EDITORIALS
New Horizons: Emergency Medicine at Sea See related article, p 1476. The article in this issue of Annals entitled " S h i p b o a r d Medicine: A New Niche for Emergency Medicine" is, in more ways than one, the p r o v e r b i a l "tip of the iceberg." In this six-month retrospective survey of medical care provided aboard two cruise ships, DiGiovanna and colleagues give many readers their first glimpse of medical practice a b o a r d the world's luxury cruise liners. I congratulate the authors for inaugurating this topic in the emergency medicine literature. The depths of this iceberg remain to be explored. Paradoxically, luxury cruise ship passengers are an undcrserved population. F o u r million Americans cruise each year a b o a r d more than 100 ships worldwide. The cruise industry is expanding rapidly with ships capable of carrying 2,300 passengers and still larger vessels being planned.1 While most of these liners have a medical d e p a r t m e n t , the qualifications of their medical staff, emergency medical equipment, and supplies are notoriously inconsistent between cruise lines. Governments and international agencies spend considerable resources to ensure quality operations in customs, sanitation, and seaworthiness but virtually nothing on shipboard medical services. The consummate ship's physician practices a combination of emergency medicine, occupational medicine, epidemiology, psychiatry, and disaster medicine. Poise, resourcefulness, and a sense of adventure are almost as i m p o r t a n t as a functioning monitor-defibrillator a b o a r d a large ship. Those readers who receive the A C E P Section on Cruise Ship and Maritime Medicine newsletters 2 have a sense from our published case studies of the enormous challenges of stabilizing and evacuating a critically ill passenger from a foreign p o r t or thousands of miles out to sea. After almost a decade of working with cruise ship medical departments, it is my bias that the experience, skills, and flexibility each of you has as an emergency physician are ideally suited for the duties of a cruise ship physician. When work first began to build the Section on Cruise Ship and Maritime Medicine almost three years ago, the first challenge was to have fellow physicians take the idea seriously. This article in Annals, our initial continuing medical education presentation at the 1992 A C E P Scientific Assembly, vigorous support from the ACEP Council and B o a r d of Directors, and more than 200 members of the section are just a beginning. Clearly, a cruise ship with thousands of people a b o a r d is a floating city with its own culture, tradition, and health needs. Medical logs can only hint at the m y r i a d and unique logistical and medical challenges encountered by shipboard medical departments. One dilemma experienced by every ship's medical staff is what I call the "heaven syndrome. ''3 Typically, an otherwise educated, mature, often well-off passenger ignores or vehemently denies a potentially serious medical event. An elderly woman with a first episode of syncope and new-onset atrial fibrillation or someone with sudden, unilateral calf swelling and tenderness refuses, despite repeated medical advice, to leave the ship for definiti,de medical care. When asked why, the passenger or family member replies to the
NOVEM!BER1992
21:11 ANNALS OF EMERGENCY MEDICINE
effect: "So what if I die a b o a r d . . . I ' m in heaven!" In a variation, friends and family bring loved ones with leukemia, AIDS, or other terminal illness "for a last fling before they die." A h u m a n i t a r i a n gesture certainly, but no solace to the ship's physician and nurse responding to a late night code. DiGiovanna and colleagues have given us a brief glance through the porthole. Broader, more comprehensive studies of s h i p b o a r d health and illness are already in progress (personal communication, C Hill, MD, August 1992). As the literature grows, it will become clear that the patient profile, categories of disease, and nature of emergencies have intriguing patterns from ship to ship and sea to sea. Some vessels attract young people with their accompanying bouts of honeymoon cystitis, ectopic pregnancies, and scuba injuries. Others, such as the Alaskan cruises, appeal to the geriatric crowd replete with gastrointestinal bleeds, hip fractures, and scopalamine psychosis. Shoreside hazards, a crewmembers from foreign ports, and long hours operating hazardous equipment add to the shipboard milieu of physical and emotional illnesses. Emergency physicians have an opportunity to lead the field of cruise ship medicine. As each of you reach out to explore this new horizon, I hope you will document your experiences. With a growing data base, the A C E P guidelines we develop will be a resource to cruise ship agencies, consumer groups, government, and professional medical organizations. Anybody who doubts the veritable ocean of medical challenges that lie ahead need only remember the Titanic. Wes Young, MD, FACEP Founder and Immediate Past Chair ACEP Section on Cruise Ship and Maritime Medicine Schools of Medicine and Public Health University of Hawafi Honolulu 1. Hemphill MA: Cruise ships of the future. DiversionMay 1990;106-109. 2. Heymach GJ: Case report: Critical care on a cruise, in Boekhoff D (ed): Sectionon Cruise ShipMedicine 1991;I:5. 3. Carlsen R: Emergency physicians take to the high seas. EmergencyMedicine News December 12, 1990;12:18-193. 4. Guptill K: American travel deaths in Mexico. WestJ Mef11991;154:169-171.
