CASE STUDY: Navigating unstable mental health on a cruise trip

The patient joined the cruise in the UK – however, crew soon became aware of abnormal behaviours and she was seen by the ship’s medical officer, who noted her to be manic, confused, disorientated, agitated, irrational and with poor insight. Initial treatment included emergency sedation and supervision. Meanwhile, the medical officer contacted the husband, who advised that the patient had a diagnosis of bipolar disorder, and received medication – but with poor compliance.

The medical officer also discovered relationship issues between the patient and her husband, although the exact events recounted was inconsistent. The patient was disembarked to a private psychiatric hospital in Portugal just before Christmas, and Med ResQ was appointed seven days later as the cruise line was receiving little information about her condition. The shipping agent advised that the situation was complex, as the patient remained unstable despite interventions. On initial contact with the hospital, Med ResQ was advised that the resident psychiatrist was unavailable until after the New Years’ break, and that the nurses were not permitted to release any information.

To understand the patient’s history, Med ResQ contacted the local Acute Mental Health Team in Wales who advised that the patient was first diagnosed in the 1990s, and had:

• Known suicidal tendencies
• A poor record of medication compliance
• Frequent relapses
• Marital issues, and
• A previous involuntary admission to a psychiatric unit.

Crew soon became aware of abnormal behaviours

Med ResQ contacted the hospital’s psychiatrist upon his return. He advised that while involuntary admission continued due to insufficient improvement – with the medical data provided by Med ResQ – he anticipated improvement. A scheduled follow-up call was cancelled as the psychiatrist was unwell, however during the subsequent call, the patient’s condition was noted to have improved, and involuntary admission was rescinded.

During the patient’s initial assessment, the patient’s mood was flat. She was tearful, anxious, and she commented about physical violence directed toward her at home. However, over the subsequent five days, trust increased, and the patient’s condition became acceptable to fly. Med ResQ gained permission for a UK registered mental health nurse to enter the hospital to assess the patient, gain the patient’s trust, and to allow for repatriation planning.

An escort doctor was sent to Portugal on day six, equipped with a medical kit containing emergency sedation. At home, Med ResQ’s medical team discovered a complex home situation. The husband reported violence toward him, including attacks with hot drinks and physical assaults, as well as a history of unpredictable behaviours, such as the patient leaving the house for days at a time. The immediate family were rejected by the wider family and friends and there was poor support from the mental health team.

The medical team noted four primary concerns:

• The need to safeguard both the patient and husband
• Inconsistencies between the patient and husband’s reports of violence
• Inconsistent, unreliable, and infrequent updates from the hospital, and
• Risk of complications during escorted repatriation.

Due to safeguarding concerns, Med ResQ decided that direct transfer to hospital was required, and arrangements were made for the patient to be brought directly to hospital in Wales for psychiatric evaluation. The escorts brought the patient to the airport, and although she was anxious, she remained stable and was repatriated without the need for emergency medication in-flight. The escorts accompanied her to Wales, where she was handed over to the hospital’s mental health team for ongoing care.

In response to the successful repatriation of the patient, Med ResQ’s client said that requesting their assistance was the ‘right call’, and that in particular, ‘sending a nurse to Portugal to assess and escort the guest made all the difference’.