MILITARY MEDICINE * MEDECINE MILITAIRE
The ugly duckling: A different kind of ship, a different kind of patient Lieutenant-Commander William Bateman, MD H ow would you like to go to the Cormorant?" they asked. "Sure", I replied. "What's the Cormorant?" Even in the military, the HMCS Cormorant draws a puzzled response. When that conversation took place in October 1985 I had been serving Her Majesty for more than 5 years, but had been involved with diving for 15. 1 learned that the Cormorant is a diving ship - I didn't know we had one - and was pleasantly surprised to find that I would become her medical officer (MO). Commissioned in 1978, she began life as an Italian trawler. When the navy bought her in 1975 and spent 3 years and $10 million performing major surgery all that remained of the old fishing boat was her seaworthiness and extremely uncomfortable ride. For that she is notorious even seasoned sailors turn green in rough seas. The Cormorant displaces 2100 tonnes and carries only 65 to 100 crewmembers, so she is one of the navy's smaller ships, but she carries a six-person minisubmarine that can handle depths of up to 615 m and can let divers in and
out via an airlock. There is also a "robot" minisub that can dive to 370 m and the Cormorant has a
ferent from that of the rest of the fleet, other sailors consider her the "ugly duckling". The undignified nicknames they have bestowed include: * The Love Boat (12 of her crewmembers are women); * F.A. T (for Fast Attack
surface-supplied mixed-gas diving capability that can take divers to 90 m. An onboard recompression chamber allows for surface decompression of divers and emergency treatment of diving casual- Trawler); ties.
* The Floating Jetty
Why does the navy need such Shearwater (in honour of an una ship? Basically, she is available complimentary spread published
in case something has to be sal- in a Halifax tabloid that had misvaged from Canada's continental taken her for one of the fleet shelf. However, since this need diving unit's tugboats). rarely arises the Cormorant Despite such silly names, the spends little time on her primary Cormorant is one of the navy's job. busiest ships, so much so that the Because her mission is so dif- home port of Halifax seems more
William Batemiian is current/v senior Canadian mnedical ojlficer at Supreme Hleadquarters A/lied Powers Europe, (asteau, Bel-
The Cormorant usually sails alone C'AN MED ASS(OXJ 1990: 142(4)
Air evacuation is not an option. In other words, if a medical problem turns up, the Cormorants MO will likely have to manage it there.
a foreign port-of-call than a home base. During my 2 years as MO her tasks included a sovereignty voyage into the Arctic, where the minisub filmed the Breadalbane, a supply ship that sank in 1853 while searching for survivors of the ill-fated Franklin expedition. Later we sailed to more hospitable seas - the Caribbean - but paid for that by spending a brisk March in the North Atlantic, monitoring catches by foreign fishing boats for the Department of Fisheries and Oceans.
The Cormorant's wide range of tasks means that her medical officer faces a wide range of problems. To help handle them she also carries a medical assistant who doubles as paramedic, nurse, pharmacist, hygiene technician, watchkeeper and administrator. Another 10 crewmembers will have had advanced first-aid train-
ing and serve as the casualty-clearing team in the event of mass casualties. Both the MO and assistant are trained in diving medicine and must be qualified navy divers. The ship has a two-bed sick bay, an examination-treatmentresuscitation area, and a remarkably complete range, though relatively small supply, of pharmaceuticals. She is well equipped to provide advanced life support and has adequate surgical instruments for even major procedures. On board, the medical practice combines the characteristics of a remote general practice with navy medicine and diving medicine. Since there are fewer than 100 potential patients and all navy personnel have been medically screened, the number of problems is not great. The type of problems, though, can make this a
The ship's sick bay is small but functional 366
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remarkably complex practice. Because she is slower than the rest of the fleet and has a different mission than other navy ships, the Cormorant usually sails by herself and is far away from other medical support. Air evacuation is not an option because she does not carry a helicopter and is usually too far away from ships that do. In other words, if a medical problem turns up the MO will likely have to manage it there. Medical screening affords little comfort because the ship often carries civilian technicians, researchers and professors who are not subject to navy standards. One elderly passenger who claimed to be fit as a fiddle was discovered in his quarters, blue as a berry and puffing away on oxygen he had smuggled aboard. That is not the sort of problem one is used to seeing in young sailors. The fact she carries women sailors broadens the scope of practice. Before one of our deployments a crewmember complained of minor menstrual irregularities and investigation revealed that an ectopic pregnancy was the cause. That condition has complications that would not have been easily manageable in heavy seas. Indeed, any pregnancy has potential complications that could be disastrous at sea. This was not a concern aboard other ships until 1988 because they carried only men. Because of the Cormorant new rules concerning the fitness of pregnant women for sea duty had to be established, and initially it was
