Medical facilities on a cruise ship...how extensive should they be?

[bowlinmoe]

I saw this story on NBC last night:

 

https://www.nbcnews.com/news/us-news/stroke-victim-suing-holland-america-not-airlifting-her-cruise-ship-n969411

 

Thoughts?

 

Personally, I think you as the passenger assume some risk when you agree to board the ship the specified period of the time.  The risk being that you won't have a full fledged hospital that is easily accessible. 

[fdwt994]

They could've done more.  The Doctor diagnosed her with a stroke and had to understand what type of facilities are capable of handling it, and what facilities are not.  

 

Time is critical for managing a stroke, and had they acted quickly, she may have been treated successfully with no permanent effects.  

 

Yes, we all assume some risk, but I think it's reasonable, when a ship is less than 100 miles away from the United States, to do more.  A "full fledged hospital" was well within reach.  

Edited April 11, 2019 by fdwt994
improper spelling

[Cruiser_1977]

I feel badly for Mrs. Gale. I don't know the laws/regulations of such situations. I would find it hard to believe that the Captain and other officers didn't act in accordance with them. If they didn't or were negligent in other ways I hope there are consequences. From the HAL cruise contract:

12. HEALTH, MEDICAL CARE AND OTHER PERSONAL SERVICES.

Due to the nature of travel by sea and the ports visited, the availability of medical care may be limited or delayed and emergency medical evacuation will not be possible from every location to which the ship sails. All health, medical or other personal services in connection with Your Cruise or ship portion of Your Land + Sea Journey are provided solely for the convenience and benefit of Guests who may be charged for such services. You accept and use medicine, medical treatment and other personal services available on the ship or elsewhere at Your sole risk and expense without liability or responsibility of Carrier whatsoever, and agree to indemnify the Carrier for all medical or evacuation costs or expenses incurred on Your behalf. Doctors, nurses or other medical or service personnel work directly for Guest and shall not be considered to be acting under the control or supervision of Carrier, since Carrier is not a medical provider. We do not undertake to supervise the medical expertise of any such medical personnel and will not be liable for the consequences of any examination, advice, diagnosis, medication, treatment, prognosis or other professional services which a doctor or nurse may or may not furnish You.  Similarly, and without limitation, all spa personnel, instructors, guest lecturers, entertainers and other service personnel shall be considered independent contractors who work directly for the Guest.

[pc_load_letter]

Wow, that's a sad story for sure. Not a doctor but I did stay at a Holiday Inn last night so I think she should have been airlifted.

[CruiserBruce]

Of course the law suit says the patient "could have easily been airlifted". No one in the business believes an lifting of a patient off a ship is easy. 

 

Sorry that this happened, but some contact with the reality of the situation is important.

[navybankerteacher]

Looking at the time-line, it appears that she had the stroke about 4 1/2 hours after sailing -making it about 8:30.  After 8:30 she was examined by ships doctor and wound up getting to the hospital in Nassau barely 3 1/2 hours later.  How much more quickly could an airlift have been requested and been approved, an appropriate helicopter gotten out to the ship, lowered staff to pick her up , lifted  her and flown her back to Florida?  Having participated in several helicopter evacuations, I know that it should not be termed “easy”.

 

With all sympathy for the woman and her family, this looks as much like an ambulance chase as anything else. 

 

Is HAL responsible for inadequate staffing/expertise at the Nassau hospital, or for the airport having closed down?

 

 

[XBGuy]

I think that NavyBankerTeacher's evaluation is pretty good.  Of course, I am not particularly knowledgeable in either medicine or law.

 

That being said, I would be a bit surprised if this case is not quietly settled.  I does cast bad publicity on Holland America.

[mom says]

I agree with navybankteacher to a point. However, with modern communications, the ships doctor should have known what facilities were available (or not) in Nassau. If he had known that adequate diagnostic and neurological facilities were absent in Nassau, wouldn't the prudent thing have been an airevac to the States? This would make the doctor possibly negligent; but since he is not a ship employee, but on an outside contractor, I don't think his negligence would extend to HAL. But what do I know. American courts do some strange things when it comes to lawsuits.

[jlp20]

I would suggest the ship's doctor did what was required. I further suggest staff informed husband of the plan and the option of an airlift that family would have to pay for.

