Code Alpha - The Beginning of the End
Aug 15, 2013 | Dr. X | Dr. X
image by: Oleg Brovko
Why does the misery and misfortune of others, people we don't even know, affect Dr X so much? Perhaps it's part of what makes us social animals. We share. Sometimes food, sometimes information, our gossip, sometimes just our company
I have moved into the junior medical doctor's room which is right across the hall from the Medical Center. The only drawback is now I have to walk a ways to the front of the ship to catch the elevator to the gym. But I suppose that's exercise in itself.
We have a new senior physician. Tal is going to be gone for a week, attending the annual Maritime Medicine conference in Miami. The new senior physician is a 73 year old emergency doctor named Buddy. He was retired for three years and then came back to practice because, he says, he grew bored and restless. I wonder if the poor economy may have had an influence in his decision. But we'll see how he does.
He seems to have trained in the old school of medical education where humiliation and embarrassment were the primary tools for motivating young minds to learn as much as they could while being torn apart at bedside rounds. Mostly the students became good at BSing their way through while knowing little.
"What kind of health are you in?" He asked me on Day One as the captain was revving up the motors to embark.
"I beg your pardon." I was taken a little off-guard by his straightforwardness.
"Do you take any medicines? Can you run?"
"I passed the health screening in Miami." I offered the obvious, then "What kind of shape are you in?"
"I run two miles a day, and do thirty pushups." He seemed so proud of himself. He had poor eye contact, none actually.
So began our journey together. I started missing Tal about then. Tal was a good doctor and earned the respect of me and the rest of the medical crew. But I was the emergency doctor and he was the family doctor. He would turn to me for ER type cases like joint dislocations or myocardial infarctions. I, in turn, would consult him for long term management of hypertension or diabetes.
Well, we only had to put up with Buddy for one week. As time would go on he seemed to be weak in cardiology and minor trauma, both ER bread and butter type cases.
I tried to build some camaraderie by talking about treatment strategies. Sometimes it seemed to work and others I would say "Well, maybe it's better if just one of us is in charge of a case like that."
Had another set of the safety classes on Wednesday. High point was the speaker, a really good speaker which is always entertaining. This one was on crowd control. What to do if you get a panicky crowd waiting for life boats, for instance.
I was chosen to be the play-pretend muster station captain. I had a group of eager crew members, ready to make things as difficult as possible, for training purposes of course.
My job was to talk to the pretend-guests and keep them calm while we waited for instructions from the bridge. Such situations actually happen, as most readers probably know, and passenger and crew alike can wait hours until the situation develops to where they can return to their cabins. It could be a fire on board, or chemical spill, or actually anything.
Anyway, my lovely group had been trained to be a problem, great fun for all.
I had my little megaphone, known as a Haler and I proceeded to start the calming-down rhetoric we'd learn during our lecture.
One "guest" pretended to have a heart attack, so I had my team drag him off to the side and toss him overboard. Told everybody else "get out of the way, for crying out loud." Because people at their muster station are supposed to stand back as far as possible in case crew needs to move around the deck. But they had been coached to speak different languages to me and create mayhem in general. I felt just like I was in my ER back home. Oh well, I passed the course and we didn't really throw anybody off the boat.
The rest of the afternoon they showed some videos of real disasters, including the Carnival's Ecstasy which had been my boat to orient on. There had been a fire in the laundry, right next to the Medical Center. A couple of crew actually died, no guests were injured.
I may have mentioned we have a handful of full time fireman. I see them all the time, just walking around, on patrol, checking this or that. And they're all 6 foot Indian men. They watch for potential chemical spills or unauthorized equipment in or near a doorway.
Finally, we learned to operate the sea doors; large heavy motor operated structures that stop the rush of sea water if the hull were to have been breached.
Me, operating a 600 pound door, calmly waiting for it to inch its way closed while the whole ocean is bubbling up toward me? I don't think so. But I learned how dangerous it was during the lecture. " Don't try to cross through the door if it's been activated, Sergie, the Safety Officer told us." It seemed two crew from another line had been killed trying to go through.
Two. Hmm. I postulated a rescuer fatality.
We finished the lecture with a review of the emergency codes: One each for fire, chemical spill, navigational emergency, security, or sometimes just a call to general quarters. And finally Code Alpha for a person overboard.
Then it was off to lunch, planning to return for afternoon clinic. Afternoon clinic hours were 2pm to 6pm.
I had my office between the two waiting rooms, one for guests, don't call them passengers, and the other for crew. All were seen in the order they came in. I would see a guest for something, then switch hats and see a crew member.
Mostly routine cases. A lot of skinned knees to wash out, one broken humeral neck. One MRSA, community staph, infection, and a lot of crew with sore shoulders and low backs on who really just want to go home but can't bring themselves to say "I want to go home." I found out later that if a crew voluntarily decides he wants to go home he has to pay for it. If a crew misses more than three straight days of work, he gets fired and sent home by the company. The other way to get sent home at company cost: Declare suicide intent.
