Troublesome Adventures on the High Seas

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Cruises aren’t always a relaxing getaway for some passengers.

Summer is back, and it’s time for that vacation you’ve always wanted: a cruise.  Cruise ship voyages are consistently rated as one of the best value for money options: the all-inclusive nature with great food, entertainment, lodging, itineraries, and activities are definite highlights.

Cruises for the most part are safe and fun.  Cruise ship incidents are rare but can include disasters (collision, sinking, grounding), mechanical issues (fires), crimes, and weather issues. A recent incident involved a ship losing engine power in heavy winds and severe waves close to Norway, which required evacuation of some passengers.[1]


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From 1979 to 2013, 55 cruise ships sank, with 106 collisions.[2,3] Crime can also be a significant problem, with approximately 10% of passengers affected for every cruise. More common issues on cruises include illness outbreaks (gastroenteritis, influenza, etc.) and injuries (falls, head trauma, broken extremities).[2,3] This article will evaluate several of the common problems passengers experience on cruise ships.

Case 1: A 43-year-old female has never gone on a cruise or traveled by ship before. She and her husband are currently on a cruise voyage to the Bahamas. She has a history of motion sickness, primary in cars, which has significantly worsened on board the cruise.

This patient is experiencing a form of motion sickness called sea sickness. Motion sickness occurs with true or perceived motion, with input from visual, vestibular, and proprioceptive receptors.[4-6] These receptors cause nausea, nonvertiginous dizziness, and in severe forms, vomiting. This affects 3-60% of patients on cruise ships, though it rarely causes severe complications.[4,7,8]


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The most significant problem is a fall that can occur. Women are more common affected and experience more severe symptoms.[9-11]  This issue can occur with any form of motion, including planes, cars, and even videogames. Once the motion stops, symptoms should resolve within 24 hours, though it may take longer for patients who have had continuous exposure for several hours.[8,11]

Motion is categorized as vertical linear, horizontal translation laterally, for-and-aft movement, and angular roll.[6,11,12] Frequency of these movements impacts symptoms, with those with a frequency of 0.2 Hz most commonly affected.[11,12]

Nausea is the most common symptom, though vomiting, malaise, fatigue, and drowsiness can also occur.[5,6] Other signs and symptoms vary. If the sensation continues after the motion stops, this is known as mal de debarquement syndrome.[13] Unfortunately, once a patient experiences one episode of motion sickness, a second is more likely.[11]

The most important aspect of evaluation and management is the differential. Other conditions that require consideration include stroke, head trauma, dehydration, electrolyte changes/hypoglycemia, and intoxication. Your assessment depends on your history and exam. As usual, an emergency physician should evaluate for the worst-case scenario.


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Complete a focused neurologic exam, specifically evaluating gait, speech, and cerebellar testing (heel to shin, finger to nose, instability, speech, rapid alternating movements, etc.). Laboratory testing is not needed for all patients, unless hypoglycemia, electrolyte abnormalities, or stroke is suspected. A pregnancy test in women of reproductive age is appropriate. Imaging is only needed if a central nervous system pathology is suspected (stroke), or if symptoms last longer than several days after the movement stops. Keep in mind that to evaluate the posterior fossa, MRI is much better than CT.[14]

Treatment can be difficult. In this case, the best offense is a good defense, and preventative measures are far more effective than treating symptoms that have occurred.[5,6,11] Recognizing risk factors for motion sickness is important, especially if a patient has already experienced an episode. Minimizing exposure to these risk factors may not be possible (ie, taking a cruise), but minimizing the amount of conflicting sensory information can assist.[5,11]

If possible, passengers with history of motion sickness should visit the ship when it is docked as soon as they can and spend time by a calm harbor. Positioning near the center of the vessel and closest to the waterline will minimize motion. Areas below the deck or high above the waterline will result in more severe symptoms, and patients should support the head and minimize motion. Patients should also ensure adequate hydration and temperature and wear sunglasses. Spicy and acidic food should be avoided.[11]

