As global travel increases following the Covid-19 pandemic, it is not surprising that the cruise industry is seeing an increase in demand. The Cruise Lines International Association (CLIA) 2022 outlook report estimates that the industry will achieve 100 per cent of global capacity by August 2022. When a passenger has a medical emergency on board, getting necessary emergency medical care and transport back home is often a difficult process.
The average cruise ship passenger is an older adult, often with medical co-morbidities or at a higher risk for orthopaedic injuries. It should not be surprising that the most common injuries on cruise ships that require hospitalisation are fractures in the elderly resulting from a fall. While cruise ships are equipped with medical staff, and many have robust clinics or equipment, they generally cannot provide the care needed for significant orthopaedic injuries.
When a cruise ship is docked in foreign ports, getting such a patient to appropriate and timely care is difficult. Sometimes the patient can be referred to local care, which may be able to definitively treat the medical problem. This poses numerous logistical challenges for the patient, the cruise line, medical insurers, and the care providers. A typical practice is to instead arrange for the patient to be transported back to their home country for care, either by a fixed-wing air medical transport provider or by commercial airline with a medical escort if needed.
An 84-year-old male suffered an isolated hip fracture following a ground level fall while on board a cruise ship docked at a resort in northern Haiti. The security situation in Haiti is tense, and while some areas (such as the cruise line resorts) are safe, travel is incredibly dangerous due to gang violence and control of roads. This issue, compounded by a lack of infrastructure, meant there was no way to transport the patient to appropriate local care.
The medical staff on the cruise ship provided appropriate care, including pain management and immobilisation of the hip. The patient’s age and comorbid conditions, along with the cruise ship itinerary, indicated that the patient should be evacuated back to the US. An air medical jet was capable of transporting the patient and assisting with the medical repatriation. The cruise line resort was only 13 kilometres from a city with an appropriate airport. However, the local road conditions were so poor the trip would take almost three hours. There was also serious concern about the risk of kidnapping because some gangs see foreigners as ripe targets for kidnapping and ransom.
Haiti Air Ambulance, a non-profit organisation, is the only air medical provider to the 11.4 million citizens of Haiti. While over 99 per cent of the patients they transport in their air medical helicopter are Haitian citizens, they have also provided transport to non-Haitian patients as well. The bilingual communication specialists coordinated with the incoming air medical jet and the cruise ship staff to coordinate transport. Haiti Air Ambulance was able to land at the cruise line dock where their multi-lingual medical team consisting of a physician, paramedic, and emergency medical technician assessed the patient in the cruise ship infirmary.
The patient was given pain medication as well as low molecular weight heparin to reduce the risk of pulmonary embolus and blood clots during the transport to the US. The medical team safely moved the patient from the infirmary to the aircraft and secured them in the aircraft. The patient’s spouse was also accompanied the patient back to the US. The flight from the cruise ship dock to the nearby airport at Cap- Haitian took less than 10 minutes.
After landing at the airport, Haiti Air Ambulance waited with the patient and continued care until the air medical jet arrived, approximately 24 minutes later. During this time, Haiti Air Ambulance assisted in facilitating clearance for the patient and spouse through customs/immigration to leave Haiti. The patient was unloaded from the helicopter and care of the patient was transferred to the medical team from the US The patient was repatriated to the United States successfully without further incident.
This case illustrates some often overlooked aspects of medical emergencies occurring to tourists abroad. One aspect is the limitations of definitive medical care on cruise ships or resorts. While local care may be appropriate and capable, extenuating circumstances such as road conditions, lack of ambulances, and security can render local care unviable. If air medical evacuation is needed, it will require coordination from multiple agencies to facilitate. This is especially true when a patient must also be repatriated through the customs and immigration process in foreign countries.
Founded in 2014, Haiti Air Ambulance (HAA) is a non-profit organisation dedicated to providing emergency helicopter services to the people of Haiti. As the only air medical transport provider in Haiti, HAA flies critically ill or injured patients to emergency medical care providers based solely on need. Their primary aircraft is a medically configured Bell 407 helicopter. Their medical team operates at the same standards of care that air medical providers in the United States operate under. Classic Air Medical, a Utah-based air medical company, provides the pilots and mechanics under their FAA Part 135 certificate.