Coronavirus (Covid-19) outbreak on the cruise ship Diamond Princess.

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Large-scale helicopter rescue of cruise passengers and freighter crew off the coast of Norway in stormy weather.

During a storm on the 23rd of March 2019, southbound Viking Sky was crossing the notorious Hustadvika bay off Norway with 1373 (915 passengers, 458 crew) aboard when power was lost and the ship drifted towards the shore. Mayday was called at 14:15. When the dropped anchors caught and one engine had started, the ship was about 100 m from the rocky coast. Helicopter evacuation was started at 15:30, but was slightly delayed around 19:00 when 9 crewmembers from a nearby powerless freighter, Hagland Captain, had to be airlifted to safety. The helicopter rescue from Viking Sky was called off at mid-day on the 24th of March. Using its own engines the ship arrived in Molde at 16:20 with 436 passengers and 458 crewmembers. In all, 479 passengers, many of them elderly and three seriously injured, had been airlifted off the ship one-by-one in rough weather by a relay of 6 helicopters, making this one of the most remarkable helicopter rescue operations ever.

Medical emergencies on large passenger ships without doctors: the Oslo-Kiel-Oslo ferry experience.

BACKGROUND: The Oslo-Kiel-Oslo route is currently the only direct ferry crossing between Norway and Germany, covered by 2 cruise-and-cars ferries carrying about 2,600 passengers each and sailing every day (20 h at sea, 4 h in port). Unlike most ocean going cruise vessels, they are not required to carry a physician but an on-board paramedic handles medical emergencies. The aim of the study was to provide data on medical emergencies leading to helicopter evacuations (helivacs) or other urgent transfers to facilities ashore from the two ferries during a 3-year period. MATERIALS AND METHODS: Data about the ferries, passengers, crew, helivacs and other medical transfers were collected from official company statistics and the paramedics' transfer reports. RESULTS: A total of 169 persons, including 14 (8.3%) crewmembers, were transferred from the ferries to land-based facilities by ambulance while alongside (n = 80; 47.3%) or evacuated by helicopter (n = 85; 50.3%) and rescue boat (n = 4; 2.4%) during the 3-year period. Transfer destinations were Denmark (n = 53), Germany (n = 49), Norway (n = 48) and Sweden (n = 19). The passenger helivac rate was 2.4 per 100,000 passenger-days. One person was airlifted from a ferry every 2 weeks. Among helivacs, 40% were heart-related, and more cardiac cases were airlifted than transferred by ambulance in port. CONCLUSIONS: All helivac requests were made after discussion between the ferry's paramedic and telemedical doctors ashore and agreement that the medical challenge exceeded the ferry's capability. This close cooperation kept the threshold for arranging helivacs from the ferries low, enabling short transport times to land-based facilities for critically ill patients. Further studies, including feedback from the receiving hospitals, are needed to determine measures that can reduce possible helicopter overutilisation without compromising patient safety and outcome.

Debriefing of the medical team after emergencies on cruise ships.

Done to improve safety and patient outcome but not to lay blame, debriefings on cruise ships should preferably be conducted as standard practice in the medical facility immediately after all critical events aboard. The key questions to be asked are: What went well, what could have gone better and what must participants do to improve care? Post-debriefing the ship's doctor might have to deal with team members' mental stress resulting both from the event and from debriefing it. Required by most cruise companies, standardised advanced life support courses teach effective high-performance team dynamics. They provide the multinational medical staff with a clearer understanding of the rescue sequence, which again will reduce the risk of mistakes and simplify post-event debriefings. Their systematic approach to the chain of survival is also helpful for post-event debriefings if something went wrong.

Cruise tap versus handshake: using common sense to reduce hand contamination and germ transmission on cruise ships.

