18 Jan 2019
We are 5 days in to a 10 day sail from Honolulu to Kobe, Japan. Literally the point of no return where it’s closer to Japanese shores than US shores (which is how I am thinking of these long stretches - which direction would we evacuate a patient who might need it). Luckily the logistics of this would be up to our Captain, a young, but experienced, by-the-book captain (per our voyagers who have sailed previously and have grounds for comparison).
Our time on board has already been interesting, medically speaking - which going by my usual mantra of “you don’t want to be interesting in the doctor’s office” - is not necessary a desirable thing.
Probably weighing most on my consciousness is the fact that we are are in the midst of a blossoming batch of influenza A cases. Four patients confirmed over the past four days, two healthy college kids and a pair of dependent children siblings, both healthy at baseline as well. High fever, myalgias and fatigue mark their illness, so far all are progressing as expected and will likely be better in 2-3 days. Dealing with flu on a ship, however, is tricky. Initially we were testing and treating everyone (in the hopes of shutting down any spread), but then quickly moved to testing only and forgoing treatment (within CDC guidelines) to try to preserve our (very) limited stores of osteltamivir (Tamiflu) in case one of our much older or very young voyagers were to take ill. Having these passengers stay in their cabins with their roommates moved, sick trays brought to them, homework assignments emailed (not that anyone has really felt perky enough to do work at least in the first 48 hours) has been the ship protocol but we are rapidly running out of spare rooms as the ship is pretty much to capacity. Will see what the next few days bring. We have requisitioned more medication from our shipping company but crew has low hopes that we will secure more in the next few ports as Japan and China are more cautious about prescribing without confirmed cases to treat (making being prepared and also have the ability to prophylax trickier). We have evolved our current approach further to testing only if there is an intent to treat (as I would do in my home clinic) to conserve resources and because with our limited supply of meds (and testing kits) and rooms. Confirming more flu A won’t change treatment (unless the voyager falls into a medically vulnerable category). Anyone with influenza-like illness is now being asked to stay in their cabin until they are fever-free x 24 hours.
A few other interesting cases - was asked to consult on a crew member with RLQ pain, lack of appetite, focal tenderness and a persistently elevated white count of 20K but no vomiting or fever. He also hadn’t pooped in two weeks, so crew medical gave IV fluids and an enema and followed him. It was a white-knuckle series of re-evaluations every two hours for the afternoon and evening and by hour 8 or so he started to turn around. Morning brought an increased appetite, decreased abdominal pain and the last CBC showed WBC 9K. Back at work in the laundry. Whew.
Also had a man (one of our staff) with left sided chest pain and shortness of breath with some convincing risk factors for both MI and PE; nerve-wracking to work it up without imaging or a d-dimer. Limited testing reassuring and after treating presumptively for GERD, he has felt increasingly well.
We have a voyager who while skateboarding two weeks prior to sailing, broke her collar bone in several places requiring surgery with significant hardware. We are planning to do her follow up X-ray here on board and will (in theory) be able to digitize the images to send to her orthopedic surgeon. As luck would have it, we also have a retired PT on board (sailing as one of the 30 or so life-long learners, pretty cool people ages 40-85 who have chosen to live in this floating dorm for the next four months with us, participating fully as part of the community and auditing classes along the way) who has agreed to work with this student to start mobilizing the area once we’ve passed the 6 week mark and gotten the ok from orthopedics back home.