I would also point out that historically, medical staff has gone out of their way to remove any pax with any serious medical issues.

[Pyrate13]

Not sure I'm even in the right frame of mind to reply to this right now. You chose to travel, a medical situation developed and it's the cruise lines fault...*****?

[GeezerCouple]

Almost all of us here on CC have read about (or been on!) cruises that had to deviate from the planned route to get to a location such that a helo-evacuation could be done.  Some of these result in missed ports or delayed port time, etc.

 

This ship wasn't in the middle of an ocean, although we don't really know exactly what its position was during the time this event took place, and perhaps the next hour or two.

 

Given that the physician on board was indeed aware of the chance/likelihood of a *severe* stroke... and the facilities at Nassau (hospital and airport) should have been known OR could have easily been determined... this does not look like prudent care at all.

 

We had experience once with onboard medical during an emergency.  We were VERY impressed with the medical staff and all of the decisions, both at the time, and in retrospect (and that's often the tricky part!).

It later turned out that our specialists at the major teaching hospital near us told us, "We would have done exactly the same thing if you had shown up in our ER!"  We now travel with some meds to take at the very earliest sign, which, well, either will or will not short-circuit another similar event just in case whatever triggered that one happens again.

 

Bottom line is that we were very re-assured and impressed by the quick action taken by the ship's physician.

On the other hand, having something life threatening that is beyond the onboard equipment (diagnostic or treatment) is, well, something one just doesn't want to have happen... especially when FAR from shore.

 

And it does not seem (from info provided) that this ship was "FAR" from shore, etc., in terms of a reasonably prompt (given the circumstances) evacuation to a top medical facility.

 

GC

[navybankerteacher]

Does no one in the Bahamas suffer strokes?  If a ship’s doctor were to ask, would the Nassau hospital advise that they could not handle stroke patients?

Was the husband offered the choice between airlift (presumably at his cost) or Nassau hospital? How promptly could a helicopter have been dispatched?

 

There are a lot of variables - and pretty much all we know comes from a liability lawyer’s filing and a press report.

[chengkp75]

There is no indication whether the Captain contacted the USCG for a medivac.  If they did, the USCG flight surgeon would have had some input as to what the risk to the patient for an hour's helicopter flight, compared to a boat transport in the Bahamas.

 

As for a helicopter evacuation "that the patient pays for", there aren't any.  Very few private helicopter companies are trained to do a landing or winch recovery on a moving ship, and the ship's insurance would be very leery of letting one of these companies getting close to the ship.

[Toofarfromthesea]

44 minutes ago, chengkp75 said:

There is no indication whether the Captain contacted the USCG for a medivac.  If they did, the USCG flight surgeon would have had some input as to what the risk to the patient for an hour's helicopter flight, compared to a boat transport in the Bahamas.

 

As for a helicopter evacuation "that the patient pays for", there aren't any.  Very few private helicopter companies are trained to do a landing or winch recovery on a moving ship, and the ship's insurance would be very leery of letting one of these companies getting close to the ship.

 

Great info, as always.  If the ship is in international waters is it still the USCG that would do the medevac?  What about in more distant places, say the Baltic?  Is there a convention or agreement governing who responds to a medevac call?  Thanks.

[Hlitner]

A really tragic story.  But one must wonder to what extent the NBC reporting is fake news!  The story makes it seem like it is a simple matter to airlift a passenger off a cruise ship at night!  The reality is that any airlift would have to be performed by the Coast Guard or military from whatever country is within range.  Neither the patient or cruise line pays for this service which is free around the world...due to various agreements between most countries.   At best, any airlift is risky and snatching a stroke patient off the deck would have added risks.    To expand on some of Chengkp75's comments, the NBC story does not provide any info as to whether the ship's physician made a determination that the patient was in a stable enough condition to handle an airlift.  And there is no info in the NBC story as to whether the ship contacted the Coast Guard to request an evacuation, whether the Coast Guard was able to provide such a service at that time, etc.  

 

I guess we shall have to wait to see the results of the law suit (although it will likely be settled out of court with no public announcement).  

 

Hank

[BlueRiband]

Perhaps I missed it, but the Zuiderdam doesn't appear to have a helipad.  So evacuations would need to be done by "low hover" with the patient winced up in a basket.  