Two medication classes for prevention and/or acute therapy include anticholinergic agents and antihistamines. Scopolamine is perhaps the classic agent used for prevention and treatment, with its efficacy through central anticholinergic activity.[5,11] It is usually prescribed as a patch that is placed 30 minutes prior to motion and left in place for 72 hours.[11,15,16] It is placed behind the ear on the mastoid area. Oral and intranasal forms are available. Antihistamines include a variety of medications. Your best bets include cinnarizine 50 mg, dimenhydrinate 50-100 mg PO, meclizine 12.5-50 mg, promethazine 25 mg, and cyclizine 50 mg.[5,7,11]

However, cetirizine is not effective, as it does not effectively cross the blood-brain barrier. Caffeine has demonstrated some benefit when combined with promethazine.[5,7,11] Agents such as benzodiazepines may prevent motion sickness, but they can cause significant sedation. They do not work as well for preventing motion sickness like scopolamine or dimenhydrinate.[17] Alternative therapies like acupuncture have not demonstrated benefit when compared to anticholinergics and antihistamines for symptom relief.[5,7,11] Ginger has also not demonstrated benefit in the literature.[5,11,18]

If motion sickness occurs, the patient should face forward and recline the head back by 30 degrees. Maintaining a steady visual view with as much open view as possible is important, while avoiding closed spaces. If symptoms continue, the patient can lie prone. If the patient has a scopolamine patch in place, another agent can be used such as promethazine.

Case #1 Conclusion:

The patient has a normal neurologic examination with normal gait, with no red flags for a central cause of vertigo or stroke. She has a scopolamine patch in place, and she is given meclizine for further therapy. The physician discusses non-pharmacologic means of decreasing her motion sickness as well. Several days later, she is markedly improved.

Case #2:

A 32-year-old male has experienced over 5 episodes of nausea, vomiting, and diarrhea. He is currently on a cruise ship with several friends, who are also sick. He has not had any fevers or abdominal pain other than mild cramps and is still able to eat and drink.

The rate of gastroenteritis among cruise ship passengers has decreased over time, though this remains a common disease on ships. From 2008 to 2014, 129,678 cases of gastroenteritis were reported (0.18% of passengers). In 2014, the rate of acute gastroenteritis episodes was 22.3 per 100,000 travel days.[19] Despite these statistics, these numbers may not accurately represent the true number, as cases must be reported when 2-3% of passengers or crew have a GI illness.

The most common cause of outbreaks on a cruise ship is norovirus, a non-enveloped, linear, non-segmented RNA virus.[20] This virus accounted for 14,911 cases of gastroenteritis between 2008 to 2014. There were 12 outbreaks of norovirus in 2010, with 10 in the first 6 months of 2016.[21,22] Norovirus is transmitted person-to-person or via food/water.[20]

Most commonly, transmission is through the fecal-oral route, with the virus brought on board by an infected passenger or crewmember. It can also be transmitted through contaminated surfaces and even the air.[23] In fact, there are documented cases of aerosolized viral particles after patients vomiting, with those in close proximity most commonly infected.[24] The most common risk factors include poor food preparation and storage and living in close quarters. The virus can survive for weeks to months in contaminated water or on surfaces used for food preparation.[25,26]

Norovirus infection can lead to sudden-onset nausea, vomiting, and diarrhea within 12-48 hours of exposure.[20,27] Abdominal cramps are also common.  Less than 20 virus particles may cause infection, but not all patients who are infected with the virus experience symptoms.[27-30]  Blood should not be present in stools or emesis.[31,32] Other flu-like symptoms such as weakness, myalgias, mild fevers, and headaches can occur.[31,32] Symptoms and the disease course are self-limited, with recovery in 2-3 days.[31-34] Patients are most infectious 2-5 days after infection, but the virus is present in stool for up to four weeks after the acute episode.[28] Severe illness and complications such as dehydration and electrolyte abnormalities are rare in healthy adults. However, severe illness can occur in patients < 5 years, the elderly, and those with immunocompromise, with up to 800 deaths per year.[35,36]

Diagnosis of a specific pathogen for gastroenteritis in the ED is rarely needed. There are tests available for identification of norovirus, including polymerase chain reaction (PCR), with results available within two hours that can detect less than 20 viral particles.[34,36,37]  An enzyme immunoassay (EIA) is also available.