One doctor would be on duty for a day then the other. Buddy kept hanging around, even though it was his day off. I got the impression he was monitoring me, after 35 years of practice he's monitoring me. I shook it off. Mae doesn't like him, I can tell because when she looks at him she seems to smell bad cheese or something.
Yesterday, was Buddy's duty day, he had kept a 70 year old woman with abdominal pain on the boat, bypassing two opportunities to disembark her in Jamaica and then Bahamas. I was uncomfortable because we have no imaging whatsoever and she looked sick. She had a host of medical problems and was a smoker. Her labs looked worse every day she was on her antibiotics, especially her kidney function tests. I asked Mae, "is anybody besides me worried about this woman going into renal failure?"
She stopped humming I Drove All Night, then, "Talk to your Senior Doctor."
Mostly what bothered me was we had absolutely no idea what she had. And no way to find out. Just abdominal pain as a chief complaint in the elderly often has a high mortality rate.
I found out later the family didn't want her transferred to shore, fearing substandard care.
In these cases the ship's doctor can invoke an involuntary transfer against the family's or patient's will if he feels it's in the patient's best interest. Touchy situation, especially if there's a bad result.
I tried to approach Buddy about it and got, "My call, my patient, my call. She's doing fine."
I pointed out the deteriorating lab results and "I don't treat labs, I treat people," came back.
Her last day with us, Wednesday, we were in Jamaica and I had Mae run another set of labs and it clearly showed she was going into renal failure. I hoped to get her ashore and asked Buddy to come down. It was, indeed, his case and I definitely didn't want to send her ashore without his knowledge.
He agreed. We learned later they did a Cat scan and she had a twisted sigmoid colon and needed immediate surgery. She spent the night in the hospital there while her daughter and husband left her behind on the boat. Her other daughter was an ICU nurse in Houston and had made arrangements for a Medievac flight from Jamaica to Houston. She was alone that night and I was so afraid she would die alone with no one there. But she made it to Houston and I learned yesterday she was doing well post-op and on dialysis.
As we were leaving Jamaica, about 15 minutes after leaving the dock while building speed, an obviously stressed voice came on the shipwide intercom. "Code Alpha, Code Alpha, Code Alpha. All hands to emergency stations."
I was just crossing over from the entrance to my room to the Medical Center and as I stepped into the large area between I could see the bustle the page had started. All deck hands were taking the stairs up to Deck 3, the lowest outside deck, and security was running back and forth, a dead run.
I weaved through the speeding bodies and went into the medical center. It was just me, Mae, and Mick. Buddy had his walkie-talkie and announced he would "Monitor the situation from my quarters." I had just had the safety lecture earlier that day. I knew that Alpha was the code for man overboard. We reviewed what we knew to do for Code Alphas. Medical personnel are supposed to report to the Medical Center and await deployment instructions: We deploy at least two people to where the victim will be brought on board. And we are to take a couple of packs of medical supplies, including airway management tools, an ER doctor's stock-in-trade. We would assess and stabilize the victim then move him to the medical center.
By then we could feel the boat listing to the side as it turned, slowing down. The tension of the moment was palpable and we were all on edge, hoping the victim would be found quickly before he suffered from exposure. Even though the water temperature stays around 65 degrees Fahrenheit many overboard victims are intoxicated and may suffer injuries that make them susceptible to hypothermia.
An hour into the code and we knew hope was fading.
Someone suggested we contact the spouse in her room. So after talking it over, somehow, the group decided I would be the best one to talk to her. It's always me. Seems I had let slip I had been a psychologist before I took up medicine, thinking my kids might want to go to college.
So Mae and I went up to try to console the poor woman, but also to get some kind of medical information like what had happened, was he on any meds, had he been drinking.
On the way we encountered Laurence from security who had posted himself outside the door to the victim's cabin. His wife was inside with her sister. Laurence was following protocol to put a suicide victim's partner on watch. There is such a thing as partner-suicide or double suicide.
We learned that due to it's being light outside and relatively crowded on the upper forward deck, several people had seen the man climb the rail and jump, doing a high dive act and landing square on his face, chest and abdomen. They further described his lying motionless, face down, as the boat cruised by.
Several life buoys were thrown after him and deck staff called the bridge within 15 seconds, then ran to the rail, pointing to the victim. Several people watched him bob and drift further aft, then he seemed to disappear toward the rear of the boat. Buddy and I later speculated that the fall, 150 ft, was not survivable, and that having been face down and not moving made it less likely. The boat had been accelerating as we left the dock. The props created cavity then an under tow that probably drew him under the boat and into the rotating props.
Several local boats heard the alarm on their radios. By convention a boat with an Alpha emergency will broadcast their Alpha status and position. All close by boats that are able to help will come and assist in the search.