 

FWIW, during a back scenes tour on a Cunard ship, the medical director said that it's his medical evaluation to weigh the condition of the patient versus stress of an air evacuation.  It's a sad situation and a lose/lose for all parties involved.  He she been evacuated by helicopter we may be reading of how the added stress worsened her condition.

[GeezerCouple]

10 minutes ago, BlueRiband said:

Perhaps I missed it, but the Zuiderdam doesn't appear to have a helipad.  So evacuations would need to be done by "low hover" with the patient winced up in a basket.  

 

FWIW, during a back scenes tour on a Cunard ship, the medical director said that it's his medical evaluation to weigh the condition of the patient versus stress of an air evacuation.  It's a sad situation and a lose/lose for all parties involved.  He she been evacuated by helicopter we may be reading of how the added stress worsened her condition.

 

Many ships do not have a helipad.

 

The recent rescue of *hundreds* of passengers off the Viking Sky (Norway) went through the night during absolutely dreadful "bomb cyclone" conditions, and worse, the ship had no power, so was just being tossed about, although anchors finally stopped the ship from being forced onto the rocks (risking another Costa Concordia disaster, but in the middle of a big storm).

Most of those passengers were winched up with just a harness... not even a basket, and at least one was lifted on a stretcher.

 

Kudos to those Norwegian SAR crews!

(And grateful thanks to SAR crews *everywhere*!)

 

What we don't know in this case, yes, is what was actually considered by medical and ship officers, etc.

 

GC

[chengkp75]

8 hours ago, Toofarfromthesea said:

 

Great info, as always.  If the ship is in international waters is it still the USCG that would do the medevac?  What about in more distant places, say the Baltic?  Is there a convention or agreement governing who responds to a medevac call?  Thanks.

Yes, under UNCLOS (United Nations Convention on Law of the Sea), I believe is the correct convention, are the provisions for search and rescue at sea, and certain nations have taken up the responsibility to provide SAR service in their area to all ships, as far out as their equipment will handle.  So, yes, the USCG provides SAR service to the northern Caribbean, and out over the eastern islands of the Caribbean via their bases in Puerto Rico and the USVI.

[DirtyDawg]

It's a sad real news story about a real couple who suffered a real tragedy. NBC reported it. Holland America declined comment so NBC couldn’t report on whether the physician determined that the patient was in a stable enough condition to handle an airlift, or whether the ship contacted the Coast Guard to request an evacuation. Should the Chicago based reporter have flown out to Seattle and camped out at Holland's HQ until they did comment? Or, should she have uncovered this story's 'Deep Throat' for her local 6pm news cast? 

 

The only fake news with this story is some of the speculation on this thread. We don’t know the all the facts of this case. None of us can say whether the law suit has merit or not. I’m sure the relevant facts will come out in the discovery process. At the end of the day, the law suit will be settled, or it will be dismissed before a trail, or the case will go to trail and the plaintiffs will win or they will loose, or they will partially win, or they will partially loose, or …..

[navybankerteacher]

9 hours ago, BlueRiband said:

Perhaps I missed it, but the Zuiderdam doesn't appear to have a helipad.  So evacuations would need to be done by "low hover" with the patient winced up in a basket.  

 

...

In January 2008 we were on Noordam (a Vista Class sister ship of Zuiderdam) northbound from San Juan - around midnight, about 10 hours after sailing,we turned around and sailed south for a couple of hours to get within range for a San Juan based Coast Guard helicopter - which did, in fact, hover and winch up a passenger needing evacuation.

Edited April 12, 2019 by navybankerteacher
Mid-stated year

[Hlitner]

Ok, so let us "speculate" which is a favorite pastime for many here on CC:).  It might be nice if some medical authorities jumped in, but I will use my meager knowledge as an ex- Paramedic who was trained to handle emergency situations along with some rescue operations.  The NBC report mentioned that a hemorrhagic stroke was suspected by the ship's physician.  That kind of stroke simply means there was a bleed into the brain.  A vessel had burst or was leaking.  This kind of patient needs to be quickly stabilized.  But as you can imagine, with a "bleed" one would want to minimize movement (especially sudden movement) and also avoid any changes in ambient air pressure (which will happen with an air evacuation).  Just like your ears pop with air pressure changes, a damaged vessel could easily pop (with instant death) with air pressure changes.  So I will "speculate" that the ship's physician would have advised against any kind of air evacuation.  A paramedic, in the field, who suspected this kind of bleed would also often refuse a Medivac rescue and use ground transportation as the preferred means of transport.  There have actually been some interesting papers/studies on the impact of air pressure changes on Aneurysmal Subarachnoid Hemorrhage.  Put a small partially inflated balloon into a vacuum chamber and reduce the air pressure (like when you go up in a helicopter or plane) and you will see that balloon quickly expand and eventually pop.  