Just like motion sickness, prevention is best. Proper hand washing is paramount, and unfortunately, alcohol-based hand sanitizers may not be as effective as soap and water.[38] This is because the virus does not contain a lipid viral envelope.[39] Antibiotics are not recommended during outbreaks. Treating symptoms with antiemetics is recommended, as well as ensuring hydration.[40]

On cruise ships with close quarters, exclusion and isolation of those infected is often utilized to minimize further transmission, though evidence on its efficacy is limited.[31-34] Infected individuals may be asked to remain within their cabin for 24-48 hours after symptom resolution. Chlorine bleach should be utilized to disinfect environmental surfaces, as well as areas with high rates of contamination such as hand rails and door knobs.[41]

Fortunately, patients are resistant to the same strain of virus for 6 months to 2 years.[42] However, there are multiple strains, so infection with a separate strain is possible.

Case #2 Conclusion:

The patient is PO tolerant, and his examination is normal with no abdominal tenderness. He is currently well-hydrated. The cases are reported to the crew, who determine the patient should remain in his quarters. He is given ondansetron with return precautions. He improves after two days.

Case #3

A 78-year-old female has been enjoying her cruise. Today she was by the pool, and unfortunately she slipped on some water and fell onto her left side. She is now complaining of significant left hip pain with inability to walk.

Similar to land, people at sea on a ship can experience trauma. Poolside activities, slippery decks, stairs, dancing, rough seas… These are just some of the predisposing factors that can result in trauma. Combine this with the statistic that over 50% of cruise passengers are between 50-74 years, you have a recipe for potential fractures, head trauma, and more.[43,44]

A 2018 retrospective cross-sectional study found that 70% of trauma patients aboard a cruise ship were 65 or older, with a ground level fall accounting for 79% of injuries.[45] The most common injury was a femur fracture (52%), with traumatic brain injuries occurring in 7.5%.[45] Other causes of injury included a fall down stairs, pool accidents, sports vehicle accidents, burns, or struck by falling object or glass.  Other studies also suggest older women are most commonly affected, with hip fractures a common injury.[46,47]  Unfortunately, this type of fracture is associated with increased morbidity, as well as a significant increase in all-cause mortality.[48]

Case #3 Conclusion:

The patient with fall is neurovascularly intact. She has no other evidence of trauma, with no loss of consciousness. The physician is concerned for a left hip fracture and obtains a radiograph, which demonstrates a left intertrochanteric fracture of the femur.

With all of these potential issues, what does a cruise ship have for medical emergencies?

Well, you are in luck. The American College of Emergency Physicians released a policy resource and education paper in 2019 detailing requirements for cruise ship medical facilities.[49] While the specific needs of a ship are dependent on size, patients, length of trip, itinerary, and several other factors, those ships carrying over 100 persons must have certain personnel and facilities available, listed in Table 1.

Table 1 – ACEP Health Care Guidelines for Cruise Ship Medical Facilities.[49]

Guideline Component Specifics
Medical Facility –          Has at least 1 exam/stabilization room, 1 ICU room, 1 inpatient bed per 1000 passengers and crew, 1 isolation room.

–          360 degree patient accessibility around at least 1 bed.

–          Has wand wash sinks, antibacterial soap, paper towels, waste bins in exam rooms. If rooms do not have sinks, hand sanitizer is available.

Staff –          Clinical staff have full registration and license for practice, with at least 3 years of post-graduate/post-registration experience.

–          Physicians must have at least 3 years of post-graduate/post-registration experience in general or emergency medicine or are board certified in emergency medicine, family medicine, or internal medicine.

–          Staff must be certified in ACLS, ALS, or an equivalent training or physician specialist training (emergency medicine, critical care, anesthesia).

–          Physicians must have a competent skill level in emergency cardiovascular care; possess minor surgical, orthopedic, and procedural skills; and procedural sedation skills.

Clinical Practice –          Medical policy and procedures must be reviewed by a senior clinician.

–          There must be a designated and trained rapid medial response team, with at least 1 exercise per month.

–          When at sea, at least 1 physician and 1 additional clinical provider must be available to provide emergency care 24 hours a day.

–          When at port, at least 1 clinical provider is available onboard the ship.

Documentation –          Well-organized, legible, consistent documentation of all medical care with patient confidentiality.
Equipment –          Vital signs equipment, at least 2 cardiac monitors, at least two defibrillators (one portable automated external defibrillator), external pacing capability, ECG capability, oxygen tanks, and at least one concentrator.