Because of the Cormorant new rules concerning the fitness of pregnant women for sea duty had to be established. It was decided that they must be transferred to shore duties once pregnancy is diagnosed. sea sickness and back pain, which questions to answer. "Where can will cause disability dispropor- this guy go?" "What can he do?" tionate to their seriousness, to se- "What if . . .?" That last one is rious medical ones. These could always interesting - a wrong deinclude immersion hypothermia, cision could mean managing a myocardial infarction, diabetes, medical misadventure in rough seizures and asthma. Surgical seas far from any help. This "what problems could range from bleed- if?" game is a large part of the ing peptic ulcers to appendicitis, practice, and although prevention but even though the sick bay is is preferred to heroics the navy equipped to handle them the ad- doctor must be well versed in both verse operating conditions mean approaches. The most demanding aspect even minor procedures are avoidof my 2 years was the Cormoed, if possible. A ship's physician practises a rant's 25 divers because there are form of occupational medicine in numerous medical conditions spewhich two interests must be pro- cific to diving and knowledge tected, those of the patient and about many of them is lacking. those of the Crown. This demands For instance, decompression sickcreativity that can make mundane ness was once thought to occur problems rather interesting. The when an inert gas - nitrogenneed to determine fitness for sea began coming out of solution as a duty is another challenge. During diver ascended too rapidly. It was a patient visit the MO has many thought that the resultant bubbling in the bloodstream caused occlusive ischemia and the severe pain known as the "bends". It now appears that although these inert gas bubbles cause the syndrome, it is the body's response to them - a complex cascade of coagulation and immune reactions - that is most significant. This is causing us to rethink our approach to such patients. Other medical problems include: * Pulmonary overpressure syndrome (POS), a dreaded condition caused by pulmonary interstitial gas after the rupture of an alveolus. It can occur if a diver ascends while holding his breath, or if an asthmatic diver has even the mildest bronchospasm while Divers can present MOs with many complex problems ascending. For this reason, anyone
felt they should be allowed to sail until at least the third trimester. However, because of concerns about obstetric complications and the effects of fume or smoke inhalation and forced vigorous exertion on the unborn, it was decided that women must be transferred to shore duties once pregnancy is diagnosed. It is interesting that medicolegal issues also affect the navy. For instance, there were concerns that the Crown would become hopelessly entangled in lawsuits if adverse outcomes were linked to sea duty. Despite such growing pains, though, the navy seems to be coping well with the switch to mixed crews. Some active combat ships will soon have women on board. The Cormorant's medical personnel must deal with everything from "trivial" problems such as
CAN MED ASSOC J 1990; 142 (4)
Boredom is seldom a feature of this practice, and the inherent uncertainties mean that the professional humility of the "ugly duckling's" doctor is both profound and ever present.
with even a mild asthmatic condition should not be allowed to dive - in 1988 there was a catastrophic case involving an asthmatic civilian diver off Halifax. Although the navy has not seen a case of POS in decades, the potential is cause enough for concern. * Oxygen toxicity is a poorly understood and unpredictable problem. The partial pressure of oxygen in breathing gas increases with depth, and since oxygen at high partial pressures becomes toxic, some divers will convulse once the partial pressure reaches 2.0 atmospheres. However, tolerance varies dramatically and can even vary in the same diver on different days. As with decompression sickness, it seems that the more research we do in this area, the less we know. * Nitrogen narcosis - "rapture of the deep" - occurs when nitrogen is breathed at high partial pressures. Although inert at the surface nitrogen becomes intoxicating with depth, and that is why the navy does not permit air dives below 46 m. Since helium has much less of a narcotic effect at high partial pressures, it is substituted for nitrogen during deeper dives. However, helium's physical properties differ dramatically from those of nitrogen, and even less is known about the way dissolved helium behaves during decompression from depth. Many of the Cormorant's diving operations take place at the frontiers of the unknown. Textbooks on the management of a diver who developed oxygen tox-
The Cormorant lowers a submersible
icity while decompressing from an exceptional exposure mixed-gas dive in the - 4C waters of the Arctic, and then had to make an emergency ascent when his hotwater suit failed, are extremely thin. Such circumstances force a physician to become creative. Not only are there specific diving-related ailments to deal with, but normally trivial conditions become not-so-trivial when they affect divers. For example, one clearance diver received a concussion while being relieved of his wallet in a delightful section of a foreign port. Although the physical examination and other investigations were unremarkable, he was left with 4 hours of persistent post-traumatic amnesia. Since some research indicates that 10% of patients who were in such a state for more than 2 hours may suffer convulsions more than 2
years after the injury, what will happen when this patient is subjected to all the rigours of diving? The safe thing to do is certify him unfit for diving, but that would deprive him of his livelihood: the navy does not want clearance divers who cannot dive. And a bump on the head incurred while being robbed in a seedy district is not exactly a service-related injury and won't be looked on too kindly by the pension board. This means that the doctor is usually left with another opportunity to live with
uncertainty. Just as there is more to the navy's "ugly duckling" than meets the eye, there is more to her medical practice, too. Boredom is seldom a feature of this practice, and the inherent uncertainties mean that her doctor's professional humility is both profound and ever present.CAN MED ASSOC J 1990; 142 (4)