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Medical Staff Orientation to Commodore Cruise Ships

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					Medical Staff Orientation
 to Commodore Cruise
         Ships



      rev. 7/31/98   Copyright MHS, Ltd.




                      1
                               Maritime Health Systems
                              Commodore Cruise Ships

                           Orientation Manual
                                           Table of Contents
Introduction ............................................................................................................................... 4

The Ships.....................................................................................................................................4

Clinical Duties .......................................................................................................................... 8
  Office Hours ............................................................................................................ 10
  Charting ................................................................................................................... 10
  Nursing Documentation .......................................................................................... 12
  Physician Documentation ...................................................................................                   12
  Billing ..................................................................................................................... 12
  Cash and Other Methods of Payment ..................................................................... 15
  Pharmacy ................................................................................................................ 16
  Pediatric Pharmacy ................................................................................................. 17
  Expired Meds .......................................................................................................... 17
  Pharmacy/Supply Restocking .................................................................................... 17
  Formulary/Supply List additions ................................................................................17
  Medical Diets .......................................................................................................... 19
  Cabin Calls .............................................................................................................. 19
  Crew Care ............................................................................................................... 19
  Drug Testing ........................................................................................................... 20
  Shoreside Referrals ................................................................................................. 21
  Backup .................................................................................................................... 21
  The Call Schedule ................................................................................................... 21
  AMA’s .................................................................................................................... 22
  Deaths ..................................................................................................................... 23
  Injuries/Accidents ................................................................................................... 25
  Evacuations/Disembarkations ................................................................................. 26
  Air Ambulance Resources ...................................................................................... 27


The Infirmary ........................................................................................................................... 28
  EKG, Monitor, Defibrillator .................................................................................... 28
  EMS Equipment ...................................................................................................... 28
  Laboratory ............................................................................................................... 28
  Housekeeping .......................................................................................................... 29
  Repairs ..................................................................................................................... 29
  Pagers/Radios/Phones ............................................................................................... 30
  Emergency Protocols ................................................................................................. 30
                                                                   2
  Secondary Medical Station ........................................................................................30
Administrative Duties .............................................................................................................. 31
  Reports and other paperwork ................................................................................... 31
  File Cabinet Organization ....................................................................................... 32
  Voyage-End Procedures .......................................................................................... 33
  Inventory and Stocking ........................................................................................... 34
  Medical Waste Disposal ......................................................................................... 34
  Transmittable Diseases ............................................................................................ 35
  Captain’s Reception and Dinner .............................................................................. 35
  MMS, V-Ships, and MHS ...........................................................................................36

Life on Board ........................................................................................................................... 37
  Who’s Who .............................................................................................................. 37
  The Important People to Know ............................................................................... 37
  Meals ....................................................................................................................... 37
  Dress ........................................................................................................................ 38
  Drinking ................................................................................................................... 38
  Entertainment .......................................................................................................... 38
  Tips .......................................................................................................................... 39
  Security/Safety/Emergency Drills/Life Boat Drills ................................................. 39
  Safe Deposit Boxes .................................................................................................. 40
  Communications ...................................................................................................... 40

Life Ashore .............................................................................................................................. 41
  Port Agents .............................................................................................................. 41
  Excursions................................................................................................................ 41
  Getting on and off, to and from the Ship ................................................................. 41
  Port Taxes ................................................................................................................ 42

Post Test ................................................................................................................................... 43

Appendix - Commodore Cruises/MHS TB Prevention Program .............................................. 47
  Prescreening ............................................................................................................. 47
  Shipboard Prophylaxis ............................................................................................. 47
  Diagnosis of Active Disease .................................................................................... 48
  Monitoring ............................................................................................................... 48
  Discharges ................................................................................................................ 50
  TB Prevention Program Chart .................................................................................. 51
  Acknowledgment of Medical Advice & Release ................................................... 53
  Discharge Instructions for PPD Negative Crew ....................................................... 54
  TB Prophylaxis Discharge Instructions .................................................................... 55

Appendix B - Code Blue Protocol ............................................................................................56

Appendix C - Panamanian Flag Crew Rules and Regulations ...................................................63




                                                                      3
                        Medical Staff Orientation to
                         Commodore Cruise Ships


      Welcome to Maritime Health Systems and Commodore Cruise Lines. You’ve signed up for an interesting
and enjoyable voyage that will take you to new places both geographic and medical.
      We hope you’ll find this manual interesting and informative, so don’t leave home without it. You’ll need
it for reference on your cruise.
      Expect your first 3-5 days to be somewhat disorienting. Just like starting a new practice anywhere else,
you can’t learn the ropes in one day. So focus completely on the office/ship routine for the first few days, and
once you’ve gotten it down, you’ll feel much more comfortable. Read on now and we’ll tell you about your
ship, your hospital, and life at sea.


                                            The Ships
      You’ll find a map of the ship on the next pages that shows the location of the infirmary - which includes
the medical office, examination and treatment rooms, and the doctor’s and nurse’s cabin's. This is your domain,
and the doctor, as chief of the medical department, is responsible for everything that goes on here. One of the
following pages shows a more detailed diagram of the infirmary. Please study this closely as it shows where
all of your pharmaceuticals, supplies, and equipment are located. Take special note of the location of the
defibrillator and emergency/crash kit. While emergencies don’t happen very often, you’ll need to know where
they are in a hurry if one does occur.




                                                       4
5
SS Enchanted Isle




        6
SS Enchanted Isle Infirmary Area
     Dolphin Deck Forward



                                            O
                                                 E S
                                                 D
                                        O   C
                                                oS




                                    W




     o = oxygen ("C" & "D" tanks)
     O= oxygen ("E" tanks)
     E= EKG
     D= defibrillator
     C= crash kit (trauma kit)
     L= office supplies
     W= wheelchairs
     S= evacuation stretcher




                           7
SS Enchanted Capri




        8
SS Enchanted Capri
 Infirmary Layout




        9
                                         Clinical Duties
    Your primary responsibility is to provide excellent medical care to passengers and crew. This is your
most important function and it takes precedence over all other activities.

Office Hours

      The infirmary will conduct office hours every day except embarkation/disembarkation day from 8:00 AM
to 10:00 AM and 4:00 PM to 6:00 PM. There is only afternoon clinic on embarkation day. Both nurse and
physician must be present during office hours. If unusual circumstances arise, the physician may negotiate
different hours with the Staff Captain. Both crew and passengers may present to the infirmary during office hours.
The crew has been instructed to appear during the last hour if possible, to avoid conflict with the passengers.
      Office hours should proceed as diagrammed in Figure 1. The nurse will initially greet patients and take
vital signs (at least a blood pressure and a pulse) while documenting the chief complaint, demographic
information, and obtaining a signature for consent to treat. If there’s going to be a little bit of a wait before the
doctor is able to see them (i.e. s/he’s still seeing another patient), the nurse should take that time to record the
credit card or courtesy card information onto the chart. The nurse then puts the chart into the “to be seen” box
for the doctor. The doctor picks up the chart and asks the patient back into the examination/treatment room. There
the physician does his/her history, physical examination, and completes the chart. S/he dispenses any
medications that may be necessary, writes prescriptions or instructions, etc. and, after completing the diagnosis
and services section of the chart, discharges the patient and gives the chart back to the nurse. If any laboratory
work is necessary, s/he requests the nurse to do it at this point. When done, the nurse records the results on the
chart and returns it to the physician. When the patient is ready to go, the nurse records the credit/courtesy card
information on the chart (if not already done), totals the charges, has the patient sign for the amount, and sends
them on their way with their instructions and their (top) copy of the chart.
      The exam may be limited by the equipment available. We do not have anoscopes, sigmoidoscopes, a slit
lamp, or X-ray. The infirmary has vaginal specula, but the ships do not have an adequate exam table with stirrups.
Non-emergency pelvic exams should be referred ashore. In situations where both doctor and nurse are male,
a female chaperone should be present during emergency pelvic exams. The patient’s husband, a female from
the housekeeping department, or a female from another department will do.
      The division of duties described above is not written in stone. It may be modified by mutual agreement
of the doctor and nurse as they see fit to improve efficiency in patient care.


Charting

      We’ve tried to keep the paperwork to a minimum, so that you can get on with taking care of the patients.
To that end MHS has instituted a computerized medical record system (CliniDoc) on the Commodore vessels.
Please review the User Manual for the CMR system and work through the tutorial as soon as you get on board
so that you will know how to use it. It's really simple, but please remember that accurate and complete charting
is just as important here as it is in a hospital emergency department or on a medical or surgical ward.




                                                        10
     Commodore
Infirmary WorkFlow




        11
Nursing Documentation

      The nurse is usually responsible for the initial interview including the consent and getting demographic
information. This consists of only a few items: the patient’s name, their birth date, the ship on which the
consultation took place, the voyage number, the date and time, their cabin number, and their phone number and
address. Check off the appropriate ship in the demographics window and fill in the other blanks. Do not fill
in the blanks for social security number, billing number, or group number, but make sure you designate the patient
as either crew or passenger.
      While taking the vital signs, one should ask about the patient’s past medical history, medications, and
allergies, and make quick notations in the appropriate lines for these items.
      The chart then passes to the physician who does the history and physical, documents the treatment or
laboratory ordered, and when the patient is ready for discharge notifies the nurse. The nurse is responsible for
checking the charges and making sure they are accurate, totaling them and recording them.
      Occasionally, a passenger will refuse to pay for treatment or need to be treated and evacuated so rapidly
that there is not time to collect the appropriate billing information. In the case of the recalcitrant patient, if all
your powers of persuasion are inadequate to convince them that they should pay their bill, then try to get as much
demographic information as possible on the chart (phone number and address). You can obtain this information
sometimes from the purser’s office if the passenger is unwilling to give it. When you send in the voyage-end
package, be sure to make a notation on the Voyage Report stating that the patient refused to pay and our office
will pursue the matter.
      For patients who are disembarked so rapidly that their billing information could not be obtained, please
go to the purser’s office and get all the demographic information (name, phone number, card number and
address) and be sure it is entered in the computer. Again, a note on the Voyage Report will allow the MHS office
to pursue the matter with the patient or their insurance company.


Physician Documentation

      When the physician gets the chart, the demographics and basic health care information should already be
on it. He/she is responsible for verifying their presence and accuracy. The physician has only to document the
history and physical examination, any orders or treatment given, any medications dispensed, the plan for follow-
up and/or the patient’s instructions for self-care, the diagnosis, and the medical charges. Remember that
complete and accurate documentation is just as important here as it is in your own office or emergency
department. Every patient, no matter how trivial the complaint, must have a medical record. We would like
you to record your history and physical exam in the standard format provided on the chart, i.e. chief complaint,
HPI, ROS, etc. all recorded separately. This makes it much easier for our office and for physicians or insurance
companies who are reviewing the patient’s chart later for follow-up or to reimburse the patient to determine
the nature and extent of the patient’s medical problem. At the bottom of the chart, please record your instructions
to the patient about how they should care for their problem, and how they should make follow-up arrangements.
Your diagnosis should be entered separately in the diagnosis module.


Billing

     We’ve also tried to keep the billing process as simple as possible so as not to impede the clinical encounter
or unnecessarily complicate the office flow. For the physician, the billing process is a simple four-step
procedure: Document the type and amount of medications dispensed (This is automatic when you generate a
"prescription" with the system), enter a visit level and/or procedure on the Medical Services Bill form, enter
any additional (laboratory, X-ray) services, and enter any supplies used.
                                                       12
      The “prescription” area of the chart should be completed by the physician when s/he gives medications
to the patient. The name of the medication and the number of pills, tubes, bottles, etc. should be entered on one
of the lines provided.
      Then, a visit level and/or procedure code must be assigned to the patient. This involves a little
interpretation by the physician, but is something with which s/he will become rapidly familiar. The coding
guidelines are as follows:

     Nurse visit - This visit level is for nurse checks - i.e., patients who comes in to have their blood pressure
checked or to ask advice only of the nurse. Thus, if a patient comes in for preventive medical advice, or the
nurse’s opinion about a non-acute problem, etc. this is the appropriate visit level to check.

     Level 1 (99281) - This level should be used for a visit that requires a single system history and physical
examination by the physician. Most patients will fall into this category. It should be used for the most common
problems on board the ship including sunburn, upper respiratory infection, seasickness (kinetosis), etc.

     Level 2(99282) - This visit level should be used for patients who require a more extensive history and/
or physical examination. It includes patients who require laboratory tests, a review of systems or a past medical
history when necessary and appropriate: patients who present with problems such as gastroenteritis,
abdominal pain, UTI, dizziness, etc.

     Level 3 (99283) - This visit level applies to patients who have multiple problems or complicated
problems. They require a complete workup including all the elements of the history (CC, HPI, ROS, PMH)
and a multisystem physical examination. Problems such as drug overdose, multiple trauma, closed head trauma,
asthma/COPD exacerbation, chest pain or altered mental status would fall in this category.

     Critical Care (99150) - This visit code is reserved for patients who require inpatient observation in the
ship’s infirmary. It does not apply to patients who merely require bed rest and periodic observation, but only
to patients who are critically ill and require the monitoring, constant observation, oxygen, or other resources
of the infirmary. Please charge only for the actual time spent at the bedside by the physician.

