The main purpose of the Ship’s MC is to give passengers and crew service for medical problems and acute emergency treatment until the patient is well or can be referred to a medical facility ashore. Although life-saving procedures and real medical emergencies have top priority, the ship’s MC is a service institution where prompt service should be given for any kind of medical problem. Hence, the MC is equipped to do most simple diagnostic procedures, such as blood tests, urine tests, non-contrast X-rays, and EKG, as well as minor surgery and limited intensive care. It also contains a small pharmacy with most commonly used drugs available.
According to the ACEP guidelines, cruise ships shall have an MC with medical staff (physicians and registered nurses) on call 24 hours a day, examination and treatment areas and an inpatient medical holding unit adequate for the size of the ship. It shall have adequate space for diagnosis and treatment of passengers and crew with 360° patient accessibility around all beds and stretchers and adequate space for storage. Since space is precious, 360° access is most easily achieved by having mobile beds in wards that are large enough to put them in positions that allow staff to move around them easily and quickly. If not, even simple nursing is difficult and resuscitation impossible.
Further ACEP recommendations are
- One examination / stabilization room per ship
- One Intensive Care Unit room per ship
- Minimum one inpatient bed per1000 passengers and crew
- An isolation room or the capability to provide isolation of patients
- Access by wheelchairs / stretchers
- Wheelchair accessible toilet (on all ships delivered after 1996).
Optimizing MC Lay-out and Function
It is in practice almost impossible to significantly improve MCs that are already built. Therefore, for optimal results amedical consultant with varied shipboard experience must be actively involved in all stages of the planning process of new builds and should be consulted before any changes involving the MC are accepted. Experience shows that during the building phase even the smallest changes will be expensive, if at all possible, and later there will be neither funds nor the will to make changes.
The ideal MC location for stability and accessibility is amidships, outboard (daylight) and away from engine and disco noise. There should be easy and preferably separate access from passenger and crew areas. For lifeboat evacuation, MC location at the promenade (boat) deck is best, since patient transfer from the ship to moving boats at sea level is very difficult in rough seas.
The lay-out of the MC significantly influences medical staff performance, as even small inconveniences, such as a door opening the wrong way, can compromise safety or cause frustration in a stressful environment over time. Correct procedures will not be carried out if they involve a constant struggle against the physical environment.
The medical staff’s cabins should therefore also be in close proximity to the MC.
An important point that cruise ship builders often seem to forget is that all treatment rooms on small ships must be as big as those on large ships are; their patients are not smaller.
It is important to remember that there must be a sufficient number of electrical outlets for both 110V and 220 V, and there must be facilities for oxygen application in most rooms.
Furthermore, when designing a future MC, it is necessary to take into consideration other factors like the ship’s itinerary and regulations of the construction yard state, the flag state, the ship’s insurer, and IMO’s SOLAS (Safety of Life at Sea) as well as demands from a number of agencies and organizations, like the US and the European Centers for Disease Prevention and Control (CDC & ECDC), US Coast Guard, Americans with Disabilities Act, ACEP and CLIA.
The Various Parts of the MC
- The Nurses’ Office = Reception should be centrally located with direct visual contact line to both passenger and crew waiting areas. Reception is a multipurpose area, a center for communication and secretarial activities with phones, computers, scanner and copy machine. It is the triage location for the waiting line where the patients are greeted, personal, medical and insurance information is gathered, vital signs are registered, and billing and filing are done. Monitors should make it possible to watch the patients in the wards and in the emergency room from the Reception. There should also be direct access to the Pharmacy.
- The Doctor’s Office should also have direct access to the Pharmacy and be close to the Nurses’ Office. In addition to the standard documentation equipment, it should always hold an examining table, a patient chair with 360o access and an extra chair for a companion (‘moral[ED1] support[jc2] ’).
- Waiting Areas for passengers and crew should be separated (for practical and strategic reasons) and have easy and separate access from both passenger and crew areas. They should be “outside” the medical center, which means that all treatment rooms of the MC should have access from the nurses’ office without staff or patients having to re-enter the waiting area to go from, say, the Reception to the Doctor’s Office to the Lab and to the Wards.
- The Pharmacy should be large enough to hold all medicines to be stored aboard and allow organization in a way that will keep all medicines of the same type or group together. It should be next to - and have independent access from - both the doctor’s and the nurses’ offices. Cabinets with fixed shelves and with doors, especially non-transparent ones, should be avoided. Instead the Pharmacy should be filled with adjustable shelves - with elevated fronts; however, a lockable drug cabinet for controlled substances is a necessary part of the Pharmacy. Inside there should be a surface for writing, tablet-counting and packing. In addition to drugs used in emergencies, including thrombolytics, the Pharmacy shouldmaintain a limited stock of standardized supplies and medicines useful in treating common medical problems of passengers and crew. Often passengers forget or loose their medicines and may need a temporary supply of the same or similar medicine. The MC staff to be familiar with all medicines aboard. A practical way to organize the medicine list is to use the World Health Organization Anatomical-Therapeutic Classification system (A for Alimentary tract, B for Blood, C for Cardiovascular etc). Organizing the medicines according to this system both in the computer and in the Pharmacy makes it easy for new-comers to order and to find the various items. The drugs should be organized by using generic/brand names within each group since supplies may come from all over the world, and trade names vary. It should be noted, however, that even generic names are not the same in all countries: acetaminophen in USA is the same as paracetamol in Europe. Also note that to order controlled substances (narcotics) and have them delivered to a ship may be a major challenge, especially in US ports.
