A cabin stewardess presented with a short history of dysmenorrhoea followed by a syncopal episode. The ship was 20 hours sail time from the next port. Clinical signs included pallor, hypotension, lower abdominal tenderness and distension. Urine HCG was positive for pregnancy. The working diagnosis of ectopic pregnancy was made and she was resuscitated with IV fluids in the critical care unit. Her haemoglobin dropped down to 7g/dl over an hour and the decision was made to transfuse her with fresh whole blood using the comprehensive protocols contained within our fleet medical regulations (see below under acute PV bleed for further details). Following transfusion of several units, her condition temporarily stabilized but significant internal bleeding persisted. Emergency arrangements were made for a helicopter evacuation to a hospital in the nearby island of Rhodes. She underwent emergency surgery and made a full recovery.
An elderly male passenger presented to the Medical Centre with severe unstable angina. He was admitted into our critical care unit and treated according to our clinical guidelines for unstable angina/non-ST elevation myocardial infarct. This included cardiac monitoring, oxygen, intravenous nitrates, LMW heparin, aspirin, clopidogrel and morphine. Unfortunately he subsequently developed worsening pain associated with acute ST elevation. He tested positive for Troponin I and CK-MB. He was immediately thrombolysed with Tenecteplase and responded well with a reduction in pain and ST elevation. He continued to improve and was safely disembarked to a coronary care unit in the UK the following day.
A female adult patient with learning difficulties presented with abdominal pain. She was particularly difficult to assess as she was not able to express herself well and was agitated by pain and the need for hospitalization on board. She was travelling with two carers, one of whom was able to stay with her at all times to offer comfort. Abdominal examination, blood electrolytes and abdominal x-rays were suggestive of large bowel obstruction. The patient was stabilised with IV fluids, analgesia, antibiotics and nasogastric suction. Her pain settled and she was landed to a shoreside hospital for further investigation and treatment.
An elderly male passenger presented with confusion and left sided hemiplegia. He was admitted for investigation and treatment of acute stroke. The patient had vomited and was thought to have aspirated. The ship was two days sailing to the next port and so medical evacuation was not possible due to the ship's isolated position. We were faced with the need to provide medical and nursing care for two days at sea. As the patient had a poor gag reflex and copious oral secretions, we felt we had no option but to intubate and ventilate to protect his airway. He already had x-ray signs of aspiration pneumonia. He was intubated using fentanyl, propofol and suxamethonium and ventilated using our onboard ventilator. He was subsequently allowed to breathe for himself in an assisted ventilation mode with lightened sedation. The efficacy of the ventilation was monitored using pulse oximetry and capnography. We phoned the hospital ahead of arrival to our next port and arranged for an ambulance staffed with a doctor and paramedics to meet the ship on docking and transfer our patient on a portable ventilator to an onshore intensive care unit.
It is not uncommon for patients on chronic ambulatory peritoneal dialysis for kidney failure to cruise and most can successfully manage their own dialysis. Arrangements can be made for the dialysis fluids to be delivered directly to the ship. One such patient presented with peritonitis, an occasional complication of this therapy associated with turbidity of the dialysate and abdominal discomfort. We were able to discuss this case by satellite phone with the Renal Unit in the UK in charge of the patient. As a result dialysis fluid was sent for culture and Vancomycin was obtained in Lisbon. The patient was successfully treated onboard and completed his cruise.
A patient presented with a two-week history of substantial PV bleeding. She was admitted into the Medical Centre and placed on bed rest, oxygen and IV rehydration. A full blood count revealed a Hb of 7g/dl. Her blood pressure gradually dropped and she became syncopal on sitting. Her FBC was analysed regularly and her Hb was noted to have dropped 0.5g/dl in two hours. We still had 18 hours to go until arrival in Southampton so we had to consider the available options.
The patient (a nurse herself) was initially against transfusion. In addition, we were unsure about the risks as she had a history of polycystic kidneys leading to renal transplant and was on immunosuppressive treatment. Diversion was not a realistic proposition given the roughness of the sea and our geographic position.
The case was discussed via satellite telephone with the duty renal registrar at Manchester Royal Infirmary where the patient had previously been treated. The registrar assured us that transfusion was not a problem.
The protocols for blood transfusion as outlined in the company's Fleet Medical Regulations were reviewed and followed. We put out a broadcast for established blood donors with donor cards and confirmed both the donor's and the patient's blood group with Eldoncards. Screening was conducted for infectious diseases such as HIV and Hepatitis B. Two units of blood initially were harvested. One unit was transfused over two hours and the second over four. Meticulous observations were made for transfusion reactions. The PV bleeding continued but eased and her general condition improved overnight. She was safely transferred by ambulance to Princess Anne Hospital Southampton for further management when the ship docked the next day.