      Follow-up Visits (99211-99215) - These visit levels are used for patients whom you’ve seen before
and have instructed to come back to the infirmary for a reexamination. It applies to any revisit or follow-up
visit for which you have already done the initial history and physical examination. It does not apply to a new
visit by an old patient who presents with a different problem than the one that you treated them for before. In
that case, the appropriate level 1, 2, or 3 visit level should be assigned.

       Charges for other services and for laboratory examination are much more straightforward and require
little interpretation. All the common services are listed on the Medical Services Bill (Superbill) form -
including the appropriate codes and charges for lacerations, procedures, medical supplies, lab tests and
treatment of fractures or dislocations. An even more extensive list than this (in case you still can’t find the
appropriate code for the procedure or service that you provided) is located in the Policy and Procedure Manual
in the “CPT Price List” section.
       One caveat: you may bill for only ONE major procedure or visit level per day. So a person with a
laceration can be billed only for the laceration repair, not for a visit level AND a laceration repair. A critically
ill patient can be billed for a level 5 OR critical care, but not both. You cannot bill for fracture care AND a
cabin call - just one or the other. This does not include critical care procedures, office procedures, laboratory,
radiology, or supplies. These can be billed in addition to a visit level or major procedure. Our number one
source of complaints is billing mistakes, so please be meticulously careful.

                                                        13
14
       When the patient is ready for discharge the nurse should enter the quantities for the medications dispensed
on the “Pharmacy Bill” form and it will calculate the amount to be charged for each medication and then a total
for all medications. S/he should then enter the ICD-9 codes and fees for the visit, any services provided, and
any laboratory examinations provided on the Medical Services Bill form. Except in the case of accidental
injury, s/he should then ask the patient for their cruise/credit card and record that information in the computer
(if not already done).
       The patient should then be given a copy of the Superbill and the pharmacy bill (except accidents. We keep
those charts). The nurse or doctor should instruct the patient on how to use this copy to submit to their insurance
company for reimbursement. The instructions are printed on the second page of the patient’s Superbill, but
should be verbally reinforced. Please point out the instructions to the patient. Mention that all they have to do
to get insurance reimbursement is to make a copy of the bill, staple it to their insurance company’s claim form,
fill in their address and insurance information on the form, and send it in to their insurance company. At the
same time, however, you must caution them that many health insurance policies do not cover office visits or
routine health care and thus their claim may be denied. This is especially important for Medicare patients as
not only does Medicare not usually cover routine office visits, but it also does not cover services outside the
United States.
       Save the chart in the documents folder. It gets sent to Baltimore electronically later. At the end of each
day the nurse should print a daily log and take it up to the Purser/accountant along with copies of all the Medical
and Pharmacy bills for the day.

                                                                    Cash and Other Methods of
                                                                    Payment

                                                                           Sorry, but we just can’t accept checks
                                                                    and we accept cash only when there is no
                                                                    alternative. Only Mastercard, Visa, Discover
                                                                    or Cruise cards, please. Unfortunately, the
                                                                    logistics of handling cash and the risks of
                                                                    handling checks are just too much for our
                                                                    small operation. Also, we can’t accept Ameri-
                                                                    can Express or Diner’s Club because of the
                                                                    expense involved and we cannot bill health
                                                                    insurers directly.
                                                                            Only as an absolute last resort, when
                                                                    a passenger has no way to pay, will we
                                                                    accept cash. Please document this clearly on
                                                                    the chart and write the name and amount on
                                                                    the cash envelope for the voyage. Send the
                                                                    cash envelope along with the charts and
                                                                    reports to the MMS office at voyage end.




                                                       15
Pharmacy

           Maritime Health Systems maintains an onboard pharmacy in the infirmary that contains both
prescription and over-the-counter medications. As you might expect, the selection is limited compared to a
pharmacy on shore, but it is generally more than adequate for the kinds of problems seen on board a ship. The
formulary is included in the Policy and Procedure Manual.
      Should you need to prescribe medications that are not included in the formulary, that have expired, or
the supply has been depleted, the doctor may write prescriptions that can be filled at shoreside pharmacies.
A supply of prescription pads is in the physician’s desk. For crew members, the physician should write the
appropriate prescription then give it to the patient or his department head. They will arrange for the prescription
to be filled and paid for. Each department is responsible for the cost of their own crew prescriptions;
passengers pay for their own prescriptions.
      For passengers, directions to local pharmacies in each port may be obtained from the port agent or may
be available in the ports of call information section of the Policy and Procedure Manual. We sell OTC meds
over the counter, just like in the U.S.
      In general, the physician is responsible for dispensing medications, while the nurse is responsible for
keeping track of medication inventory (including narcotics) and billing; however, the nurse may dispense also
as the situation warrants. The dispensing procedure is diagrammed in Figure 4. and covered in the User Manual
for the CMR system. For some commonly used medications, preprinted dispensing envelopes may be available
that have complete instructions and precautions for the patient on them. The physician merely dispenses the
appropriate amount of medication into the envelope, seals it, and hands it to the patient along with his verbal
instructions. S/he records the drug and amount dispensed on the chart, and when the nurse discharges the patient,
s/he bills him/her for the medication in addition to the usual visit charge and any other services.
      The procedure for dispensing narcotics is somewhat different. Since the nurse is ultimately responsible
for the narcotics, s/he must enter any narcotics dispensed in the narcotics log. This log is a notebook that is
kept in the locked drawer with the narcotics. The dispensing procedure is otherwise the same as for non-
narcotic medications. For security reasons, narcotic inventories will be performed at the completion of each
voyage (that is on the evening before embarkation/disembarkation day) and whenever a new physician or nurse
comes onboard. These inventories should be completed simultaneously by the doctor and nurse, signed and
dated. Send them to MHS in the voyage-end package. Please note that streptokinase is treated as a narcotic
for security reasons. That is, the streptokinase should be kept locked up in the narcotic drawer and counted
with the narcotics every time this operation is performed.
      Aspirin, acetaminophen, meclizine and Band-Aids are free to passengers and crew. There is also no
charge to crew for supplies (Ace wraps, splints, bandages, etc.). Passengers may purchase OTC medications
(Maalox, Fleet’s enema, Orajel, etc.) without incurring an office visit charge. The nurse will record the sale
in the CMR system and use the "Pharmacy sale" form. There is a three dollar minimum for medication charges.
In other words, if the total for medications (OTC and/or prescription) is less than three dollars, you should
charge a flat three dollars for medications.
      We do not give professional courtesy except to the extent that if a physician from among the passengers
asks to purchase a prescription drug for a relative or him/herself , we will allow them to purchase the drug
(at the passenger price) without requiring that we see or examine the patient. The only requirement is that they
show us their medical license.




                                                       16
Pediatric Pharmacy

     Most of the time, there are few children on the ships so you won’t have to worry too much about pediatrics.
Because of this, we stock few pediatric medications (they would mostly just expire unused).
     This means that you will occasionally have a pediatric patient but not have the pediatric medication that
you want to treat them. Exercise your ingenuity! You want Bactrim suspension? Smashing one Bactrim DS
tablet in 20ml (4 teaspoons) of liquid (water, Coke, ginger ale, apple sauce, baby food, . . .) gives you the
same concentration as the commercial version.
     Here’s a handy table of similar conversions:
                Pediapred        =       Prednisone, 10mg tab in 10cc
                Amoxil          =        Amoxicillin, 500mg cap in 10cc
                Eryped            =      Erythromycin, 400 mg tab in 10cc

Expired Medications

      We do not throw away expired medications, but return them for credit. When, in the course of inventory
taking or clinical duties, you come across a bottle of medication that has passed its expiration date, you should
place it in the “Expired Meds” box. This is usually a medium sized cardboard box which is placed on a shelf
or in a cabinet near the end of the pharmaceuticals (i.e. at the end of the alphabet near Vitamin C, which is the
last of the oral medications). Keep it there until we do one of our regular shipments (we will tell you when
and how to ship them). Do not forget about them, however, because if you run out of something important, an
expired med is better than no med at all!

Pharmacy/Supply Restocking

         We routinely restock the infirmary at about 1 month intervals. The first week of every month you should
check your inventory of medicationsa nd supplies; fill out a pharmacy and/or Supplies order form (in the
FORMS category of the Clinidoc software); print it and fax it to the MHS office for fulfillment. You should
receive the supplies in abouta week.
      If you run short of something before a regular restocking time, fill out a pharmacy/supplies order form
(in the FORMS category of the Clinidoc software) and fax it to the MHS office for fulfillment. We will either
send you supplies or authorize you to purchase them at a Port-of-Call. Do not ask the purser’s office or port
agent to buy supplies for the infirmary. They are not authorized to do so, and you will be personally charged
for them. Similarly, if you purchase medications for the pharmacy, especially non-formulary medications,
MHS may reimburse you at its discretion.

Formulary/Supply List Additions

     Obviously for logistical, financial, and space reasons we cannot change the formulary/supplies every
month to suit the practice pattern of each new physician. Over the past seven years we have evolved a supply
and medication list which seems to be acceptable to most doctors and nurses. Everyone has their own
preferences, of course, but this list is a compromise by everybody.
     To make it onto the formulary or supply list a new item has to meet four criteria: It must be requested by
multiple people (indicating it's more than just one person'w preference). It must be of medically proven value
(aminophylline, for instance was deleted from the formulary when better agents for treating asthma became
available). It musat be within the capabilities of the Infirmary and staff (We don't have a thoracotomy tray).
And it must not duplicate the function of something already on the formulary or supply list.


                                                      17
18
     Everyone's requests are taken into consideration, but until we get three requests for a particular item we
don't investigate adding it to the formulary/supply list. Therefore you may not get everything you request in an
order if it includes things which are not approved for the lists yet.

Medical Diets

      The galley has the ability to prepare special diets for passengers (or crew) when medically necessary,
however, they like to be given some time for planning. When the medical team determines that a special diet
is needed (for instance, clear liquid diets for people with gastroenteritis), you should immediately tell the Hotel
Manager about the diet and any restrictions on the patient (i.e. if they are confined to their cabin). He will, in
turn, arrange with the food department and Bell Box for appropriate food and its delivery. This applies as well
to passengers who may receive a regular diet but are confined to their cabins for medical reasons (broken leg,
migraine headache, etc.)

Cabin Calls

      At times you will be called to a passenger’s cabin to render medical care either for an emergency or
because the patient cannot for some reason come to the infirmary. The procedure is somewhat different
depending on the reason for the call (Figure 5). If the call is for seasickness, which usually happens in mini-
epidemics when the ship gets into rough seas or bad weather, you should rapidly go through the appropriate
history of the present illness, review of systems, past medical history, and get right to the point of administering
relief to these patients. You’ll want to take along the “Cabin Call Kit” which contains a stock of the appropriate
seasickness medications and administration paraphernalia.
        When you arrive at the cabin, the nurse and doctor should divide the duties and work simultaneously.
The physician should go through the history and ask all the pertinent questions while the nurse performs a rapid
physical examination on the patient and prepares them to receive an injection. Once the history and physical
are completed, the determination may be made to administer an antiemetic injection. The nurse may administer
the injection while the physician has the patient or relative sign the consent form for treatment and gets the
demographic and cruise card information. As you leave, give the patient an envelope of antiemetic medication
and remind them to come by the Infirmary later to get a copy of their bill.
       If the call is of a more random nature (i.e., a fall, or seizure, etc.) or an emergency, you should respond
immediately with whatever equipment you have at hand that you think is necessary. Evaluate the patient rapidly
and begin whatever immediate measures are necessary at the scene. You can call upon the Stretcher Team to
get things that you need from the infirmary (crash kit, evacuation stretcher, splints, bandages, etc.). It is best
not to treat patients in the public areas and the patient should be moved as rapidly as medically indicated to
the infirmary for further care. Once the patient is stabilized, you can worry about the details of filling out a chart
and getting the necessary information. Later, when patients come to the infirmary for follow-up or (inpatients)
are ready for discharge, demographic/financial information should be obtained and entered into their chart.
Failing this, the information can be obtained from the purser’s office.

Crew Care

      The officers, crew, and hotel staff are dependent upon the medical department for their medical care at
sea. Since they come from all over the world, they present a diversity of medical and social problems. One
that you will have to deal with early on is the language barrier. Most of the crew speak at least a little English,
but many do not speak enough for medical purposes. For medical staff who are not proficient in a variety of
languages, we have provided a language phrase book in the infirmary. In addition, the patient’s supervisor can
almost always find an interpreter among the patient’s coworkers if needed.