–          Airway equipment: BVM, supraglottic device, laryngoscopes, ET tubes, stylet/bougie, lubricant, portable suction, surgical airway.

–          Capability for electronic IV infusion and nebulizer therapy.

–          Wheelchairs, stair chair and stretcher, automatic ventilator, refrigerator and freezer, long and short back boards with C-spine immobilization capabilities, trauma supplies.

–          Laboratory testing: CBC, UA, qualitative HCG, blood glucose, electrolytes (at least Na and K), renal function, cardiac enzymes, malaria, legionella, influenza A and B, HIV.

Pharmacy –          Maintain an evidence-based formulary on each ship with sufficient medications from the following classes:

–          GI: Antacids, H2 antagonists, laxatives, PPIs, hemorrhoidal preparations.

–          Respiratory: Bronchodilators, steroids, oxygen.

–          CNS: Anxiolytics, hypnotics, drugs in psychoses and related disorders, drugs for nausea/vertigo, analgesics, antiepileptics.

–          ID: Antibiotics, antifungal, antiviral, antimalarial medications.

–          Endocrine: Diabetic and thyroid medications, steroids.

–          MSK: NSAIDs, steroids, medications for soft tissue and topical pain relief.

–          Ocular: Antibacterial, antiviral, steroids, anti-inflammatories, mydriatics and cycloplegics, glaucoma therapies, local anesthetics, lubricants, diagnostic preparations.

–          Skin: Emollient and barrier preparations, topical and local anesthetics and antipruritics, topical steroids, antiviral/antifungal/antibacterial preparations, skin cleansers and antiseptics.

–          Anesthesia: IV anesthetics, anti-muscarinics, anxiolytics, non-opioid and opioid anesthetics, neuromuscular blocking drugs, antagonists for respiratory depression, tetanus toxoid vaccine.

Imaging –          X-ray imaging capabilities: at least 1 x-ray generator and one processing/developing system.

–          Radiation protection equipment for patients and staff.

Medico-Legal Practice –          Each ship should have at least 2 sexual assault evidence collection kits.

–          Each ship should have at least one clinical staff member with training that meets guidelines established by ACEP or an equivalent training relating to sexual assault evidence collection kits.

–          Each ship should carry sufficient stock of emergency post-coital contraception and post-exposure prophylaxis anti-retroviral and antibacterial medications to reduce risk of pregnancy, HIV, and STIs.

–          Before disembarkation, patients should be provided with a report for their own physician with details of the incident, findings of exam, treatment, psychological assessments, and requests for further follow-up, treatment, testing, or counseling.

–          Ships with passengers < 12 years should carry resuscitation equipment and supplies: at least 1 Broselow/Hinkle system and pediatric medications.

Contingency Medical Plan –          Comprehensive medical contingency plan subject to regular review and mass casualty incident drills conducted on a regular basis

–          Contingency medical plan with 1 or more alternate care sites.

–          Portable equipment: mass casualty triage documentation, airway equipment, IV fluids/supplies, immobilization equipment and supplies, battered powered and portable diagnostic and laboratory supplies, dressings, treatment, defibrillator, medical waste, PPE.

 

Key Points:
  • Cruise voyages are safe for the most part. The most common issues include gastroenteritis and minor trauma. Major cruise ship incidents are very rare.
  • For motion sickness, assess for focal neurologic deficit, inability to walk/speak, or sudden worsening of symptoms. These issues suggest severe, central nervous system
  • When it comes to motion sickness, prevention is best. For acute episodes, medications include anticholinergic agents and antihistamines. Other agents are not as effective.
  • Gastroenteritis outbreaks may occur on cruise ships, associated with poor food preparation and storage.
  • The most common cause of GI illness on cruise ships is norovirus, and treatment focuses on symptom management.
  • Trauma is common on cruise ship voyages, especially minor trauma. Fractures (hip) and minor head trauma may result from ground-level
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ABOUT THE AUTHORS

Brit Long, MD is an EM Attending Physician at San Antonio Uniformed Services Health Education Consortium.

Alex Koyfman, MD is a Clinical Assistant Professor of Emergency Medicine at UT Southwestern Medical Center and an Attending Physician at Parkland Memorial Hospital. He is also Editor-in-Chief for emDocs.

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