreed to send
a helicopter. The husband who had previously been told he could
not go with his wife now would be allowed to go. At three a.m.
I received a phone call from one of the Italian officers informing
me that the 'helicopter is broken'. He followed with a pregnant
pause, which I believe he expected me to yell at him. (I didn't)
I asked and found that the next one would be available at 0500.
The copter arrived with a wire litter basket and hoisted the patient
up. In this case the patient was seen in Fort Lauderdale and had
a 3.5-hour debridement surgery. Her husband hearing of her state
was forced to have his cruise by himself until we reached Grand
Cayman one and a half days later.
Appendix
1 Recommendations for Onboard Medical Staffing aboard Cruise ships
ACEP Revised October 2000
The specific medical needs of a cruise ship are dependent on variables
such as: ship size, itinerary, anticipated patient mix, anticipated
number of patients' visits, etc. These factors will modify the applicability
of these guidelines especially with regards to staffing, medical
equipment and the ships' formulary. Medical care on cruise ships
would be enhanced by ensuring that cruise ships have: 1.
A ship medical centre with medical staff (physicians and registered
nurses) on call 24 hours per day, examination and treatment areas
and an inpatient medical holding unit adequate for the size of the
ship. A medical centre with adequate space for diagnosis and treatment
of passengers and crew with 360° patient accessibility around all
beds / stretchers and adequate space for storage.
One examination / stabilization room per ship
One ICU room per ship
Minimum number inpatient beds of one bed per1000 passengers and
crew
Isolation room or the capability to provide isolation of patients
Access by wheelchairs / stretchers
Wheelchair accessible toilet on all new builds delivered after January
1, 1997
A contingency medical plan defining:
One or more locations on the ship that should:
be in a different fire zone (from the primary medical centre)
be easily accessible o have lighting and power supply on the emergency
system.
Portable medical equipment and supplies including:
Documentation and planning material
Medical waste and personal protective equipment
Airway equipment, oxygen and supplies
IV Fluids and supplies
Immobilization equipment and supplies
Diagnostic and laboratory supplies
Dressings
Treatment - medications and supplies
Defibrillator and supplies
Communication equipment for each member of the medical staff
A clear procedure in case the primary medical space cannot be used
Crew assigned to assist the medial staff 2.
Medical staff who have undergone a credentialing process to verify
the following qualifications:
Current physician or registered nurse licensure
Three years of post-graduate / post-registration clinical practice
in general and emergency medicine OR
Board certification in:
Emergency Medicine or
Family Practice or
Internal Medicine
Competent skill level in advanced life support and cardiac care.
Physicians with minor surgical skills (i.e. suturing, I&D abscesses,
etc)
Fluent in the official language of the cruise line, the ship and
that of most passengers 3.
A medical record and communication system that provides:
Well organized, legible and consistent documentation of all medical
care
Patient confidentiality
4. Emergency medical equipment, medications and procedures:
Equipment:
Airway equipment - bag valve mask, ET tubes, stylet, lubricant vasoconstrictor,
suction equipment (portable)
Cardiac monitor and back-up monitor (2)
Defibrillators, two (2) portable, one of which may be semi automatic
External cardiac pacing capability
Electrocardiograph
Infusion pump
Pulse oximeter
Nebulizer
Automatic or manual respiratory support equipment
Oxygen (including portable oxygen)
Wheelchair
Stair chair and stretcher
Refrigerator / Freezer
Long and short back boards cervical spine immobilization capabilities
Trauma cart supplies
Medications Emergency medications and supplies for management of
common medical emergencies, to include:
Thrombolytics and sufficient quantities of advanced life support
medications, in accordance with international ALS guidelines, for
the management of two complex cardiac arrests
Gastro-intestinal system medications
Cardiovascular system medications
Respiratory system medications
Central nervous system
Infectious disease medications
Endocrine system medication
Obstetrics, gynaecology and urinary tract disorder medications
Musculoskeletal and joint disease medications
Eye medications
Ear, nose and oropharynx medications
Skin disease medications
Immunological products and vaccines
Anaesthesia medications
Procedures
Medical operations manual as required by international safety management
code
Medical staff orientation to the medical centre
M aintenance for all medical equipment as recommended by manufacturer
Code team trained and updated regularly
Mock code and contingency medical plan drills on a recurrent basis
and as recommended by ships' physician
Emergency preparedness plan as required by the international safety
management code o Internal and external audits 5.
Basic laboratory and X-ray capabilities
Haemoglobin / haematocrit estimations, urinalysis, pregnancy tests,
blood glucose (all with quality control program as recommended by
the manufacturer)
X-ray machine for new builds delivered after January 1, 1997 6.
A process whereby passengers (prior to embarkation) are requested
to provide information regarding any medical needs that may require
medical care on board. (FYI-ACEP Board) 7.
A health, hygiene and safety program for medical personnel
A regular health, hygiene and safety program for medical personnel
An annual TB screening program for all medical personnel References
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