                                                        19
      We maintain files on all ship personnel and keep them in the file cabinet in the infirmary. The drawer is
divided into four sections: Deck/Engine, Hotel, Food, and Concessions. Each crew member’s folder is filed
alphabetically within their department’s section. The procedure for seeing the crew in the infirmary is
somewhat different from passengers and is outlined in Figure 6.
      When a crew member first signs on to the ship, s/he should bring a “Pre-Physical” form completed by a
physician attesting that s/he is fit for duty. This form is collected by the crew Purser or department head and
sent to the infirmary. When you receive it, you should check it to see if any recommendations were made by
the examining physician. If so, take the appropriate action. Then make up a file folder with the crew member’s
name and department, place the copy of the pre-physical inside and file it in alphabetical order under his/her
department in the second file drawer.
      All crew members, when reporting to the doctor’s office for treatment, must have a “permit to see ship’s
doctor” slip that is signed by their department head. If they do not have this slip and it is not an emergency,
they should be sent back to their supervisor to get one. At the conclusion of the visit, the doctor will sign
the slip and state whether the crew member is fit for duty or not or what restrictions he may be under and note
the time that the individual leaves the infirmary. If a crew member needs a shoreside referral, be sure to mention
it on this form so their department head will know.
      When you see a crew member for the first time, you should enter demographic and clinical data in the same
manner as for a passenger (except be sure to note that they are crew in the appropriate box). The crew is not
charged for medical care, so you don't need to do a pharmacy bill or a Medical Services bill.
      There is one exception to the “no charge” rule. All crew are required to have had a physical exam before
they come on board. Some, however, do not and present to the infirmary requesting a physical examination.
In this case, the physical exam can be done, but is charged to the employee or his department and should be
directly collected by you. Please generate a Medical Services Bill for a Level 1 Follow Up visit (99211) in
this case.
      The following tests are required along with the pre-employment/annual physical excamination: PPD,
CBC, UA, HIV, VDRL, HBSAg on food service workers only, CXR on PPD positives and crew from Central/
South America and Southeast Asia. Crew pay for these on their initial exam (We charge them on the Medical
Services Bill for venipuncture, if necessary, and the shoreside lab charges them for the actual tests) but
Commodore pays for them on the annual re-exams.
      Crew are also required to pay for their own medications for medical conditions such as hypertension and
diabetes which predate their employment on the ship. Concessionaire employees are required to pay for their
own medications and can then be reimbursed by their employer.
      When a crew member leaves the ship, s/he is entitled to take a copy of his/her medical record. All the
original medical records must stay onboard the ship in the crew member’s file folder, but if they come by to
pick a copy up on their disembarkation day, please print a copy from the CliniDoc system for them. In order
for the crew medical record drawers not to get too crowded, a separate drawer (usually the bottom one) or
file cabinet is set up for inactive crew medical records. Anytime a crew member disembarks, his/her file folder
should be removed from the active crew drawers and placed in the inactive drawer or file. The inactive file
should be organized the same way as the active medical files are - alphabetically by crew member last name
within departments. Periodically, when the crew inactive file becomes full, it should be purged and all the
records sent to Commodore’s office.

Drug Testing

     We have no facilities aboard for drug testing. There are specific indications under the Department of
Transportation rules for the conducting of drug testing in U.S. Territorial waters. The Policy and Procedure
Manual outlines these indications and procedures. Their objective is to gather evidence about drug or alcohol
use on board ship that may have contributed to an accident or that are causing unsafe conditions.

                                                       20
Shoreside Referrals

      Every effort should be made to provide complete medical care on board the ship because shoreside
medical care is expensive, complicated and time consuming. However, when you find that the medical care
needed by a crew member or passenger is more than you can provide on board the ship (pelvic exams, x-rays,
dental work, etc.), then you need to make a “shoreside referral”. This means that you’re sending the patient to
a medical facility on land to receive further medical attention. To accomplish this, you fill out a “shoreside
referral form” (in the CliniDoc forms), which details what the patient is being sent ashore for, who the patient
is, and why they are going ashore rather than being treated on the ship. This form should be given to the purser’s
office who will then make arrangements with the next port agent to get the patient to the appropriate medical
facility. Please notify the crew member’s department head by noting the Shoreside Referral on their “permit
to see doctor” paper (which they are supposed to take back to their department head to show them).
      It is the Staff Captain’s responsibility to arrange the patient’s contact with the port agent and the port agent’s
responsibility to arrange the appointment and transportation. Figure 7 shows the detailed procedure. It is the
physician’s responsibility to write a detailed SSR form that includes the reason that the patient is being referred,
the presumptive diagnosis, and what you would like the consultant to do. If you want the patient to bring anything
back with them, such as the results of the lab tests, x-rays or a consultant’s opinion, please be sure that you
mention this on the form so that the port agent knows what to expect.

Backup (See “Communications” also)

      If you should find that you’re in a situation beyond your medical expertise or onboard capabilities, and
you can’t wait until the next port to get medical assistance, you should call or fax us. If the situation is urgent
or emergent, please call our on-call physician through our office at 410/729-1945 or 410-499-8311. Leave
a message if no one answers and we’ll get back to you immediately.
      If it is not urgent, you can call our office from the next port. We have an “800” number service that works
from most U.S. and Canadian ports. To get Dr. Harrison’s office, dial 1-800-435-1960 or 410/987-5616. To
get the MMS office, dial 410/729-1945. Alternatively, you can call send a fax to 410/987-4980. If you need
specialist consultation, we can arrange that for you over the phone and answer any questions that you may have
of a medical nature. Administrative problems can usually wait until the next port, in which case you can phone
from the port’s long distance telephones or use our 800 number much more inexpensively.
      While we want to assure you that direct call is available, we also want you to know that it’s very expensive
- as much as $15 per minute for phone conversations between ship and the United States. Therefore, we ask
you to use careful medical judgement in deciding whether it’s necessary to call for expert consultation
immediately as opposed to waiting until the next port. For problems involving infirmary operations, supplies,
medications or personnel, do not bother the Hotel Manager, Purser, Port Agents, or Staff Captain. They have
no authority over our internal policies and will just have to call us for authorization to make any changes,
purchases, etc. Instead, call, fax, or write MHS directly with your questions. Somebody (usually Dr. Harrison)
is on call 24 hours a day to deal with them.

The Call Schedule

      The physician and the nurse rotate on-call duties. Nevertheless, on ships where there are two radios/
pagers, both medical team members must keep them on at all times (because there may be an emergency that
requires both in attendance). The bell box has a call schedule that tells them which of the two to call on a
particular day for a minor emergency. The nurse takes call on odd-numbered days and the physician takes call
on even-numbered days. Occasionally this works to the nurse’s disadvantage, however, the doctor is backup
call for the nurse at all times and it’s much easier for the bell box to remember a simple schedule such as odd
and even days than try to make a new schedule and post it for every voyage.
                                                         21
AMA’s

      This is the reverse of the situation you are used to on land. On ships, patients sometimes decide that they
want to stay on board against medical advice (rather than leaving against medical advice). This situation usually
happens when the physician decides that the patient has an illness or injury that cannot be adequately cared
for onboard the ship and advises the patient to disembark. The passenger, however, having paid good money
for this cruise, is sometimes loathe to do this and will refuse to seek medical attention onshore. If this happens,
the medical team should report it to the Hotel Manager at once and have the patient sign a release form - a reverse
AMA form.

                                                       22
Deaths

     In the event of the death of a passenger or a crew
member, the Staff Captain or Hotel Manager should be
notified immediately. He will, in turn, notify ship
operations. On entering the next port, the local officials
also must be notified (U.S. Public Health Service if
entering a U.S. Port). And they will usually require a
death certificate equivalent called the “Declaration of
Death” that is to be found in the forms folder in
CliniDoc. Usually three copies of this are sufficient.
     Mortuary bags are kept in the supply cabinets/
shelves. Arrangements should be made with the food
department to store the corpse in a designated refriger-
ated area until shoreside authorities examine and re-
lease it. For short term storage (2-3 days), corpses
should be kept at normal refrigeration temperatures
(32°-40°F). Longer storage can be at freezing tempera-
tures.




                                                       23
24
                                                                     Injuries/Accidents

                                                                         The cruise lines are very concerned
                                                                   about litigation from people (both crew
                                                                   and passengers) involved in accidents.
                                                                   Whenever a patient presents to the infir-
                                                                   mary with a complaint of injury suffered
                                                                   from some accident onboard the vessel or
                                                                   on an excursion, the medical team should
                                                                   perform a thorough examination; complete
                                                                   documentation of the extent of the injury;
                                                                   complete the medical portions of the acci-
                                                                   dent report form; then notify and give
                                                                   printouts of the chart and forms to the Staff
                                                                   Captain. The medical department should
                                                                   fill in the patient’s name and fill in the
                                                                   medical section completely and legibly.
                                                                   The physician should then sign the print-
                                                                   out. Call the Staff Captain at once about
                                                                   serious accidents. Take the pax chart to
                                                                   the Staff Captain and s/he willauthorize it
                                                                   so that Commodore will reimburse us for
                                                                   it.
                                                                         If a passenger presents to the infir-
                                                                   mary for evaluation and treatment of an
                                                                   injury sustained ashore, you should treat
                                                                   and charge this passenger in the usual
                                                                   manner providing the injury was in no way
                                                                   cruise line/ excursion related (in which
                                                                   case follow the procedure above.) In all
                                                                   cases, the Staff Captain will decide whether
                                                                   Commodore or the passenger will pay.
                                                                         The flow chart ion the previous page
shows the accident reporting procedure. All accidents, even those requiring no treatment, should be handled
this way. The Staff Captain will follow up with a complete investigation of the circumstances of the accident.
The Staff Captain or Department Head is responsible for investigating the scene of the accident and
photographing/documenting the conditions, getting witness reports, etc.




                                                      25
                                                                       Evacuations/Disembarkations


                                                                             Occasionally, you will have a patient
                                                                      who is so ill that they must be sent immedi-
                                                                      ately to a higher level of care. Try to think
                                                                      ahead and plan evacuations in port. Don’t
                                                                      wait until you’re out in the middle of the
                                                                      ocean as they are extremely disruptive. But
                                                                      when this occurs, you must notify the Hotel
                                                                      Manager and Staff Captain at once. If you are
                                                                      near enough to port, they can arrange for an
                                                                      ambulance to meet the ship and take the
                                                                      patient off. If you are too far from port, but
                                                                      within helicopter distance of the U.S., they
                                                                      can arrange for U.S. Coast Guard helicopter
                                                                      evacuation. Please read the EMS chapter in
                                                                      your Cruise Medicine book and have the
                                                                      patient properly prepared when the EMS
                                                                      team arrives. Don’t forget the Shoreside
                                                                      Referral Form and copies of the medical
                                                                      record.
                                                                             If the patient’s condition is not critical
                                                                      or if the patient must be evaluated shoreside
                                                                      to determine whether they need admission to
                                                                      the hospital or not, then you must arrange for
                                                                      disembarkation. For instance, patients with
open fractures that require operation, or chest pains that require MI to be ruled out, may need to be hospitalized,
but not emergently. In fact, their conditions may require only transient hospitalization and they may rejoin the
cruise later. For these patients, you must fill out a Shoreside Referral Form, notify the Staff Captain of their
disembarkation, and explain to the patient their options. Usually local hospitals (non-American/Canadian) are
adequate but not great. Frequently there are language barriers, local customs and procedures that the patient
will not understand. We have written profiles of medical facilities in different ports. These are in the Policy
and Procedure Manual in the Ports-of-Call section. The port agent or Staff Captain may be familiar with the
shoreside facilities and be able to advise as to their suitability. The port agent will be responsible for making
local arrangements for the patient and their family.
      Some patients may elect to be transferred back to the United States or Canada, if their condition allows,
rather than be hospitalized in a foreign country. It would be helpful in this case to inform the patient and family
that this is expensive (typically between US$5,000 and US$10,000) and that their insurance may not cover it.
There are a number of air ambulance companies that provide this service and Commodore’s Operations
department is familiar with them. You should put the patient or their family directly in contact with the Staff
Captain to make such arrangements and have them negotiate the details. You should be available, however,
to explain to the air ambulance company what medical facilities are needed during transport and to describe
the patient’s condition.
      In the case of crew who need to be evacuated to the U.S., you should notify the Staff Captain. He will
work with Commodore, MHS, and the air ambulance services to arrange the details.


                                                         26
Air Ambulance Resources

     If an air ambulance is required to evacuate a passenger, it is necessary to contact the Commodore Cruise
Operations office to make arrangements. You and the Staff Captain should send them a fax with the following
information: Age, sex, patient name, diagnosis, condition, any monitoring or therapy needed during transport,
insurance company name, telephone, address, policy number, patient destination.
        A couple of air ambo services are:
        National Air Ambulance          (305) 359-9900;                  Fax (305) 359-0039
        Air Evac International          (619) 278-3822 (24 hrs.)



                                                     27
                                         The Infirmary
EKG, Monitor, Defibrillator

      Your monitor/defibrillator is a standard Lifepak manufactured by Physio Control. Please note its location
in the infirmary and, when you come aboard, take a moment to familiarize yourself with it. If you’re not used
to this kind of defibrillator, please take a minute during your first day on board to get oriented to it. Particularly,
we’d like you to perform the following sequence:
                                   Turn the monitor/defibrillator on and off
                                   turn it on and attach the electrodes and leads to your arms
                                   adjust the EKG monitor to see a good sinus rhythm
                                   run a rhythm strip
                                   charge the paddles to 200 watt seconds
                                   turn the synchronize switch on and then back off
                                   discharge the paddles internally.
                                   Turn the machine off.