The woman was appropriately distraught, tearful, and seemingly oriented. She told me, that she and her husband had been fighting about the amount of alcohol he was drinking. It had happened before. He would get angry and storm off, but this time he had gone to a bar, had a few more drinks with a family member, then proceeded to jump off the highest point on the whole boat, deck 14, above the Crow's Nest bar.
She was still hoping.
"I keep hoping he'll show up. That they'll find him. That he didn't really jump."
No one mentioned that if he hadn't jumped we had someone else who'd been seen jumping. We let her have her denial, it would be short lived.
He had no significant medical history, had been in anger management counseling, took no psyche meds, he was 40 years old. His only problem, she said, was impulse control. "He does crazy things when he gets mad or frustrated." He'll just run off or put a hole in a wall or something.
He fit into a class of suicide victims with poor impulse control, a compromised ability to see consequences, failure to consider the feelings of others. They kill themselves on the spur of the moment, usually younger people, often with impaired reasoning due to drugs, alcohol. They may or may not have a psyche history. Their first impulse to end their own lives may be their last.
Her sister was there with her, holding her hand. Our eyes met, we both knew, the wife said "I keep hoping he'll turn up." And finally, "Today is his birthday, he's 40 years old today."
I asked and they had no children. "If you need anything ma'am, you tell this gentleman right here," I motioned to Laurence the security guard, "He can reach me with his walkie-talkie." She nodded. I concluded "There are a few hundred people looking for him, you know." I knew they wouldn't find anything, it was obvious the props had churned him up.
Nurses universally have a need to get people to take Valium if they are upset. And Mae had been trying repeatedly to get both women to take some Valium, and she must have asked 10 times. The wife took one in her hand, "Maybe later, I've been drinking."
Then it was back to the medical center. Some woman in Houston was calling, somehow, asking me to check her mother who was upstairs in her room, having seen the entire thing from her balcony.
"How could you let something like this happen, my mother is distraught." I told her I would check her mother out and got the room number. Before I could call her, she called me, frantic, crying, "I saw the whole thing, my sister and I saw the whole thing, My God. He just climbed up the railing and jumped off."
I told them I would be up to check on them, but they decided to come down to us, so as to get away from the scene.
About this time it was an hour into the search and the Captain came on the ship-wide speakers: "We have to abandon our search for our unfortunate guest, we will leave behind six other local boats to conclude the search."
They were frantic, crying, went through 4 boxes of tissues. But no chest pain, and their blood pressure was OK. Mae had to take them one at a time into the triage room where the blood pressure cuff was. That gave me an opportunity to do some crisis management on them. I did what I'd been seeing grief counselors do for years in the ER: Stay quiet, don't talk, listen and nod, wait till they're through then say "You are experiencing normal emotions that everyone has. Tomorrow will be better, I promise. Maybe not a lot better, but the human mind is good at dealing with grief and loss." It worked. They both thanked me, calmer, and left. Well they had to leave, we were out of tissues.
But not before Mae could ask "How about some Valium. It will calm you down. Are you sure?" I think she got some down them eventually.
They next morning, today, my loyal group again decided I was the logical person to call the women upstairs and see how they were doing. Turns out they were doing relatively well. I didn't talk to the man's wife, thinking a phone call would be too impersonal. I was about to go to her room when Tiffany from guest services called and told me she had just spent an hour with her and she was doing as well as could be expected.
Sad when others end their lives, especially when it's a younger person with a future ahead of them. We, the left behind, will never know what their lives could have been: Their relationships their careers, their choices for a spouse, their children and grand children, their joy and their sadness, tragedy and triumphs will never be.
Why does the misery and misfortune of others, people we don't even know, affect us so much? Perhaps it's part of what makes us social animals. We share. Sometimes food, sometimes information, our gossip, sometimes just our company. Sometimes our emotions, our happiness and our grief. What joy, what sorrow we encounter in our human experience, as we dance through our lives bobbing and weaving in and out of our relationships, triumphs and our failures.
I have a recurring dream, two of three times a month, it's always the same. I'm high up in the air, floating over an ocean and I look down and see several boats. Some bigger than the others. All are Barks, the kind of boat Christopher Columbus used. The wind is at our backs and the boats are making good speed, bouncing through the waves. It's a wonderful sunny day, bright with lots of wind.
And I remember thinking none of the boats had a particular destination, their main purpose, our mission, was to just sail and be proud of how we sail and to sail as fast as we could.
Then occasionally one of the boats seems to lose the wind out of its sails, sometimes quickly, sometimes slowly. They stop going straight ahead and begin pitching from side to side, falling behind the others and eventually backwards, below me and then I can't see them anymore.
Ship Physician's Log: Cruise V, Fort Lauderdale Day 1, Submitted by Dr X, Ship's Physician
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Come aboard as Dr X's Private Sea Journal reveals with great story telling and wit the practice of medicine on the high seas including some of the deep dark secrets of maritime medicine, as well as Dr X.
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