A firm handshake is a widely used greeting, but contaminated fingers and palms can also transfer bacteria and virus. Hand sanitation is important to prevent spreading of contagious diseases, but to wash hands properly takes too much time to ensure satisfactory compliance. Banning the handshake from health care settings has been proposed, but an alternative, less contagious form of greeting must be substituted. Cruise ships are particular vulnerable to infectious diseases that are transferred from person to person. The fist bump, common in some subcultures, has become increasing popular as the greeting-of-choice on smaller cruise vessels. To further reduce the contact area, a modification of the fist bump, the 'cruise tap', where only two knuckles briefly touch each other, is recommended.

Head injury and anisocoria on a cruise ship.

A previously healthy 65-year-old female passenger presented on the 3rd day of her voyage with a small facial laceration after she fell and hit her forehead, following sudden blurred vision and dizziness. When the ship's doctor noticed that one pupil was much bigger than the other, he feared intracranial bleeding and considered helicopter evacuation. Her symptoms had started shortly after she had removed a transdermal scopolamine patch from behind her ear. Getting scopolamine from her hands in direct contact with the eye surface caused mydriasis. To prevent it, after handling the patch, the hands and the application site should have been washed thoroughly with soap and water and dried. Only time was needed for the dilated pupil to normalise.

Cruise ship's doctors - company employees or independent contractors?

Traditionally, cruise companies have stated that they are in the transport business but not in the business of providing medical services to passengers. They have claimed not to be able to supervise or control the ship's medical personnel and cruise ship's doctors have therefore mostly been signed on as independent contractors, not employees. A United States court decision from 1988, Barbetta versus S/S Bermuda Star, supported this view and ruled that a ship's owner cannot be held vicariously liable for the negligence of the ship's doctor directed at the ship's passengers. Some years ago a cruise passenger fell and hit his head while boarding a trolley ashore. Hours later he was seen aboard by the ship's doctor, who sent him to a local hospital. He died 1 week later, and his daughter filed a complaint alleging the cruise company was vicariously liable for the purported negligence of the ship's doctor and nurse, under actual or apparent agency theories. A United States district court initially dismissed the case, but in November 2014 the United States Court of Appeals for the Eleventh Circuit disagreed and reversed. From then on independently contracted ship's doctors may be considered de facto employees of the cruise line. The author discusses the employment status of physicians working on cruise ships and reviews arguments for and against the Appellate Court's decision.

Head injury in a cruise passenger during a shore excursion.

A 66-year-old overweight insulin-dependent male passenger with diabetes and severe arthritis was on a 4-week circle-Pacific cruise. He fell ashore and hit his head. The ship was about to leave on a non-stop voyage - without any evacuation possibilities for the next 8 days. He was examined and had X-rays taken at the local hospital, but as his head injury was considered mild, he returned to the ship "for 48 hours of observation for signs of intracranial bleeding" - against the ship's doctor's advice. Delayed suspicion of a non-displaced cervical fracture caused extra work and worries and could have, but did not complicate matters. When there are no life-saving therapy and no timely evacuation possibilities in case of deterioration, on-board observation is counterproductive. The patient should be kept in - or near - the local hospital during the necessary observation period, followed by safe repatriation.

Referring cruise ship patients to specialists in Norway--a welfare state with a national health care system.

Northern Europe is a popular cruise destination, but many non-Scandinavian cruise ship's doctors who are used to enthusiastic service from specialists ashore, get frustrated when referring passengers or crew to out-patient medical evaluation. Norway's national health care system is described and used as an example of medical conditions in a welfare state with a relatively well-functioning national health care system: Emergency cases are usually promptly admitted. Out-patient specialist consultations are available in public polyclinics, but waiting time can be considerable, also for patients from ships. Private specialists are fully booked weeks in advance and do not work from Friday to Monday and during holidays. Public and private medical service capacity is significantly reduced during the summer months. Hence, most specialists ashore are not eager to see demanding ship patients. Ship's doctors should limit referral to conditions that require specific procedures that are not available on the vessel but are necessary for the patient to be able to continue cruising or working aboard. Crewmembers who are unfit for work aboard, should instead be signed off and repatriated for diagnostic work-up and follow-up at home. In cases of hospitalisation or necessary referral ashore, the ship's doctor should always confer in advance with the company's ship's port agents and make necessary shore-side arrangements through them.