      Conditioning of the batteries in the Lifepak units should occur every 3 to 4 weeks. To exercise the batteries,
turn on the unit with the batteries installed in the monitor and defibrillator and turn on the monitor and operate
for about 1 1/2 hours or until the low battery indicator comes on. If the low battery indicator is coming on earlier
than 1 1/2 hours then the battery is weak or getting weak. The defibrillator should be charged and discharged
at 100 watt seconds at least 15 times in a 40 minute period again every 3 to 4 weeks. The batteries can be rotated
from charger to unit (we assume you have 2 sets of batteries with each Lifepak). NiCads lose 10% of their charge
if they sit over a 24 hour period without being on the charger and power applied. After the batteries are tested
they, of course, need to be recharged. The Lifepak units should be tested at least on a weekly basis to insure
that everything is functioning. The batteries will last the longest when they are used regularly and not charged
over long periods of time without being discharged. If there is a volt meter available, the voltage can be
measured on the battery and it should be around 13.35 to 13.6 volts. If it measures below 13.00 volts after
complete charge, the battery should probably be replaced since it has lost full capacity.

Orthopedic/EMS Equipment

       The ships have wheel chairs, traction splints, walkers, and other orthopedic aids in their equipment
closets. These are reusable items and are not to be sent off the ship. If a patient needs to use one, please be sure
it is retrieved and put back in its proper place before the patient disembarks. Each ship also has a rescue
stretcher/evacuation litter that can be used to move a patient about the ship or to disembark bedridden patients.
Please note its location.

Laboratory

      Laboratory equipment is quite limited compared to what you are used to. There is no x-ray machine, no
chemistry or hematology lab. The most elaborate equipment on board is that which is used for testing the water
of the ship for appropriate chlorine content and bacteria levels. For clinical laboratory use there is a glucometer,
hemoglobinometer, and a supply of reagent strips. There are also dry reagent strip tests for urinalysis,
pregnancy, and fecal occult blood.

                                                         28
     More sophisticated laboratory work must be done onshore, but blood tubes for drawing such things as
CBC, chemistries, serology, etc. are available in the infirmary. Blood can be drawn while the patient is in the
infirmary and sent to onshore labs via the port agent when the ship arrives in port. (Again, use the shoreside
referral form.)

Housekeeping

      The ship’s Infirmary is assigned a particular housekeeper . The housekeeper is responsible for emptying
the wastebaskets, sweeping and mopping the floors, making beds, changing towels, etc. If you need special
assistance for things such as spills, burned out light bulbs, etc. you can call the housekeeping department anytime
to have them send someone to deal with it. The housekeeper assigned to the cabin may be different from the
one assigned to the Infirmary, so ask if it’s unclear who’s responsible.

Repairs

      Maritime Health Systems is re-
sponsible for repairs and maintenance
of the medical equipment in the infir-
mary. Commodore Cruises is respon-
sible for repairs and maintenance of the
non-medical equipment, furniture, and
fixtures. Therefore, if you have a prob-
lem with the EKG machine, or the
glucometer, you should send a fax de-
tailing the problem (to speed things up
use one of the Equipment Problem Re-
port forms from the forms folder in
CliniDoc) and what, if anything, you’ve
done about it to MMS from the next port.
We’ll send you back detailed instruc-
tions as to how to proceed.
      On the other hand, if you have a
problem with the ship’s equipment
(chairs, tables, the bulkheads, the elec-
trical or plumbing system, etc.), you
should fill out an AVO form (in tripli-
cate) and take it to the Purser’s office or
contact the chief engineer or the staff
captain to have somebody come and take care of it. There are well qualified electricians, carpenters, plumbers,
etc. on board who know how to deal with these things and they can usually take care of your problem rapidly.
      The one item of medical equipment that requires constant maintenance is the defibrillator/monitor. Since
this piece of equipment is rarely used but critical when needed, it’s essential that it be kept in top operating
condition. This means that its function has to be checked weekly. On the afternoon of each embarkation day
you should do the following checks: 1) Turn it on and attach the EKG leads and make sure that the monitor
shows an EKG and, 2) Charge the defibrillator paddles up to their maximum and then discharge them internally
in the machine to see if they discharge appropriately. If you run into any problems with either of these tests,
please notify the MHS office.
      The MHS office will handle repair of medical equipment. If equipment is beyond repair, please notify
us, give all the details, and we will arrange for its replacement.
                                                       29
Pagers/Radios/Phones

     Both the nurse and doctor carry rechargeable pagers/radios and have in the Infirmary a recharger and
an extra rechargeable battery. The pagers are to be worn at all times and kept in the recharger at night so that
you may be reached immediately under any circumstances. The pagers/radios are very simple to operate and
you should have no difficulty discovering how to turn them on and off, test them, and recharge them. They
will work throughout the ship and even a short distance from the ship. Detailed instructions are in the Policy
and Procedure Manual. The Staff Captain or Bell box is able to perform minor repairs on pagers/radios and
can replace yours if it dies permanently.
     The Infirmary desk phone number is 3963 on the Enchanted Isle and 126 on the enchanted Capri.
Memorize this as you’ll probably need to know it early on. Other important phone numbers are:
     Enchanted Isle:                                   Enchanted Capri:
     Doctor’s cabin: 3863                      `       Doctor's cabin: 128
     Nurse’s cabin: 3963                               Nurses cabin:
     Purser’s office: 0                                Purser: 0
     Bridge: 3998, 3999                                Bridge: 310
     Emergency: 911 (also goes to bridge)              Emergency: 0

Emergency Protocols
     The ship has a number of protocols for different situations. Here’s what the signals mean:
     “Mr. Mob” paged over the PA system means “man overboard”. The nurse should stand by.
     “Mr. Skylight” paged over the PA system means there is a minor emergency somewhere. The medical
team reports to the Infirmary and awaits any instructions.
     General Alarm: Seven short blasts and one long blast on the ship’s alarm bells. Major emergency -
proceed to youremergency station (the Infirmary).
     Lefeboat alarm: One long blast on the alarm bells - embark the lifeboats (#1 for the doctor, #2 for the
nurse)and abandon ship.
     Code 7: paged over the PA system for the doctor.
     Code 8: paged over the PA system for the nurse.
     Code Blue: Medical emergency. Doctor and nurse respond to the scene immediately. The rest of the code
blue team assists at the scene or brings equipment from the Infirmary. See Appendix B for details.

Secondary Medical Station
     A secondary medical station has been established on the Bridge in the event that the Infirmary becomes
inaccessible during a disaster/emergency. It has a defibrillator/monitor, oxygen tanks, and supplies likely
to be needed in a disaster for triage and first aid care.




                                                    30
                               Administrative Duties

      As the administrators of the medical department, the physician and nurse’s goal in life is to keep the Staff
Captain happy. This means handling all the paperwork and procedures properly; presenting a competent,
efficient image to the public; and handling all the problems that you can directly (department to department)
or internally without bothering the Staff Captain while at the same time keeping him/her apprised of all
significant situations.

Reports and other paperwork

      Unfortunately, paperwork is a fact of life as much on ships as elsewhere in the world. There is no escape.
The one redeeming factor of paperwork on board a ship is that since the practice is small the amount of
paperwork is also relatively small. The sidebar shows a list of the required reports and their appropriate
schedule. Most of these reports are submitted at the end of each voyage to the purser’s office or MMS
headquarters. Some of them are kept in the ship’s infirmary itself and others are required for customs purposes
when the ship comes into port, especially when entering a new country. Forms for all of the reports should be
found in the forms folder of the CliniDoc
system. Extra supplies are in the bottom
drawer.                                       Voyage-end Infirmary Forms
      Besides the reports filed with the
Purser, the medical staff is responsible       MHS Voyage forms: These go by priority mail to the MHS
for sending by express mail at the end of                      office after every voyage -
each voyage the following items to                  Floppy diskette with voyage data
MMS’s Baltimore headquarters office:                Medical Staff report
the infirmary/pharmacy Log for the voy-             Summary Report of ship's Medical revenue
age, all of the passenger charts for the            Memoranda from Hotel Manager, Staff Captain, etc.
voyage, checked packing lists for any               Packing slips (if any)
supplies received, the cash envelope,               Cash envelope (if any)
and the Summary Report of Ship’s Medi-
cal Revenue. In addition, there is a Medi-      Commodore Voyage Forms: These go in the big brown
                                                       envelopes to the Purser or Staff Captain -
cal Team voyage report form that the
                                                    Shoreside referrals forms (printouts)
physician and nurse should complete
                                                    Transmittable Disease report (printout)
and send along to report any suggestions,
                                                    Voyage Log (printout)
problems, deficiencies, recommenda-
tions, etc. All reports and forms are in      Port Authority Forms: These go to the Purser's Office for
cliniDoc. A supply of pre-addressed                              the Port Authorities -
express mail envelopes will be found in             Controlled Substances Report (Customs Form 1303 or
the desk or file cabinet (usually bottom               Ship's Stores Declaration)
drawer).                                            Death reports




                                                      31
File Cabinet Organization

      In order to keep ourselves organized and maintain continuity between ships and between changes of staff,
the file cabinets are organized in a uniform way throughout all the ships. The top file cabinet drawer is for forms
- both blank forms (paper backups in case the computer system goes down) and the completed forms that need
to be kept on the ship (Water Testing Reports, Transmittable Disease Reports, Infirmary Logs). The second
drawer is used for crew medical records. The third drawer is used for overflow of crew medical records if
they don’t all fit in the second and for purged crew medical records (the originals of medical records of crew
members who have left the ship). The fourth (bottom) drawer in the file cabinet is used to store paper supplies
such as express mail envelopes, file folders, blank passenger medical records, etc.). The organization of the
drawers is as follows:

                Top Drawer
                      AMA forms
                      Cardiac arrest record forms
                      Crew Charts
                      Crew Pre-physical exam forms
                      Death Reports
                      Disembarkation forms
                      Evacuation checklist
                      Infirmary Log
                      Medical Staff Report
                      Narcotic Inventory
                      Office Inventory
                      Pax Charts
                      Permit to See Doctor
                      Pharmacy Inventory
                      Pre-Physical Exam Forms
                      Priority Mail Envelopes
                      Repair Request (A.V.O. forms)
                      Report of Personal Injury
                      Shoreside Referral Forms
                      Statement of Injured Pax/Crew
                      Summary Report of Ship’s Medical Revenues
                      Supply Inventory
                      Transmittable Disease Report (Blank)
                      Transmittable Disease Report (Completed)
                      Vital signs (ICU) flow sheet
                      Voyage End Folders (MHS)
                      Voyage End Envelopes (Commodore)

                Second File Drawer
                      Deck & Engine Crew Medical File Folders
                      Food & Bar Department Medical File Folders
                      Hotel Department Medical File Folders
                      Concessions Medical File Folders




                                                       32
                 Third File Drawer
                        Overflow Crew Medical File Folders
                        Purged Crew Medical File Folders

                 Fourth (Bottom) File Drawer
                       Priority Mail Envelopes
                       Passenger Medical Record Forms
                       Shoreside Referral Forms
                       File Folders
                       Pendaflex Folders

     Please keep the file cabinets organized in this manner so that everybody will know where to find things.

Voyage End Procedures

      At the end of each voyage, the medical team needs to complete all its reports, package everything up and
send it off to the appropriate places. This is really only a simple three-step procedure.
      First off, coming into most ports a controlled substances report or controlled substances customs form
must be completed.
      Secondly, all the reports for Commodore Cruises’ Operations office, must be completed and delivered
to the Staff Captain ‘s Office. This includes the printouts of the log, copies of all shoreside referrals , and the
transmittable disease report (copy goes in infirmary’s onboard file). MHS provides large labeled envelopes
with a checkoff list for these reports.
      Thirdly, Maritime Health Systems requires all the pax medical records from each voyage. Please pick
out a priority mail envelope. On the morning of embarkation/disembarkation day, follow the procedure for
copying all the medical records to floppy diskette and put the diskette into the express mail envelope. In addition
to the medical records, we also need the medical staff report for the voyage, and the medical revenues summary.
We would also like to have copies of any non-routine memoranda from the Staff Captain, Miami Operations,
or other departments, the cash envelope, receipts for expenses, and packing slips from items received. Finally,
in order to get paid, you need to complete the “Summary Report of Ship’s Medical Revenue”; do the
calculations, sign it, and have the Accountant sign it. The Accountant gets a copy and you send a copy to MHS
in the Voyage end folder.
      Once you’ve gotten all this stuff together, put it in the file folder with the check list sticker on it (or better
yet, collect the documents in such a folder during the week), check off all the items, and then put the folder inside
the envelope and check the address on the outside of the envelope. The envelopes are preaddressed to MMS’s
office, so all you have to do is fill in the ship that you are sending it from on the “From” side of the airbill. Once
this is all accomplished, you can take it up to the purser’s office and ask them to give it to the port agent who
will, in turn, deliver it to the Post Office.