 

So now you have some real "speculation."  If that NBC reporter had contacted a local ER physician or paramedic they would have likely received the same "speculation" given the suspected diagnosis that was part of NBC's story.  We await comments from others who have some medical knowledge.  But it all comes down to a judgement call that medical rescue personnel make every day.  Which is better, using the fastest means possible to get a person to a hospital ("scoop and run") or stabilizing the patient and handling them with kids gloves?

 

Hank

[Texas Tillie]

16 minutes ago, Hlitner said:

Ok, so let us "speculate" which is a favorite pastime for many here on CC:).  It might be nice if some medical authorities jumped in, but I will use my meager knowledge as an ex- Paramedic who was trained to handle emergency situations along with some rescue operations.  The NBC report mentioned that a hemorrhagic stroke was suspected by the ship's physician.  That kind of stroke simply means there was a bleed into the brain.  A vessel had burst or was leaking.  This kind of patient needs to be quickly stabilized.  But as you can imagine, with a "bleed" one would want to minimize movement (especially sudden movement) and also avoid any changes in ambient air pressure (which will happen with an air evacuation).  Just like your ears pop with air pressure changes, a damaged vessel could easily pop (with instant death) with air pressure changes.  So I will "speculate" that the ship's physician would have advised against any kind of air evacuation.  A paramedic, in the field, who suspected this kind of bleed would also often refuse a Medivac rescue and use ground transportation as the preferred means of transport.  There have actually been some interesting papers/studies on the impact of air pressure changes on Aneurysmal Subarachnoid Hemorrhage.  Put a small partially inflated balloon into a vacuum chamber and reduce the air pressure (like when you go up in a helicopter or plane) and you will see that balloon quickly expand and eventually pop.  

 

So now you have some real "speculation."  If that NBC reporter had contacted a local ER physician or paramedic they would have likely received the same "speculation" given the suspected diagnosis that was part of NBC's story.  We await comments from others who have some medical knowledge.  But it all comes down to a judgement call that medical rescue personnel make every day.  Which is better, using the fastest means possible to get a person to a hospital ("scoop and run") or stabilizing the patient and handling them with kids gloves?

 

Hank

 

You are always the voice of reason. I'm reminded that there are always differences in how medical emergencies are handled. It has been reported that if the American system of airlifting critical patients to the hospital and into the OR as quickly as possible might have saved Princess Diana rather than the French system of sending a doctor in the ambulance and stabilizing at the scene.

[Capt_BJ]

originally posted in reply to similar questions about rescue procedures in 2017 ....

 

Retired USCG Captain here ... who was Captain of helo carrying ships and launched helos for this type of situation many times .... I was "On Scene Commander" ... but I'm not a pilot ..

a few comments

- We trained a BUNCH to remain 'helo certified' for landing and launching helos and our equipment and procedures were examined OFTEN. Pilots (IME) are NOT fans of landing on 'unknown' platforms (not to mention needed extra annual training to be ship landing certified). IF something goes wrong they want the fire teams to be on the same page they are - knowing access to the helo, standard procedures, who will do what if things go bad. They will land on (inspected) fixed oil platforms but 'moving things' tend to be another story.

- A helo sitting on the deck of a moving ship is VERY unstable ... a BIG part of our training involves tying down the copter as quickly as possible, and removing tie downs at the LAST second for take off. Military ships and CG cutters have some fancy systems for this procedure - cruise ship???? The helo does NOT want some guys and some ropes with no clue . . .

- a MOVING ship is almost always more stable then a stopped ship (remember those stabilizers you like so much). In order to keep the ship's heading steady and get the best ride the helo pilot will direct the course and speed to the ship.

- a MOVING helo is more responsive and typically has more reserve power then one in a stationary hover .. another reason for the moving ship. When we landed or launched helos we were moving and there is a specific range of relative wind speed and direction (wind realized across the deck), and pitch and roll limits for the ship. Or in simple terms "turn the aircraft carrier into the wind . . ."

