Tag Archives: cardiac emergencies

Cardiac Care Revealed On Celebrity Cruise Lines: Afibbers Fear Not

In a previous post, the skeptical cardiologist was dealing with a patient about to embark on a 16 day cruise through the Panama Canal who was having frequent episodes of atrial fibrillation.

I was concerned about the medical care on board her cruise ship and had not been able to contact medical personnel on board.

I’m happy to report that I have been in email contact with Dr. C, of  Celebrity Cruise Lines who is on board the Celebrity Infinity as it sails down the Pacific coast of Mexico and prepares to dock in Cabo San Lucas today.

Dr. C tells me that they have excellent medical personnel and resources available and should my patient go into afib they will be very comfortable dealing with the situation:

“Well I can not speak for any other cruise line but Celebrity, Royal Caribbean and Azamara (the 3 are part of Royal Caribbean Intl), which I have work on the 3 lines. As requirements for the Physicians and Nurses is to have BLS, ACLS, PALS and ATLS certification every 2 years, but most of us like to perform it at least once a year. Most of the ships have 2 Physicians and 3 Nurses, except the Oasis class ships, where there are 3 Doctors and 5 Nurses. 

Regarding equipment, we have the necessary equipment to stabilize cardiac emergencies (obviously not all of them)… we have the mentioned monitors with described capabilities, a portable pressure/volume ventilator (used in the US Army in areas of combat). For IV cardiac medications, we have Adenosine, epinephrine 1:1000 and 1:10000, atropine, amiodarone, procainamide, dopamine, dobutamine, furosemide, metoprolol, diltiazem, verapamil, labetalol, digoxin, calcium gluconate and chloride, furosemide lidocaine 2%, magnesium sulfate, norepinephrine, sodium nitroprusside, nitroglycerine, enoxaparin, clopidogrel (oral), aspirin  and tenecteplace as fibrinolytic.”

What Is The Scope Of Cruising Cardiac Emergencies?

After publishing my last post ,  Dr. Sergio Pinski tweeted me  a link to a paper from 2010 entitled “Cardiovascular Emergencies in Cruise Ship Passengers” that he co-wrote.

The Cleveland Clinic Florida apparently provides “contracted cardiology consultations” to cruise ships and they recorded the nature and outcome of their consultation over a two year period.

 “One hundred consecutive patients were identified (age 66 +/- 14 years, range 18 to 90, 76% men). The most common symptom was chest pain (50%). The most common diagnosis was acute coronary syndrome (58%; ST elevation in 21% and non-ST elevation in 37%). On-board mortality was 3%. Overall, 73% of patients required hospital triage. Of the 25 patients triaged to our institution, 17 underwent a revascularization procedure. One patient died. Ten percent of patients had cardiac symptoms in the days or weeks before boarding; all required hospital triage. Access to a baseline electrocardiogram would have been clinically useful in 23% of cases.”

As a result of these observations they recommended the following:

“A pre-travel medical evaluation is recommended for passengers with a cardiac history or a high-risk profile. Passengers should be encouraged to bring a copy of their electrocardiogram on board if abnormal.”

Finally, the authors write (and this seems a little self-serving and not supported by data) that:

“Cruise lines should establish mechanisms for prompt consultation and triage.”

Dr. Pinski also tells me he has witnessed two electrical cardioversions performed onboard cruise ships.

I don’t know if Cleveland Clinic is consulting with my patient’s ship but I’d prefer cardioversions be done on land, preferably in a hospital with appropriate anesthesia (see my post on defibrillation).

More Research Needed: Volunteers Saught

If any of you are aware of cardiac emergencies or episodes of atrial fibrillation on cruise ships  and how they were handled please let me know. I’ll collect as much first hand information as I can and share it with you.

In my office this morning I spoke with an afib patient who is planning on a several week cruise in the Mediterranean on a Royal Caribbean ship. He has agreed to be my investigative reporter on the status of medical care on that cruise.

I don’t know if you can expect this level of cardiac medical care on every cruise but it makes sense, if you are a heart patient,  to find out what is available in terms of medical personnel, cardiac and pulmonary monitoring/pacing/cardioversion equipment and medications should you go into afib or another cardiac emergency  on your particular ship.

Finally, ask the cruise company if they contract for cardiology consultation services with any entity and, if so, what that entity is and how the consultation works.

Cruise on my friends, but query as you go!

-ACP

 

What Happens If You Go Into Atrial Fibrillation On A Cruise?

This question popped into my head as I was talking to a patient (we’ll call her Barb)  who has paroxysmal atrial fibrillation (PAF) and was about to embark on a 17 day cruise from San Diego through the Panama Canal and on to Fort Lauderdale.

Screen Shot 2016-04-11 at 6.12.04 PM
The recording I pulled up shows atrial fibrillation going at a rapid rate.