                                                          33
Inventory and Stocking

      We need to take inventory of our pharmaceuticals and supplies periodically so that you can know how
fast they are running out and when and how much to reorder. This is a painless procedure which should take
less than an hour. It should be done by the doctor on his/her first day (that way it doubles as an orientation).
There are two forms for doing inventory: One is entitled “Medication Order/Inventory List” and the other is
called the “Supply Order/Inventory List”. They can be found both in the forms section of CliniDoc and, (a master
copy) in the “Forms” section of the Policy and Procedure Manual. Both nurse and physician are responsible
for the inventories. This will help them learn the formulary quickly. The process is simple: go down the
inventory list and write in the blank space provided the number of units of each supply or medication item that
you have on hand. This does not mean that you have to count every pill in every bottle or every single alcohol
wipe in a box. Make estimates. If you have a bottle that contained 100 pills and its about half full, write 50 in
the “# of units on hand” column. If the alcohol wipe box started out with 500 and now is about a quarter full,
write down 125 for the number on hand. All small items that come in large quantities should be estimated this
way. Fill in only the “# units on hand” and “# dosage units on hand” columns. Do not fill in the “Office Use”
column.
      This should not take long, as all the medications and supplies should be arranged in alphabetical order
according to the inventory list. Do not change this arrangement. Years of experience have shown it to be
the best for overall use. There will be some exceptions to this for medications which must be kept refrigerated
and for injectables which will be kept in the treatment room. Similarly, some supply items such as canes and
crutches may have to be stored outside the usual alphabetical order because of their size or shape. Nevertheless,
all of the storage spaces should be well labeled so that you can find things easily. If they are not, then this is
your opportunity to do so.
      When the “Medication Order/Inventory List” and the “Supply Order/Inventory List” are completed, send
them back to MMS in the next voyage-end express mail package. The MHS office will automatically track your
medication and supply usage.
      We also need you to let us know how much of which meds and supplies you receive each time a shipment
comes in so that we can be sure it’s what we ordered. This only happens about once a month, so it’s pretty easy.
Just check the amounts of the items that you received in the shipment as you put them on the shelves against the
numbers on the enclosed packing list or invoice. Circle any discrepancies and put a note explaining them. Then
send the lists back to MMS in the next voyage-end express-mail package.

Medical Waste Disposal

      Eventually your sharps boxes will be full or you will have some kind of infectious medical waste that needs
to be disposed of. This is usually done through the port agent in the home port. You will need to package the
waste securely ahead of time and notify the Staff Captain’s office that you need to dispose of it. At some ports
the authorities will require a form to be completed describing the kind of waste and what is to be done with
it. Ask the Staff Captain about this. On the appropriate day you should bring the container to the Staff Captains’s
office where they will deliver it to the port agent.




                                                       34
Transmittable Diseases

      The medical team is required to keep a log of all transmittable diseases found onboard. The close living
quarters and common facilities of shipboard life make contagious disease a high risk. Thus, any passenger or
crew member who present with the following diagnoses must be recorded in the separate transmittable diseases
log: diarrhea (any kind - defined as more than three loose stools in a day), sexually transmitted diseases,
hepatitis, etc. Outbreaks of contagious disease should be aggressively managed, and the Staff Captain notified
and involved in the strategy for containing the problem. The original of this log should be sent to Commodore
at the end of each cruise. Every week a copy should put in the designated file folder in the top drawer of the
infirmary filing cabinet and they should be kept for a year. CDC inspectors will ask to see these logs when they
come on board periodically at American ports.
      Because a high portion of the crew come from areas where tuberculosis is endemic, and because they live
in close quarters, there is a constant threat of tuberculosis. Despite the fact that all crew members are tested
for TB before they come on board, nothing is 100%. So medical staff must sustain a high level of awareness
and suspicion for possible tuberculosis signs and symptoms (please see Appendix A). If you find a patient whom
you believe to have a presumptive diagnosis of tuberculosis, you should notify the Hotel Manager immediately
and fax both Maritime Medical Systems and theCommodore Operations office about the situation from the next
port.

Captain’s Reception and Dinner

      Sometimes on the second or third day of each voyage, the captain has an evening reception at which he
introduces his staff. This occasionally includes the physician, who is the department head of the medical
department. On your first day out of port the doctor should ask the Staff Captain if this is to occur so that s/he
knows what time to be there. The passengers will be mingling and having drinks in the lounge and there will
be some form of entertainment. This is a good opportunity for the doctor to present his/her card to the captain
and introduce him/herself so that he knows your name. The cruise director will announce the captain who
will in turn give a short speech and then ask all of his department heads to come on stage and be introduced.
This usually does not include the physician since s/he is not an employee of Commodore. A white dinner jacket,
dark suit, or tuxedo for men - or a similar professional looking outfit for women - would be appropriate for
this occasion. The format may vary and it may be done in two seatings depending on the particular ship, so be
flexible.
      Sometimes during a tour of duty you may be invited to sit at the captain’s table for dinner. Usually the
invitation will be written and formal but it may be informal and conveyed by word of mouth. This is a good
opportunity to get to know the officers of the ship since you will rarely see them in your routine duties. The
captain’s table will usually include two or three officers besides yourself plus three or four invited passengers.
The physician’s duty is to make small talk, keep the conversation going, and to entertain the passengers with
tales of medical exploits without making them uncomfortable or spoiling their appetites (and please, no stories
about diarrhea or seasickness epidemics).




                                                       35
MMS, V-Ships and MHS

       MMS (Maritime Medical Systems, Ltd.) and MHS (Maritime Health Systems, Ltd.) are two separate
companies. MHS is a Bahamas corporation that contracts with Commodore Cruise Lines to provide all the
health care services on board its ships. MHS’s function is to organize these health care services. In order to
do this, MHS contracts with nurses, physicians, and vendors to provide all the services, supplies, and equipment
required to deliver health care. MMS is one of the vendors that MHS contracts with. MMS’s responsibility
is to recruit physicians and nurses and to provide administrative and medical support for them. Thus, while
physicians and nurses are recruited by MMS and supported by MMS, they are employees (independent
contractors) of MHS and are paid directly by MHS.
       V-Ships Marine is the managing agent for the Enchanted Isle. They are responsible for all shipboard
operations. Commodore manages its own operations on the Enchanted Capri.




                                                      36
                                        Life On Board
Who’s Who

      As the head of the medical department on the ship, the physician is in a privileged and responsible position.
The nurse, as the only other member of the department and as the acting department head when the physician
is ashore, also carries considerable clout. While the doctor probably does not need to worry about having to
take over for the captain if he should fall overboard, there are significant authorities vested in the position of
department head and with them come the duty to act responsibly.
      You’ll notice that there are two major divisions among the ship staff: ship employees and hotel employees.
The number of ship employees is small and consists of the officers, deck hands, and engineering staff. These
are the people who take care of the ship itself and make sure that it gets where it’s going. The other, and much
larger group of employees, is the hotel staff. The ship operations are headed by the Staff Captain, who supervises
several department heads, including the physician. As you can imagine, he is a very busy person. Please do
not bother him with questions or problems which you can resolve by direct communication with MHS, but be
sure to visit him and introduce yourself as soon as you get on the ship.

Important People to Know

      The Staff Captain (your direct superior - please keep him/her advised of any unusual happenings), the
Pursers (shipboard accountants and administrators), engineering (they fix things), the Hotel Manager, your
housekeeper (responsible for keeping the infirmary clean, picking up trash, making the bed, etc.), and the cruise
director (his/her office is responsible for booking tours, shows, etc. and planning the entertainment). It’s a good
idea to seek these people out and make their acquaintance early in your tour of duty. The Captain always likes
to get to know their Physicians, so take your earliest opportunity to go to the bridge, introduce yourself, and
have a short chat with him.

Meals

      The physician is in the position of being both a passenger and crew member at the same time. This really
gives him/her the best of both worlds and, in terms of food, and allows the widest choices of places to eat.
Here are the possibilities:
      The passengers’ dining room - usually the passengers are divided into two seatings, early and late, and
have their meals at a large dining room in the middle of the ship. The nurse and physician may join them for
these meals. If s/he has a family with him, this provides an opportunity and gathering place for conversation
and review or planning of activities. Since the meals here are on a fixed schedule, everybody can know exactly
when and where they are expected to be there. The food is, of course, excellent and very well presented in a
civilized atmosphere. If you chose this option, please notify the maitre d’ at the beginning of each voyage and
s/he will assign you to a table and seating.
      Officers’ mess/staff mess - This is a separate dining room used by the officers and/or staff which serves
the same food as is served to the passengers, and sometimes some special extra dishes. It’s located outside
of the passenger areas of the ship and is somewhat more utilitarian in decoration. On the other hand, the timing
is more flexible here. The officers/staff mess is open for a few hours for each meal and one can come anytime
during that period and be seated and order from the menu. This is a nice place to escape from the passengers.
                                                        37
      Lido buffet - This is a buffet which is usually open for breakfast and lunch and is located in the aft part
of the ship. It opens earlier for breakfast than the regular dining room seatings and stays open later for lunch.
Because of its popularity with the passengers, the staff should not use the buffet at the times when it is most
popular and should sit in the less popular sections.
      Crew mess/crew bar - These are areas in the crew section of the ship where snacks, ordinary food (pizza,
hamburgers, etc.) and discount drinks can be had at appropriate hours of the day. This is where the housekeeping
staff, deck hands, and other employees among the 300+ people who keep the ship going take their meals and
entertainment.
      Midnight buffet - At about 11:30 or so each night, the kitchen puts out a special theme buffet. This is your
last chance to gain more weight before retiring for the evening.

Dress

      While on duty in the ship’s infirmary, the nurse and physician are expected to dress and act in a professional
manner. This means nursing uniform for the nurse and shirt and tie or suitable similar dress for the doctor. You
can wear the MHS logo golf shirt instead of a shirt and tie or blouse. White shirts and white pants/skirts are
always part of a good onboard wardrobe for the doctor. The lab coat supplied by Maritime Health Systems
should be worn by the doctor and nurse while working in the infirmary. Both the nurse and the doctor will receive
name badges which should be worn on the lab coat. Dress as you would for work in a typical U.S. medical
office. The clean-cut conservative look is appreciated. Please, no designer haircuts or weird hairdos.
      Off duty the medical staff should follow the passenger dress code: shorts or bathing suits only in
appropriate areas and not after 6 p.m. anywhere; semiformal and formal wear on the appropriate evenings in
public areas. Keep in mind that you may be called to see a patient any time of the day or night and thus it may
be best to stay dressed appropriately for such encounters. Do not wear epaulets or an officer’s uniform at any
time.
      The weather in which the ship travels varies considerably, from the cool climate at the beginning and end
of the Alaska cruise season to the hot, tropical Caribbean. Be sure to investigate beforehand what weather is
to be expected on your cruises and bring appropriate clothing along.

Drinking

    The nurse and physician may not become intoxicated. Since they are professionally responsible at all times
and may have to exercise medical judgement at anytime of the day or night, they cannot allow themselves to
become impaired in any way.
    In addition, the doctor and nurse are viewed by the public as representatives of the cruise line and the
medical profession and therefore, drinking of alcoholic beverages is discouraged and should be done in
moderation if at all.
    Any intoxication is grounds for immediate dismissal.

Entertainment

     The physician and nurse, as representatives of the ship staff, may not go into the casino. They may attend
movies, shows, etc. that don’t conflict with their duties and don’t interfere with the passengers’ enjoyment of
these entertainment activities. The passengers always get the first choice of seats at shows or movies and first
choice of places on excursions. Doctors and nurses should not participate in any shipboard activities intended
exclusively for passengers, such as bingo, dance contests, and masquerades.




                                                       38
Tips


     Since you are part of the officer contingent of the ship, you are expected to leave tips for your less well-
off colleagues - particularly your housekeeper and perhaps, your waiter and busboy if you dine routinely at
the same table or in the staff mess. Unlike passengers, you are not expected to tip large amounts; however, a
reasonable and courteous tip at the end of each voyage does wonders to improve service during your tenure.
$5-$10 per week is appropriate.
     On the other hand, if you (and your companions) routinely dine in the passenger dining room then you are
expected to tip at the same rate as the passengers.

Security/Safety/Emergency Drills/Life Boat Drills

       All cruise lines keep tight security around who is getting on and off the vessel, for obvious reasons. Within
your first day or two of arrival onboard, you will be asked to have a photo I.D. made for security purposes.
You will also be issued a life jacket which you should keep in your cabin.
       Also within a few days of your boarding, you will be requested to attend a safety class conducted by the
safety officer. At this time, the safety officer will explain the emergency drill procedure and instruct you in your
responsibilities under such circumstances. Usually in an emergency drill, the physician is required to stay in
the hospital while the nurse takes oxygen and emergency medical equipment to the scene of the emergency. Your
life jacket will have come with a “boat card” attached that shows you your emergency fire station and boat station
duties.
       The ship usually conducts one emergency drill per week. Be prepared to participate in this early in the
cruise.



                                                        39
Safe Deposit Boxes

      We don’t encourage you to take anything of considerable value along with you, but should you want a place
to store valuables, safe deposit boxes are available. Ask the purser’s office about the availability of crew safe
deposit boxes. If none are available, ask if you can use a passenger safe deposit box - they are rarely all used.