- The Laboratory must be large enough to permit all equipment to be permanently set up for immediate use as stored equipment will be underutilized. It should have wall cabinets with transparent (glass or plastic) doors to allow quick orientation of contents and to promote order and neatness. There should be extra light and electrical outlets under the wall cabinets. There must be a lavatory close by or connected to the Lab. The ACEP guidelines recommend ‘Basic laboratory capabilities’ like hemoglobin / hematocrit estimations, urinalysis, pregnancy tests, blood glucose (all with quality control program as recommended by the manufacturer). On most cruise ships today this will be considered insufficient. It is more or less taken for granted that the MC can perform tests like cardiac enzymes, blood count, electrolytes, liver enzymes, creatinine, urea, uric acid, amylase, C-reactive Protein, D-Dimer and INR.
- The Emergency Room should have easy and preferably direct stretcher access from outside the MC and have at least a triple function: patient stabilization, operating theatre for surgical procedures, and X-ray room. Instead of a fixed operating table there should be a mobile stretcher/emergency trolley. Also the X-ray machine should be mobile to avoid unnecessary transfers of a patient in pain. Emergency medical remedies recommended by ACEP:
- Airway equipment - bag valve mask, endotracheal tubes, stylet, lubricant, vasoconstrictor, suction equipment (portable)
- Cardiac monitor and back-up monitor (2)
- Defibrillators, two (2) portable, one of which may be semi-automatic
- External cardiac pacing capability
- Infusion pump
- Pulse oximeter
- Automatic or manual respiratory support equipment
- Oxygen (including portable oxygen)
- Stair chair and stretcher
- Refrigerator + freezer
- Long and short back boards cervical spine immobilization capabilities
- Trauma cart supplies
- Assault kits (2)
- Emergency medications and supplies for management of common medical emergencies
It is worth noting that equipment for surgery and fracture immobilization is missing from the ACEP list.
- The X-ray Room. Most ships will not have a separate X-ray room, but the Emergency room should have a mobile X-ray unit (see above), and a set-up for taking upright (standing) chest-rays and flat abdominal plates. The ACEP guidelines only recommend ‘basic X-ray capabilities’ and merely point out that there should be ‘X-ray machine for new builds delivered after January 1, 1997’. For conventional X-rays a darkroom with an X-ray film developer is necessary, and a copy machine for X-ray films is strongly recommended and especially useful for referrals. As radiation from modern X-ray machines is very limited, lead-enforced walls are unnecessary and lead aprons provide sufficient protection for patient and medical staff. The darkroom must actually be pitch dark and cannot have an emergency light that usually comes without a switch, a fact that the building yards tend to ignore. Automatic developers contain two liquids, fixer and developer, which can not be mixed, and therefore makes film development in rough seas impossible. More ships are now turning to digital technology with all its advantages, including less chemical waste, clearer images and internet transfer possibilities. Hence, all new build must be planned with digital X-ray technology in mind[jc3] .
- Toilet Facilities for Disabled Persons should be centrally located in the MC to serve outpatients and all wards. The toilet should be large enough to admit a wheelchair (4x4 m), and it is practical to also include a shower area and a ‘sitz-bath’ with access from 3 sides for (partial) immersion of burn victims.
- Facilities for Telemedicine. Telemedicine with video conferences comprising shipboard patient, ship’s doctor and a specialist in a hospital ashore attracted much media attention some years ago. However, it proved time-consuming, not cost-effective, and is now hardly prioritized. However, telemedicine by satellite phone calls is widely used, as is internet transmission of digital photos, videos, X-rays, and EKG scans, and these procedures do not need a specially assigned MC room.
- The Morgue / Mortuary. A standard morgue has cooling capacity for 3-4 bodies, sliding trays for the bodies and temperature regulation on the outside. Traditionally, the morgue has been a separate room within the MC, but there it takes up valuable space. Hence, it makes more sense to place it in a less popular area of the ship. However, the location must allow discreet transport of bodies from the MC, and for psychological reasons it should be separated from the passenger and crew living quarters.
- A Secondary Medical Center must be maintained on all CLIA member vessels and is intended to be available for emergency treatment if the primary MC becomes inaccessible due to flood, smoke, fire, etc. An easily accessible location must be designated in a different fire zone than MC with both regular and emergency lighting and power supply. The space should be located near an open area where patients can be spread out and treated (e.g., adjacent to a show lounge), be lockable to guard against loss, and be properly marked for quick identification and location. The ACEP guidelines give details about necessary contents (See APPENDIX1).
Some General Principles for Equipment in the MC:
- Electrical equipment should have the possibility to be used with both 110V and 220V
- Redundancy (repair is difficult at sea and service often unavailable)
- Cheap is expensive (use stainless steel, avoid rusting or easily breakable instruments)
- Only use brands with worldwide distribution and service
- Use reliable, long-lasting, sturdy and simple equipment
- Avoid sensitive, complex, rare, sophisticated and new (= not extensively tested) equipment
- The equipment should be serviceable aboard by engineers or nurses
- Suppliers should be committed to provide loaners during service/repair
- All equipment must be easy to operate, service and maintain
- Concentrate on equipment that is necessary - not “nice to have”