- for a CG helo, if they land on deck and certain mechanical issues arise they can be unable to take off .... NOW STUCK on the cruise ship. BAD. If they stay in the air ... the same issue often means return to base immediately ... even a cutter has mechanics, special tools and some parts.

- a cruise ship does not just call for a CG chopper and off they go .... The ship contacts a Rescue Coordination Center and evacuation options are discussed usually involving a USCG (actually PHS) Flight Surgeon who then consults with Operations to see what options are available.

- I've never seen a private LifeFlight type helo do an at sea rescue. I'm sure someone will say they saw it but in my 30 years doing the job in question, I never saw it.   Military/CG assets are limited by 'where they are'. USCG is not deployed internationally ... well, there ARE exceptions... For example .... While CO of a cutter working between Jamaica and Haiti we got the call at zero dark hundred about a cruise passenger with a hot appendix. The cruise ship was over 100 miles away but we COULD launch our helo, pick up the pass' and fly on to Guantanamo where a surgeon was waiting. We had the helo off deck in 30 minutes. If we had not JUST HAPPENED to be in the right place ... this didn't work.

- sometimes a helo lift, even if in range and possible - is NOT the right choice ..... some patients can be more stressed by the helo lift than their malady! (Example, at one time CG recommended scuba divers were medical alert bracelets for 24 hours after diving ... in case they were found unconscious after a dive .. to warn that an air evacuation might NOT be a good idea if the issue was decompression related!  Still have mine.)

just some food for thought . . .

[Blondilu]

I was on a ship once during a medical evac by helicopter and I can tell you it was not easy.  Or quick.  

 

For years I spent many, many long hours in the ER with my mother.  Back in 1972 she had a brain aneurysm and from then on she fell often and only after her last, and ultimately fatal fall, it was determined that she MIGHT have been having little strokes for years.  Actually she fell even before the aneurysm, so who knows?  And then there were the issues with her heart. 

 

It was never easy and never quick.  Even when rushed to the ER by ambulance it often took hours for diagnosis and treatment.  

 

The point is even here on land with access to countless doctors, so-called experts and all the equipment modern medicine has to offer there is no guarantee you will get all the help you need to recover fully, if such help exists at all. 

 

 

[Hlitner]

4 hours ago, Texas Tillie said:

r 

You are always the voice of reason. I'm reminded that there are always differences in how medical emergencies are handled. It has been reported that if the American system of airlifting critical patients to the hospital and into the OR as quickly as possible might have saved Princess Diana rather than the French system of sending a doctor in the ambulance and stabilizing at the scene.

When Diana died in her auto accident, the issue of whether she should have been taken to the hospital or treated at the scene was a popular topic among the paramedics I knew and even in some ERs.   In the USA, paramedics and other first responders, located relatively close to ERs, will often make a decision to "scoop and run."   With auto accidents I was trained to assess the patient, stabilize obvious injuries, and get them to a trauma center ASAP.  Apparently in France, they were trained to render more extensive treatment at the scene.  The problem with spending a long time at the scene is that it can be difficult to impossible to fully assess internal injuries (what killed Diana).  If I had treated Lady Di in our city, she would have been in a hospital within minutes after we could extricate her from the car.  I can still remember being "yelled at" by my command physician for spending too much time at the scene...and that would have been when we were working at a faster pace then what they did in Paris.  On the other hand, we did not have a physician on our units and the on-scene decisions were made by the senior paramedic (who usually would have been able to consult with a command physician via radio or phone).  

 

Calling in Life Flight (or other air evac) is sometimes a tough call on land.  At sea I would think it is even a tougher call because of the inherent increased risks associated with any rescue  at sea.   It will be very interesting to see how this law suit plays out if it goes to court.  I would think  that the cruise line could easily get experts to testify that their physician made the best decision given the circumstances.  And the patient would likewise be able to find experts to say that she should have been quickly evacuated.  It sounds like a no-win situation for everyone involved.  If the ship physician had been able to arrange for an air evac, then it is possible the patient would have sued claiming that the air evacuation further worsened the medical condition.  And if the patient had died because of the stress related to an air evacuation then you can be sure there would have some questioning "why on earth did they try an air evac with a brain bleed?"

 

Hank