Communications

      Many ports have long distance phone terminals located in or near the cruise terminal and have AT&T
calling card or USA Direct service. These are usually your best bet as they are much less expensive and the
quality of transmission is better. The “Ports of Call” section of the Policy and Procedure Manual gives details
for some ports.
      If you need non-emergent communication with MMS, we encourage you to have the port agent’s office
send us your fax or fax us from the machine in the terminal building if you're in New Orleans. Our fax has an
800 number in addition to the regular number: dial 1-800-255-0141, then dial 4980 when it asks you for your
ID number. The regular fax number at 410/987-4980 is also on twenty four hours a day. A fax to this machine
will usually get you a response within twenty four hours. If you want to talk to us, you can call our 800 number
(800-435-1960) if you’re in a port where you can direct dial the U.S. using just an area code or USADirect.
This number works from Alaska, Canada, and most places in the Caribbean where direct dial is possible.
      To reach Dr. Harrison’s office, dial 1-410-987-5616. To call the MMS office, use (410) 729-1952.
      To get hold of the on-call MMS physician, call the MMS office and someone (usually Dr. Harrison) should
respond within a reasonable period time.
      There are a couple other ways that you can maintain communications with the rest of the world while you’re
onboard the ship. Ship-to-shore telephone is convenient, but this is quite expensive - approximately $15 a
minute - so it’s not usually used except for emergencies. The ship phone numbers are (these call into the ship’s
radio room):
      Enchanted Isle 133-3171
      Enchanted Capri

        Faxes cost about the same, but are more convenient sometimes. The fax numbers onboard the ships are
as follows:
     Enchanted Isle 133-3201
     Enchanted Capri

      The area code which is used to reach the ship depends on where it is. The previous page shows a map
of the maritime area codes. These are international codes, however, and usually require an AT&T line to dial
directly. The dialing sequence, therefore, is: 011-area code (usually 874)-ship number.
      Write or send things to MMS at our office:
                        Box 463
                        Millersville, MD 21108 USA




                                                       40
                                            Life Ashore
Port Agents

      Port agents are the local representatives in each port for the cruise line. They take care of preparing all
the things that have to be done shoreside during the ship’s short time in port. They are also your connection to
the outside world. The port agent’s office has telephones, fax machines, and an in-depth knowledge of the local
community.
      When you are on ship business, the port agents should act as your taxi, ferrying you to and from the local
hospital, drug stores, or their office, depending on your needs.
      The port agent is also your local post office. If you want to send letters, you can give them to the port agent
along with appropriate postage. To receive letters, give the port agent’s address to your correspondent and
have them send the letter to you, Enchanted ____________ Infirmary, care of port agent’s name and address.
This is one way you can get your paychecks. A list of the port agents is in the Policy and Procedure Manual.
      The port agents do not have authority to purchase things, so don’t expect them to do anything for free. If
they purchase something for you, they will expect you (personally) to pay for it.
      All requests for port agent services should go through the Staff Captain/Purser’s Office so that they’re
properly authorized.

Excursions

      The medical staff, like any other staff, is allowed to go on the shore excursions providing these do not
interfere with hospital hours or other required duties. As a staff member, you would be eligible for any staff
discounts. Excursions are available on a first come, first serve basis and, of course, subject to first choice by
the passengers.
      If you’re interested in going on some excursions, you should look over all of the offerings as they are
displayed on the first or second day of the cruise. Usually the ship also has a video presentation which gives
an idea of what the different excursions are all about. After the passengers have all made their selections of
excursions, you may go to the cruise director and ask to be added to the excursions you want. If space is available,
he’ll put you on the waiting list and let you know on the day of the excursion when and where to go. Obviously,
you’ll have to coordinate your excursion going with your call schedule to avoid conflicts.

Getting on and off and to and from the ship

      We would encourage you to arrive the night before embarkation and spend the night in a local hotel. Next
morning, take a cab to the ship at the appointed time. This way, you’ll start the trip well rested, get to meet the
departing medical staff before they sign off, and have a whole day for your initial orientation.
      When you get to the ship, you should report to the crew purser’s office or go directly to the Infirmary.
Frequently on embarkation/disembarkation days they will have a table set up at the main gangway for the
purpose of processing arriving crew members. You should present your passport and letter of employment to
the Purser who will make arrangements for you to be shown to your cabin.
      When you sign onto the ship, you must declare on the “crew customs list” all dutiable items which you
are bringing onboard (e.g., cameras, binoculars, stereos, TV’s, liquor, cigarettes, etc.). This form should be
updated from time to time during your tenure as you acquire or dispose of items. When you finally disembark,
your “crew customs list” must correspond to all the items you take off the ship unless you intend to declare things
to the local customs officers.
                                                       41
      When the ship is in port, you will get on and off either by the gangplank to the dock or via a tender vessel.
In ports where the ship is docked, the crew waits for the passengers to disembark before they go to the gangplank.
Occasionally this may be a lengthy procedure, especially at the beginning and end of the voyage. For security
reasons, each crew member must get a photo ID tag. You’ll get this shortly after you start your tour-of-duty and
it will be kept in a cabinet by the security staff. This cabinet is movable so each time the ship comes into port,
the cabinet will be moved to the main gangplank. When you leave the ship, you will take your photo ID card
with you and when you return to the ship, you’ll show your photo ID at the gangplank in order to get back on
and then return it to the security officer’s cabinet.
      You follow the same procedure when you’re at a port where the ship is tendering. The only difference
is that instead of going down a gangplank to the dock, you will go down a stairway on the side of the ship and
board a small boat for the short trip to the shore.
      Because the passengers all like to come back to the ship at the last minute, the crew is encouraged (required)
to get back to the ship about an hour before embarkation time. Please plan your itinerary accordingly and,
especially when tendering, be sure you get back to the ship well before the last minute rush.
      When you finish your tour-of-duty, you’ll have to collect all of your things and make arrangements for your
departure. Usually the ship’s purser’s office has arranged for the local customs officers to come onboard and
set up a room where departing crew can clear customs and do immigration forms. There will be some final
forms to fill out, but you’ll have plenty of time as the crew will be asked to wait to disembark until all of the
passengers have gotten off the ship. Please don’t disembark until you’ve met your successor and given them
an orientation tour. They, like you, have been asked to get to the ship early for this purpose. Since you have
no clinic on the morning of embarkation day, there should not be any time problem. In certain ports, notably
San Juan, disembarkations at the completion of your tour of duty are limited to certain times of the day depending
on the availability of customs officials. You may be required to leave the ship by 8:00 am. If you are planning
to come back aboard to help orient the next doctor or nurse, be sure the Staff Captain gives you a visitor’s pass.

Port Taxes

      “Nothing is certain except death and taxes,” said Benjamin Franklin. Obviously, he’d been on a cruise!
All the cruise ports of the world look upon tourists as easy prey. They impose a head tax on all passengers who
dock at their port - even if they never get off the ship. For ordinary passengers, this tax is included in their fare,
but if you have a spouse along who’s not paying the fare, he/she will still be assessed the port taxes - usually
about $100-$150/week. We’ve tried may times to get around this but, unfortunately, there just doesn’t seem
to be any escape - so be prepared.




                                                         42
         Maritime Health Systems’ Orientation Quiz
Circle   correct answers, then make a copy and send it to MMS.


   1. What do you do if a patient wants to pay cash?
      A. Take the cash and pocket it.
      B. Tell the patient that we can’t take cash and that he’ll have to seek medical attention
       elsewhere.
      C. Accept the cash only if neither he nor his spouse has any acceptable credit cards - put it in the cash
      envelope and send it in the voyage-end express mail.
      D. Take the cash and don’t quibble.

   2. Which infirmary room is the defibrillator room kept in?
      A. The treatment room.
      B. The doctor’s office.
      C. The inpatient room.
      D. The Critical Care room.

   3. Which room is the crash kit in?
      A. The treatment room.
      B. The doctor’s office.
      C. The inpatient room.
      D. The Critical Care room.

   4. Who do you notify first if you want to evacuate a patient from the ship?
      A. The staff captain.
      B. The Hotel Manager.
      C. Commodore’s office.
      D. The purser’s office.

   5. Which deck is the purser’s office on?
      A. Upper deck.
      B. Main deck.
      C. Rendezvous deck.
      D. Atlantic deck.
      E. Bahamas deck.

   6. Which visit level do you check off for a sunburn?
      A. Level 1
      B. Level 2
      C. Level 3
      D. Level 4

   7. Where are the patient’s instructions for filing an insurance claim to be found?
      A. In the filing cabinet under “insurance”.
      B. Medical Chart.
      C. Accident report.
      D. Medical Services Bill

                                                    43
8. Who does the medical department report to in the shipboard hierarchy?
   A. The Purser.
   B. The Staff Captain.
   C. The Master.
   D. The Hotel Manager.

9. How much is the charge for a routine seasickness visit where an injection is given?
   A. $55.
   B. $77.
   C. $111.
   D. $45.

10. What is kinetosis?
  A. Bad breath.
  B. A disease of the gums.
  C. Seasickness.
  D. An orthopedic problem of the feet caused by prolonged standing.

11. Where is the doctor station for emergency drill?
  A. On the main deck.
  B. In the ship’s hospital/infirmary.
  C. On the bridge.
  D. On the Aft deck.

12. When should you come back to the ship at a port where the ship is tendering?
  A. Fifteen minutes before departure time.
  B. Thirty minutes before departure time.
  C. An hour before departure time.
  D. Two hours before departure time.

13. What do you do if a patient needs an X-ray?
  A. Call a helicopter and have them evacuated.
  B. Tell them to go ashore and find a hospital at the next port.
  C. Fill out a shoreside referral form for the patient and give it to the Purser’s office.
  D. Give temporary care and tell the patient to wait until they get home to have it X-rayed there.

14. Which of the following papers go into the priority mail package to MHS at the end of each voyage?
  A. The pharmacy/infirmary log.
  B. The database diskette
  C. Voyage Financial Summary.
  D. Water Testing Report.
  E. Transmittable Disease report.




                                               44
15. What papers go to the Purser’s office for delivery to Commodore’s office at the end of each voyage?
  A. The pharmacy/infirmary log.
  B. Copies of all Shoreside Referrals.
  C. Any cash collected.
  D. Water Testing Report.
  E. Transmittable Disease report.

16. When a patient has sustained an onboard injury, which reports/forms are required?
  A. Release of Medical Information.
  B. Medical Chart.
  C. Accident Report.
  D. Report of Transmittable Disease.
  E. Report of Personal Injury.

17. If the accident patient was a passenger, to whom should the reports/forms be given?
  A. The Purser.
  B. The Hotel Manager.
  C. The Staff Captain.
  D. Save in file cabinets.
  E. V-Ships Marine

18. If the accident patient was a passenger and was sent by the hotel staff for evaluation, who pays for
  the infirmary visit?
  A. The Hotel Department.
  B. The Patient.
  C. MMS.
  D. The Staff Captain decides whether Commodore or the patient will pay.

19. How often do you test the defibrillator?
  A. Daily.
  B. Weekly.
  C. Monthly.
  D. Annually.

20. Which reports are copied each voyage and kept in the top drawer of the infirmary file cabinet?
  A. Shoreside Referrals, Accident Reports.
  B. Medical Charts, Repair Requests.
  C. Death Reports, Narcotic Counts.
  D. Report of Transmittable Disease, Infirmary log
  E. Voyage Financial Reports, Medical Release forms.

21. What is the correct dress for clinic hours?
  A. Officer’s uniform
   B. Street clothes
  C. Scrubs
   D. Lab Coat
  E. MHS logo shirt

                                                  45
46
                                            Appendix A
     Commodore Cruises/Maritime Health Systems
         Tuberculosis Prevention Program
      Cases of active tuberculosis among crew members of cruise ships have prompted Commodore Cruises
and Maritime Health Systems to institute a tuberculosis prevention program onboard Commodore ships. This
was thought necessary because crew members on cruise ships are particularly susceptible to transmission of
tuberculosis since many of them come from Third World countries where tuberculosis is endemic and because
their living quarters provide constant close contact with each other in a setting of restricted ventilation.
      More detailed information on screening, diagnosis, and treatment of tuberculosis can be found in the
Tuberculosis Chapter of the Cruise Medicine Textbook and in the onboard copy of the Centers for Disease
Control’s monograph “Core Curriculum on Tuberculosis”.

                                           Prescreening
      In order to try to prevent anyone with tuberculosis coming onto the ship, Commodore has instituted a
prescreening program which mandates that all joining crew members must have a chest x-ray. If the chest x-
ray is negative and there are no other suspicious signs or symptoms of tuberculosis, the crew member need
not undergo a workup. However, if the chest x-ray is positive, if there are other suspicious signs and symptoms,
or if they are from Southeast Asia, the embarking crew member must also have a skin test which must be
interpreted by a qualified nurse or physician.
      Crew members with an abnormal chest x-ray should not be allowed to join the ship until they have been
medically cleared for active TB by their shoreside physician.