On a rainy Sunday afternoon while watching the Cardinals pummel the Braves, I had logged onto my AliveCor account to pull up some office patient recordings I had made earlier in the week when I noticed that Barb had made a recording the day before which was interpreted as atrial fibrillation at a rate of 133 beats per minute. I had heretofore been aware that she was having  recurrent episodes of PAF and so I called her and found out she was in San Diego.

At her last office visit in early March she was in normal rhythm as usual but reported having spells of palpitations, usually at night. We discussed various monitoring methods and I demonstrated the Alivecor device to her. She purchased one and had been making recordings but had not let me know that some of them were showing atrial fibrillation.

Fortunately, she was on the blood thinner Eliquis and  was protected against clots in the heart or stroke but I was worried that she might go into Afib on the cruise, persist in it and develop problems.

What, I wondered, would the cruise ship crew or doctor do in that situation?

Would  they be capable of even monitoring my patient’s heart rhythm or would the AliveCor Mobile ECG device she had on her smart phone be the best monitor on the ship?

Are there any medications, like beta-blockers available that could be given to slow the heart rate?

I’m still waiting for the answer to the questions.

What Do We Know About Medical Care on Cruise Ships?

No so much.

Consumer Reports has an informative  article entitled:  “What you need to know about medical care on cruise ships.”

The middle four items are relevant to any cardiac issue:

“-Cruise ships aren’t hospitals

Many ships have a doctor on board who is trained in emergency medicine—but not all of them. According to international maritime law, they aren’t required to; a crew member with medical training is sufficient, says Ross Klein, Ph.D., author of “Paradise Lost at Sea: Rethinking Cruise Vacations.” The medical facilities are generally more like an infirmary or walk-in care clinic than a “floating” hospital. You might find a ventilator and a small X-ray machine and the doctor may be able to perform simple laboratory tests to check for infection or electrolyte or blood sugar levels. But there’s no MRI or CT scanner, intensive care unit, or blood bank (although the crew has usually been blood-typed and may be asked to serve as donors if a passenger needs a transfusion).

– In an emergency, you may be on your own

. You probably could get basic treatment, such as stitches or IV fluids, but for anything serious, there’s a very good chance that you will have to disembark at the next port of call—whether you want to or not. It’s up to the ship’s medical personnel, not you, to decide, You’d be treated at a local hospital, and the ones in more remote areas may not have the same standards of medical care or facilities available in the U.S. And once you recovered, you’d have to arrange another way to get back home.

What if you have a heart attack or develop appendicitis miles from dry land? Don’t assume the Coast Guard will airlift you out. Bad weather can make flying a helicopter dangerous, and the Coast Guard isn’t obligated to take that risk. Even in calm waters, if the ship is 500 miles or more away from shore, it’s unlikely that the Coast Guard will respond, Klein said.

-Get ready for sticker shock

Check with your health insurance company before you set sail to be sure, but most plans don’t cover medical services you get on board, … (In fact, this is usually the case anytime you receive medical treatment from a doctor or hospital outside the U.S.) This means you pay out-of-pocket. The bill can range from a few hundred to several thousand dollars…

Travel health insurance is your best protection. Consumer Reports recommends avoiding commission-driven policies sold by tour operators, cruise-line representatives, and travel agents. Instead check out an online broker, such as insuremytrip.com, that sells coverage from multiple companies and allows you to tailor a plan to your needs. Ask for quotes, but be sure you’re comparing apples to apples. What’s covered under policies can vary. For example, some may not include emergency evacuation.

-Your Ship Does Not Have A CVS

Most ships do have common prescription drugs on board, but you can’t count on it. What’s more, if you needed one, you’d be charged full price—not just your insurance co-pay—for each drug dispensed on the ship.

The Plan

I developed a plan for my patient and called in a prescription for her to fill prior to getting on the Celebrity Infinity.

Then I tried to get some information on what medical support would be available on her ship.

I called  Celebrity Cruise Lines to see if they had a doctor and whether I could communicate with him.  I was immediately told yes, however when I asked what the doctor’s qualifications and if I could talk to him this was apparently a novel request. After multiple transfers I spoke to someone in “Special Needs” who gave me an email address. I’m told by email that they have my contact info and the doctor will contact me if needed.

At this time, I’m assuming Barb is on the Celebrity Infinity and cruising down the Pacific Coast of Mexico, enjoying the cool ocean breezes and lounging by the ship’s pool.

Hopefully she won’t have a prolonged episode of afib that needs any urgent medical care.

If she does or if the cruise ship doctor gets back to me,  I may get that information I’ve been seeking on  how cardiac urgencies and emergencies are handled on cruise ships and I will be sure to share it with all of you.

Nautically Yours

-ACP