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New Horizons: Emergency Medicine at Sea See related article, p 1476. The article in this issue of Annals entitled " S h i p b o a r d Medicine: A New Niche for Emergency Medicine" is, in more ways than one, the p r o v e r b i a l "tip of the iceberg." In this six-month retrospective survey of medical care provided aboard two cruise ships, DiGiovanna and colleagues give many readers their first glimpse of medical practice a b o a r d the world's luxury cruise liners. I congratulate the authors for inaugurating this topic in the emergency medicine literature. The depths of this iceberg remain to be explored. Paradoxically, luxury cruise ship passengers are an undcrserved population. F o u r million Americans cruise each year a b o a r d more than 100 ships worldwide. The cruise industry is expanding rapidly with ships capable of carrying 2,300 passengers and still larger vessels being planned.1 While most of these liners have a medical d e p a r t m e n t , the qualifications of their medical staff, emergency medical equipment, and supplies are notoriously inconsistent between cruise lines. Governments and international agencies spend considerable resources to ensure quality operations in customs, sanitation, and seaworthiness but virtually nothing on shipboard medical services. The consummate ship's physician practices a combination of emergency medicine, occupational medicine, epidemiology, psychiatry, and disaster medicine. Poise, resourcefulness, and a sense of adventure are almost as i m p o r t a n t as a functioning monitor-defibrillator a b o a r d a large ship. Those readers who receive the A C E P Section on Cruise Ship and Maritime Medicine newsletters 2 have a sense from our published case studies of the enormous challenges of stabilizing and evacuating a critically ill passenger from a foreign p o r t or thousands of miles out to sea. After almost a decade of working with cruise ship medical departments, it is my bias that the experience, skills, and flexibility each of you has as an emergency physician are ideally suited for the duties of a cruise ship physician. When work first began to build the Section on Cruise Ship and Maritime Medicine almost three years ago, the first challenge was to have fellow physicians take the idea seriously. This article in Annals, our initial continuing medical education presentation at the 1992 A C E P Scientific Assembly, vigorous support from the ACEP Council and B o a r d of Directors, and more than 200 members of the section are just a beginning. Clearly, a cruise ship with thousands of people a b o a r d is a floating city with its own culture, tradition, and health needs. Medical logs can only hint at the m y r i a d and unique logistical and medical challenges encountered by shipboard medical departments. One dilemma experienced by every ship's medical staff is what I call the "heaven syndrome. ''3 Typically, an otherwise educated, mature, often well-off passenger ignores or vehemently denies a potentially serious medical event. An elderly woman with a first episode of syncope and new-onset atrial fibrillation or someone with sudden, unilateral calf swelling and tenderness refuses, despite repeated medical advice, to leave the ship for definiti,de medical care. When asked why, the passenger or family member replies to the
NOVEM!BER1992
21:11 ANNALS OF EMERGENCY MEDICINE
effect: "So what if I die a b o a r d . . . I ' m in heaven!" In a variation, friends and family bring loved ones with leukemia, AIDS, or other terminal illness "for a last fling before they die." A h u m a n i t a r i a n gesture certainly, but no solace to the ship's physician and nurse responding to a late night code. DiGiovanna and colleagues have given us a brief glance through the porthole. Broader, more comprehensive studies of s h i p b o a r d health and illness are already in progress (personal communication, C Hill, MD, August 1992). As the literature grows, it will become clear that the patient profile, categories of disease, and nature of emergencies have intriguing patterns from ship to ship and sea to sea. Some vessels attract young people with their accompanying bouts of honeymoon cystitis, ectopic pregnancies, and scuba injuries. Others, such as the Alaskan cruises, appeal to the geriatric crowd replete with gastrointestinal bleeds, hip fractures, and scopalamine psychosis. Shoreside hazards, a crewmembers from foreign ports, and long hours operating hazardous equipment add to the shipboard milieu of physical and emotional illnesses. Emergency physicians have an opportunity to lead the field of cruise ship medicine. As each of you reach out to explore this new horizon, I hope you will document your experiences. With a growing data base, the A C E P guidelines we develop will be a resource to cruise ship agencies, consumer groups, government, and professional medical organizations. Anybody who doubts the veritable ocean of medical challenges that lie ahead need only remember the Titanic. Wes Young, MD, FACEP Founder and Immediate Past Chair ACEP Section on Cruise Ship and Maritime Medicine Schools of Medicine and Public Health University of Hawafi Honolulu 1. Hemphill MA: Cruise ships of the future. DiversionMay 1990;106-109. 2. Heymach GJ: Case report: Critical care on a cruise, in Boekhoff D (ed): Sectionon Cruise ShipMedicine 1991;I:5. 3. Carlsen R: Emergency physicians take to the high seas. EmergencyMedicine News December 12, 1990;12:18-193. 4. Guptill K: American travel deaths in Mexico. WestJ Mef11991;154:169-171.
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