                                 Shipboard Prophylaxis
      If a crew member has been exposed to tuberculosis but does not have active disease (i.e. s/he has a positive
skin test but negative symptoms and x-ray) and has not previously undergone prophylaxis, s/he must be enrolled
in the TB prevention program. The flow sheet on the following page diagrams the steps involved in this
program.
         For tuberculosis prophylactic therapy, the patient must be assigned to one of three groups: high risk,
medium risk, or low risk. The “risk” in these categories refers to the risk of INH toxicity, not to the likelihood
of contracting active pulmonary tuberculosis. Some groups of patients are at more risk for toxicity from
isoniazid than others and must be separated and monitored more closely or taken off INH therapy altogether.
For details, see the Tuberculosis Chapter of the Cruise Medicine Textbook.
      The crucial distinctions are the presence or absence of liver disease and the age of the patient. If the patient
has normal liver function tests, is less than 35 years old, and has no other chronic medical problems which
may leave him/her susceptible, then they may be placed in the low risk group. Any abnormality of these tests
or age over 35 would put the patient in the medium risk group, and very elevated liver function tests would
make the patient ineligible to take isoniazid altogether and would put them in the high risk group.
          When a patient is placed in the TB prevention program, an initial workup and follow-up form must
be completed and placed in their medical record. This form is entitled “TB Prevention Program Chart” and
is reproduced here on pages 51 and 52.
         At the same time, the patient must be added to the ongoing list of crew members in the prophylactic
program so that their compliance with therapy can be monitored.
                                                        47
                          Diagnosis of Active Disease
       Because of the risk factors associated with the crew, a high index of suspicion is necessary to discover
active tuberculosis early. This means that any patient with a cough of over three weeks duration, or any of the
other typical signs or symptoms of tuberculosis such as fever, night sweats, weight loss, etc. must be skin tested
and/or have a chest x-ray performed. If the chest x-ray is abnormal, the patient must be disembarked and referred
shoreside for a complete tuberculosis workup. If the chest x-ray is negative but the symptoms are suspicious,
the patient must be closely followed and a repeat chest x-ray performed if symptoms do not resolve within a
few weeks. Sputum for acid-fast stain and culture (both shoreside) may be collected in the meantime and
appropriate caution observed.

                                             Monitoring
         Since prophylaxis of tuberculosis infection is a long term prospect (six to nine months), it’s necessary
that compliance be monitored and that the patients be checked for signs of medication toxicity. Each patient
enrolled in the program should have a “TB Prevention Program Chart” history and physical form completed
initially and placed in their medical folder. This form will be used for each reevaluation of the patient during
the term of their therapy. It has spaces for eight follow-up evaluations.
         For patients in the low risk group, it is probably adequate to do reevaluations only once every one to
three months. For patients in the medium risk and high risk groups, evaluation should be performed every two
weeks for the first six weeks and then monthly thereafter. The evaluation exam consists of a quick review of
symptoms (looking for signs or symptoms of liver toxicity) and a brief physical exam. Medium risk crew should
have LFTs (AST and ALT) checked every 3 months.
         Monitoring for compliance is a little more difficult. The patient should be instructed to return twice
a week on appointed days to the infirmary to take their medication. They should take their medication under
the direct supervision of the nurse who should then record its administration on the TB prophylaxis flow sheet
in the appropriate date column.
        When a patient first starts on the TB prophylaxis program, his name should be entered in the first column
of the current TB prophylaxis flow sheet along with his crew ID number, birth date, and the date on which his
therapy will end. The administration of his first dose should then be recorded in the appropriate date column.
TB prophylaxis should be dispensed two days a week, preferably neither of which should be an embarkation/
disembarkation day. Mondays and Thursdays are usually the best choice. This allows all the clinical and
administrative work associated with the program to be done at one time rather than sporadically throughout
the week. It is also best for this to be scheduled at sometime after the usual end of crew-clinic hours so that
no passengers or other crew are around who might misinterpret the program. Problems have arisen in the past
from patients who overheard the physician or nurse talking to TB prophylaxis patients and started rumors aboard
the ship about tuberculosis. For the same reason, the TB prophylaxis program should not be discussed with
crew members or passengers other than those directly involved. Copies of the TB prevention flow sheet should
be kept in a folder in the top drawer of the file cabinet along with the other TB prevention program forms.
       Failure of compliance with the TB prevention program should be reported immediately to either the Staff
Captain or to the crew member’s department head. Missing even a single dose of the prophylactic medication
is a serious event because resistant organisms can develop very rapidly. The department head and Staff Captain
are responsible for disciplinary action/encouragement of crew members who do not want to comply with the
program.



                                                       48
49
                                            Discharges
     When a crew member leaves the ship or declines to participate in the TB prophylaxis program, s/he should
be given instructions and informed consent as to the consequences of their action. MHS has prepared three
forms for these contingencies:

     AMA form (page 58) - If a patient refuses to participate in the TB prophylaxis program despite having
indications for doing so, s/he should be asked to sign the “Acknowledgment of Medical Advice and Release”
form. Once signed, the form should be copied, and the copy given to the patient and the original placed in his/
her medical record.

      Exposed Crew (page 59) - In the unlikely event that an active case of tuberculosis does occur on a ship,
there will be a number of crew members who will have been close contacts of the affected crew member and
therefore at risk for developing tuberculosis. If their TB skin tests are negative and they are disembarking they
must be given the “Discharge Instructions for PPD Negative Crew” form which instructs them on how to get
a follow-up PPD skin test. Again the patient should sign and date this form and then receive a copy. The original
should be placed in their medical record.

      Prophylaxis Discharge Instructions (page 60) - For crew members who disembark while they are enrolled
in the TB prevention program, the “Tuberculous Prophylaxis Discharge Instructions” form must be signed and
given. The details of their prophylactic regimen should be filled in on the form and it should be signed by the
crew member, the physician, and the department head. A copy is then given to the patient and the original goes
into the patient’s medical record.




                                                      50
                     TB Prevention Program Chart
                                                   Crew #:_____
           Name:_____________________________________                   Age:________ Sex:______
           PPD:__________ CXR:_______________________ SGOT:_______ SGPT:_______
ROS:paresthesias____ numbness____ nausea___ vomiting_____ diarrhea_____dark urine______
                                    discolored stool_____ abdominal pain ____
             PMHx: Alcohol consumption:_______________________________________________
      Liver disease (hepatitis, jaundice)_____________Diabetes________________HIV_____
                     Hypertension___________ COPD___________ ASCVD__________
           Other chronic diseases________________________Current Medications:___________________
              PE:HEENT (icterus)____________________________________________________
                 Chest:__________________________________________________________
                Abdomen (liver)____________________________________________________
                 Neuro (peripheral sensation)_________________________________________

                                           Prophylaxis regimen:
              ___INH (Isoniazid), 900mg twice a week              ___Pyridoxine, 100mg twice a week
                                       for 6 months beginning ___/___/___
                                           Monitoring Regimen:
                             __Medium risk - every two weeks for 6 weeks then monthly
                                             __Low risk - every month

                                        First Followup:   date_____/_____/______
           Review of Systems:________________________________________________________
                      paresthesias____ numbness____ nausea___ vomiting_____ diarrhea_____
                             dark urine______ discolored stool_____ abdominal pain ____
           PE: Eyes (icterus)_________________________________________________________
             Abdomen (liver)_______________________________________________________
             Extremities (neuropathy)_________________________________________________
            Conclusion:_____________________________________________________________
            Treatment recommendation:_______________________________________________

                                                Second Followup:      date_____/_____/______
           Review of Systems:________________________________________________________
                      paresthesias____ numbness____ nausea___ vomiting_____ diarrhea_____
                             dark urine______ discolored stool_____ abdominal pain ____
           PE: Eyes (icterus)_________________________________________________________
             Abdomen (liver)_______________________________________________________
             Extremities (neuropathy)_________________________________________________
            Conclusion:_____________________________________________________________
            Treatment recommendation:_______________________________________________

                                                  Third Followup:    date_____/_____/______
           Review of Systems:________________________________________________________
                      paresthesias____ numbness____ nausea___ vomiting_____ diarrhea_____
                             dark urine______ discolored stool_____ abdominal pain ____
           PE: Eyes (icterus)_________________________________________________________
             Abdomen (liver)_______________________________________________________
             Extremities (neuropathy)_________________________________________________
            Conclusion:_____________________________________________________________
            Treatment recommendation:_______________________________________________




                                                   51
                                        Fourth Followup:     date_____/_____/______
    Review of Systems:________________________________________________________
               paresthesias____ numbness____ nausea___ vomiting_____ diarrhea_____
                      dark urine______ discolored stool_____ abdominal pain ____
    PE: Eyes (icterus)_________________________________________________________
      Abdomen (liver)_______________________________________________________
      Extremities (neuropathy)_________________________________________________
     Conclusion:_____________________________________________________________
     Treatment recommendation:_______________________________________________

                                           Fifth Followup:    date_____/_____/______
    Review of Systems:________________________________________________________
               paresthesias____ numbness____ nausea___ vomiting_____ diarrhea_____
                      dark urine______ discolored stool_____ abdominal pain ____
    PE: Eyes (icterus)_________________________________________________________
      Abdomen (liver)_______________________________________________________
      Extremities (neuropathy)_________________________________________________
     Conclusion:_____________________________________________________________
     Treatment recommendation:_______________________________________________

                                          Sixth Followup:     date_____/_____/______
    Review of Systems:________________________________________________________
               paresthesias____ numbness____ nausea___ vomiting_____ diarrhea_____
                      dark urine______ discolored stool_____ abdominal pain ____
    PE: Eyes (icterus)_________________________________________________________
      Abdomen (liver)_______________________________________________________
      Extremities (neuropathy)_________________________________________________
     Conclusion:_____________________________________________________________
     Treatment recommendation:_______________________________________________

                                         Seventh Followup:     date_____/_____/______
    Review of Systems:________________________________________________________
               paresthesias____ numbness____ nausea___ vomiting_____ diarrhea_____
                      dark urine______ discolored stool_____ abdominal pain ____
    PE: Eyes (icterus)_________________________________________________________
      Abdomen (liver)_______________________________________________________
      Extremities (neuropathy)_________________________________________________
     Conclusion:_____________________________________________________________
     Treatment recommendation:_______________________________________________

                                           Eighth Followup:    date_____/_____/______
     Review of Systems:________________________________________________________
                paresthesias____ numbness____ nausea___ vomiting_____ diarrhea_____
                       dark urine______ discolored stool_____ abdominal pain ____
     PE: Eyes (icterus)_________________________________________________________
       Abdomen (liver)_______________________________________________________
       Extremities (neuropathy)_________________________________________________
      Conclusion:_____________________________________________________________
Treatment recommendation:_______________________________________________




                                           52
     Acknowledgment of Medical Advice and Release

        I am aware that it is the Center for Disease Control’s (CDC) recommendation that I take prophylactic
medication for tuberculosis. I am aware that if I do not take this medication I could lose my lung function; develop
active tuberculosis with bleeding from my lungs; become contagious to my close companions; and ultimately
die an early death. In declining this treatment I release Commodore Cruises, Inc., Commodore Maritime Corp.
and Maritime Health Systems, Ltd., their directors, officers and employees and the Commodore Ship SS
Enchanted ____, its owners, officers, and crew from all claims, including claims for negligence and
maintenance and cure, relating to my exposure to tuberculosis.
         I have received a copy of this advice and understand it.


     ________________________ ___________                    _____________________________
     Signature                Date                            Witness


     _______________________________________
     Crew Member Name


     Rechazo de Tratamiento Medicinal y Relevo de Responsibilidad

         Yo entiendo que el Centro para Control de Enfermedades de los Estados Unidos recomiende que yo
tome antibioticos profilactico contra tuberculosis. Tambien entiendo que si no me tomo medicina profilactica
yo puedo desarollar tuberculosis activa, cual enfermedad puede causar que uno sangre de los pulmones; que
los pulmones fallen; que uno sea contagioso; y que uno muera prematuramente. En rechazar este tratamiento
yo le alivio de responsibilidad a Comodore Cruises, Inc., Commodore Maritime Corporation, Maritime Health
Systems, Ltd., sus directores, oficiales, y empleados, y la SS Enchated ______, sus duenos, oficiales y
tripulacion, de cualquier demanda de negligencia, manutencion y remedio, relacionado a haber sido expuesto
a tuberculosis.
          Yo he recebido una copia de esta aviso y lo entiendo.

     ________________________            ____________         _____________________________
     Firma del Paciente                  Fecha                 Testigo


     _______________________________________
     Tripulante




                                                        53
     Discharge Instructions for PPD Negative Crew

        During your time on the SS Enchanted ______ you may have been exposed to tuberculosis. You do
not have tuberculosis at this time and do not need prophylactic medication, but you still have a small risk of
getting it in the future. For this reason, you need to have your PPD skin test (not tine test) repeated in 10-12
weeks. Please have your local physician or clinic do this test.
        If the test is positive by the CDC guidelines, you will need to take INH medication (900 mg, twice a
week) for 6 months to prevent tuberculosis. Please present this paper to your physician so he will know what
to do.
        Your employer will pay for the necessary examinations, tests and medications if you need it.
         I have received a copy of this advice and understand it.

     ________________________ ___________                   _____________________________
     Signature                Date                           Witness


     _______________________________________
     Crew Member Name


     Instrucciones al dar Alta para Tripulantes que son Negative de PPD

        Durante su tiempo en la SS Enchanted ______, podia sido expuesto a la tuberculosis. Usted no tiene
tuberculosis ahora mismo, y no necesita medicina profilactica, pero todavia hay un riesgo pequeno de
desarrollar la infeccion en el futuro. Por esa razon, usted necesita repetir su prueba de la piel PPD (no le prueba
de tine). For favor, vea su medico o clinica local para obtener esa prueba.
         Si la prueba es positiva, por las lineas directrics del Centro para Control de Enfermedades (CDC)
de los Estados Unidos, usted necesita tomarse la medecina Isoniazid (INH) 900mg. dos veces a la semana por
seis meses para evitar tuberculosis. Por favor presentele este papel a su medicopara que el sepa como ayudarle.
        Su patron pagara por los gastros de examenes, pruebas, y medecinas si usted to necesita.
         Yo he recebido una copia de esta aviso y lo entiendo.