Briefing notes on maritime teledermatology.

All coastal states must provide telemedical assistance services (TMAS) 24 h a day free of charge to all ships. Skin lesions account for many urgent TMAS consultations, but may be difficult to describe for seafarers without much medical training - and even for medical personnel on cruise ships. By following simple instructions provided in this article, good photographs - taken by digital cameras or smart phones and transmitted by e-mail to TMAS - can compensate for imprecise descriptions. The on-line TMAS physician can then easily consult with a dermatologist if necessary. Highly specialised teledermatology services are commercially available for cruise companies. Their ship's doctors thereby get prompt access to expert medical opinion without the time, logistical issues and costs associated with seeking dermatologic care ashore. Teledermatology allows cruise medical staff to effectively manage skin conditions aboard and limits unnecessary dermatology clinic referrals. For the ships' medical staff the teledermatology service is also an opportunity for continuous education which may benefit skin patients aboard in the future.

Briefing notes on emergency medical disembarks by helicopter at sea in North America.

Physicians and nurses from shore based practice who move to work on cruise ships often have concerns about the management of critically ill patients and questions about the resources available to transfer by helicopter to a tertiary care facility. This article seeks to outline some of the clinical, operational and logistical issues associated with using a helicopter to transfer a patient from a ship to a shore-side hospital. While it focuses on resources available in the maritime areas around North America, most of the clinical comments would apply to helicopter evacuations anywhere in the world.

Legal aspects of cruise medicine - can a non-US ship's doctor be sued for malpractice in Florida?

An English ship's doctor treated a non-US female patient for abdominal discomfort on a foreign-flagged cruise ship off the coast of Haiti. In Mexico the patient underwent abdominal surgery, followed by complications, for which her lawyers wanted to take the ship's doctor to court in Florida, USA. A trial court granted their wish, but this decision was reversed on appeal as the factors discussed were insufficient to establish Florida jurisdiction over the ship's doctor. The decision is not about whether malpractice occurred; it is about limiting the possibility of taking the ship's doctor to a court in a location preferred by the plaintiffs' lawyers. The appeal court ruling is important for non-US doctors working as independent contractors on cruise vessels that visit US ports, and it will hopefully prevent some of the more frivolous law suits from being filed in the future.

Long-lasting adverse effects after short-term low-dose treatment with metoclopramide for vomiting.

Metoclopramide is commonly used to treat vomiting caused by seasickness and acute gastroenteritis on cruise ships and serious adverse effects have not been reported from use at sea. We report severe long-lasting adverse effects in a young female seafarer following short-term, low-dose use of metoclopramide. During rough seas a 25-year-old female musician on a cruise vessel presented with nausea and vomiting. She was given intramuscular metoclopramide 10 mg and diphenhydramine 25 mg. Vomiting stopped after the injections, but she felt tired, confused and dizzy. She then had been taking metoclopramide 5-10 mg a day, but stopped after a total per oral dose of 30 mg as she developed disturbing symptoms that she related to the medication, including dizziness, anxiety, fatigue, depression and involuntary movements (twitches, jerks, ticks, and tremors of the eyelids, tongue, neck, fingers, arms and legs). Neurological examination, blood tests, electrocardiography and magnetic resonance imaging of the brain were all normal. Although gradually reduced in strength and frequency, the adverse effects were very disturbing for about 10 months, but at 13 months she was almost fully recovered. For many years numerous vomiting sea travellers have been successfully treated with a single parenteral 10 mg dose of metoclopramide. There are no obvious reasons why our previously healthy patient experienced such serious and long-lasting side effects after low-dose, short-term metoclopramide administration. Until more is known, metoclopramide should be reserved for debilitating cases - and only be given after other remedies have been tried and found ineffective.