     ______________________           ______________         ________________________
     Firma                              Fecha                 Nombre deletreado




                                                       54
     Tuberculosis Prophylaxis Discharge Instructions

         You do not have tuberculosis disease, but because you have tested positive for TB infection you are
at risk of getting active tuberculosis disease. To prevent this you should continue taking:
         ______ INH (Isoniazid), 900mg., twice a week
         ______ Pyridoxine, 100mg., twice a week
      for a total of six months. You should also have a brief examination by a physician every two weeks for
the first six weeks and then once a month until your treatment is complete because INH occasionally causes
liver problems.

       By signing below, I fully understand and will comply with the medical treatment prescribed to me by
Maritime Health Systems, Ltd. as described above. It will be my responsibility to arrange follow-up treatment
as prescribed above. The cost for such treatment will be the responsibility of my employer. I have received
a copy of these instructions and understand them.




     _______________________ __________                     _______________________
     Signature                Date                        Name (printed)




     Profilaxis para Tuberculosis Instrucciones al dar de Alta

        Usted no tiene la enfermeded tuberculosis, pero ha sido expuesto porque tiene una prueba positiva,
y existe posibilidad que desarolle esta enfermedad activa. Para evitar esto debe tomarse:
        _____ Isoniazide (INH), 900mg., dos veces a la semana
        _____ Pyridoxine, 100mg., veces a la semana
      por seis meses. Tambien debe visitar un medico cada dos semanas por tres visitas, y despues cada mes
hasta que complete su tratamiento, porque la medicina de vez en cuando causa problemas con el higado.
        En firmar abajo, yo entiendo y me someto al tratamiento prescribuido por Maritime Health Systems,
Ltd., como describido arriba. Los gastros por esta tratamiento sera la responsibilidad de mi patron. Yo he
recebido una copia de estas instrucciones y las entiendo.

     _______________________________________
     Tripulante

     ___ _____________________________________________________________
     Firma                    Fecha          Nombre deletreado




                                                    55
                                           Appendix B
                               CODE BLUE PROTOCOL
     The following outlines the protocol to be followed when the CODE BLUE TEAM is activated:

      1. The CODE BLUE TEAM will be, by definition, a group of Officers, Staff, and Crew members who
will assist the Ship’s Doctor and Nurse during the event of life threatening emergencies onboard. It consists
of the following members:

       - Ship’s Doctor(07)
       - Ship’s Nurse(08)
       - Staff Captain(02)
       - Safety Officer(03)
       - Security Officer(06)
       - Crew Purser(33)
       - Assistant Purser
       - Assistant Cruise Director(42)
       - Social Hostess(44)
       - Chief Steward(51)
       - Third Steward(54)
       - Bell Station(53)
       - Purser Desk(34)

     (A more detailed description of basic duties follows)

     The Team’s main duties include the following:

        a. Proper recognition of emergencies.

        b. To prepare an adequate scenario for proper resuscitation techniques, including clearing of the area
adjacent to the emergency and removal of unnecessary goods such as furniture, etc., which can interfere with
delivering and use of standard emergency equipment.

      c. To assist in the transportation of the above-mentioned standard emergency equipment from the
Medical Facility to the scene of the emergency.

        d. To assist the Ship’s Doctor and Nurse as necessary during the actual attendance of the emergency
with non-medical related issues like keeping the area clear from bystanders, plugging or unplugging of
electrical equipment, close-by mobilization of the victim and so on. Under no circumstances will CODE
BLUE TEAM Members have responsibility with actual treatment being delivered to the patient unless
specifically instructed by the Ship’s Medical Personnel.

         e. To assist relatives or friends of the affected person as they may also need special assistance, mainly
in the elderly.



                                                      56
       f. To keep records on the Crash Sheet (Cardiac Arrest Record) of all different therapies and procedures
performed during the mentioned treatment.

        g. Other duties as specifically instructed by the Ship’s Medical Personnel or Department Heads.

     2. A CODE BLUE situation is one in which a life-threatening emergency occurs and delay in the delivery
of emergency medical assistance may result in death or severe deterioration. These include: Cardiorespiratory
Arrest (absence of pulse or breathing), massive hemorrhage, severe choking, drowning, unresponsiveness to
external stimuli or suspiciousness of highly probable cardiorespiratory collapse, as in severe chest pain or
seizures. By definition, the CODE BLUE signal should not be called for trivial problems.

     3. In assisting the Officers on the Bridge who are to decide whether or not such a signal should be sounded,
the main parameters for proper activation would include:
        - Recognition of the patient by himself or his/her relatives or witnesses of life-threatening
        emergency.
        - Complete or partial unresponsiveness to normal stimuli (like shaking or shouting to the
        affected person).
        - As otherwise instructed by Ship’s Medical Personnel or Officers.

     4. A CODE BLUE signal is to be called ONLY from the BRIDGE after obtaining the relevant
information by different means:
       -From the Front Desk
       -Through the 911 system called upon the crew members or passenger witnessing the emergency.
       -By calling the Bridge directly on ____ or via radios on channel 07.

    Once the signal has been received by the Bridge and there is a high probability of a real emergency, the
Bridge will call the CODE BLUE signal in the following way:

        -CODE BLUE, To Cabin # ______
        -CODE BLUE, To Cabin # ______
        -CODE BLUE, To Cabin # ______ (or wherever area may be)

    The message will be delivered throughout the PA system in all areas, except passenger cabins.
Subsequently, the Front Desk will deliver the CODE BLUE signal to all CODE BLUE Team Members via
pager system already established onboard.

     As soon as the CODE BLUE signal has been delivered, automatically ALL RADIO CHANNELS must
be switched to channel 07 for direct communication with the Bridge. CODE BLUE Team Members with
radios should then report via radio to the Bridge that they are on their way. Simultaneously, the officer on duty
on the Bridge will check off the names on the chest list. Those without radios should telephone to notify the
Bridge Officer that they are on their way to the scene. Any members not reporting in immediately will be
phoned in their cabin or paged via the PA system.

     6. The CODE BLUE Team currently consists of the following members. Also listed you will find the
description of each member’s basic duties. IT SHOULD BE KEPT IN MIND, HOWEVER, THAT THESE
DUTIES ARE ONLY NOMINAL AND A GREAT DEGREE OF FLEXIBILITY IS TO BE EX-
PECTED:


                                                      57
       SHIP’s DOCTOR: In Charge of the CODE BLUE Team. Should proceed to the scene of emergency.

       SHIP’S NURSE: In charge of the CODE BLUE Team when Doctor is absent. Should proceed to the
scene of emergency.

        STAFF CAPTAIN: Should proceed to the Medical Facility to unlock doors and will assist as necessary
either with distribution or actually transporting emergency equipment.

        SAFETY OFFICER: Should proceed to the Medical Facility to assist either with distribution or
actually transporting equipment.

       SECURITY OFFICER: Should proceed immediately to the scene of the emergency and will perform
crowd control, removing bystanders from the emergency sight.

        CREW PURSER: Should proceed immediately to the scene of the emergency and will be in charge
of recording the information of all cardiac procedures on the Crash Sheet.


        ASSISTANT PURSER: Will proceed to the scene of the emergency and will assist in the process of
recording the information on the Crash Sheet. He/She will be in charge of this duty if Crew Purser is not
available.

        SOCIAL HOSTESS: Shall proceed to the Medical Facility to assist with either transportation or
delivering or emergency equipment. If all pieces of equipment have been delivered, she will then proceed to
the scene of the emergency.

        CHIEF STEWARD: Should proceed directly to the Medical Facility and will assist in the distribution
of the emergency equipment. He will remain in stand-by position in the Medical Facility and will prepare
Facility to receive the patient.

        THIRD STEWARD: Should proceed directly to the Medical Facility and assist with either distribution
or transportation of medical equipment. In the absence of the Chief Steward, the Third Steward will remain
in the Medical Facility on stand-by and prepare the Facility to receive the patient.

         BELL BOX: All on-shift members of the Bell Box would proceed directly to the Medical Facility and
assist in the transportation of medical equipment to the scene of the emergency.

        These members are to remain stable. If one of the members is leaving the ship, he will automatically
be replaced by whomever fills their position. Orientation and proper training of all existing and new CODE
BLUE TEAM Members is the responsibility of the Ship’s Doctor. The different pieces of emergency
equipment have been positioned on a portable cart that is located in the ICU room of the hospital for easy
distribution and transportation.

    7. The HOTEL MANAGER should report directly to the scene of the emergency. The CHIEF PURSER
should report immediately to the Front Desk.

      8. The CAPTAIN will be kept informed by the STAFF CAPTAIN regarding all aspects of the Team
activities.

                                                    58
     9. A specific CODE BLUE Emergency Drill will be held approximately once per month without prior
notice and at the discretion of the CAPTAIN.

    10. It must be also highlighted that a marked degree of cooperation and interest need to be shown by all
Team members, as well as motivation and willingness.




                                                    59
                                   CODE BLUE PROTOCOL - BELL BOX

         1.After receiving notification of a CODE BLUE situation, report to the Bridge that the team is on the
way. One member should report to the scene of the emergency immediately while the other two members report
to the assigned station (Medical Facility) to obtain the required emergency medical equipment.




                                                     60
                                   CODE BLUE PROTOCOL - BRIDGE

   1. After receiving notification of an emergency onboard, announce CODE BLUE as follows: CODE
BLUE, to Cabin # ______ (or wherever) three times.

    2. Be ready to receive notification from the members of the team by either radio (channel 07) or phone.

    3. Use checklist to identify reported members and contact those members who have not notified the
Bridge that they are on their way to the scene of the emergency.




                                                   61
                               CODE BLUE PROTOCOL - PURSER DECK

     1. After receiving notification of the CODE BLUE situation, page those personnel that have numbers
assigned and are members of the CODE BLUE TEAM.

     2. Assistant Purser report to the scene with clipboard and assume responsibilities of recording the
information on the Crash Sheet.




                                                  62
                  Appendix C
       PANAMANIAN RULES AND REGULATIONS
       Shortened Version

       1.To follow the ship to its various ports.

       2.Resignation before completion of your contract must be for a good reason, if so then the seaman will
be repatriated per the vessel’s regulations. A relief must be obtained before you can sign off.

      3.The contract will not be lengthened by the company because a seaman has changed portion or ship.
You may be transferred to another ship owned by Crown if needed.

     4. Allotments can be made to your family or direct to your bank account, if approved by the proper
       Panamanian authority, and will be noted in the articles.

       5.No cash advances are to be made until that money is earned.

       6.Crew members are not allowed to have any dangerous weapons.

       7.Crew is to work cargo and/or ballast if required by the Master.

       8.To keep your cabin and living area clean, subject to a fine.

       9.No shore leave without the Master’s permission.

      10. All crew must be sober for duty and may be fined or discharged if this is not the case. If the crew
member is dismissed for this reason, then there may be loss of pay to compensate for the hiring of someone in
their place.

      11.A crew member’s rights and claims for compensation for illness or damages are all governed by the
laws of the Republic of Panama.

      12.No unauthorized people or alcohol or illegal items are to be brought onboard. This can result in a
fine and the items being confiscated.

     13.The authorities of the Republic of Panama will settle any disagreements between crew members with
the Master or the company.

      14. Being absent from the ship without permission can result in loss of two days pay per day absent. If
this keeps happening, then the crew member can be discharged with loss of pay to compensate for the expense
of hiring a replacement.




                                                     63
      15. The crew member agrees to act in an orderly, faithful, honest and sober manner, to work hard and
to obeyinstructions. If this is so then the crew member will receive his wages. Any destruction of ship property
will be paid for out of a crew member’s wages. If a crew member accepts a position that he is not capable of
performing, then his wages can be reduced to fit in with his ability. A crew member who feels that he is not
being treated in accordance with his contract may make a complaint to the Master, so long as this isdone in
a respectful manner.

      16. If a crew member fails to join the vessel, the Master can have him replaced.

     17. Eight hours per day is a regular working day when in port or when regular watches are not kept.

    18. There are to be no naked flames. Smoking is permitted only in those places specified. Anyone not
complying with this can be subject to a fine or discharged.

     19. Overtime is hours worked over the usual duty period or journey time.

     20. If a contract expires while at sea, it is considered active until the next home port of call.

     21. Crew to connect and disconnect cargo and bunker fuel hose.

     22. Please pay special atention to the following extracts from the law of the Republic of Panama:

     A. From Section 1119

     i. A crew Member must be on board when his contract states and can be used to help load the vessel.

      ii. Not to leave the vessel or stay overnight off the vessel without the Master's permission. This can resulkt
in loss of one month's pay.

    iii. Not to take any items ashore without being through Customs or the Master. Subject to loss of one
month's pay.

     iv. To obey the Master and Officers, not to argue, get drunk, or act in a disorderly manner.

     v. To help the Master in case of an emergency. Failure to do so can result in a fine or loss of wages due.

     vi. A crew member agrees to work as per his contract for which he will be paid. If this is not the case then
the crew member may have his pay deducted.

     B. FromSection 120 or 133 of the Worker's Code.

     i. If a crew member signs on and then deserts the vessel, he is liable to repay any money he/she may have
been advanced and is to work a monmth without pay.

    ii. If any expenses are incurred should a crew member desert the vessel, then these expenses will be
deducted from their wages.


                                                        64

				
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