eMJA: Lamberth, Death in Antarctica

Crisis

Death in Antarctica

Antarctic tourism is flourishing, but Antarctic cruises are often more physically demanding than typical "tropical" cruises. An 82-year-old Antarctic tourist died of probable septic shock secondary to lower respiratory tract infection six days after sustaining a suspected vertebral fracture in a minor fall from an inflatable boat. This case highlights the need for Antarctic cruise ships to be equipped to provide life support and for better screening and education of prospective Antarctic tourists.

Paul G Lamberth

MJA 2001; 175: 583-584

Clinical record - Discussion - References - Authors' details

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Antarctic tourism has increased rapidly in recent years, possibly because the collapse of the Soviet Union has made available a fleet of icebreakers.¹ The combination of cruise ship conditions and the hostile, remote environment portends health risks for travellers.

Doctors on scientific expeditions to the Antarctic report dealing with a range of major medical problems, including acute abdomen requiring laparotomy,² ruptured intracranial aneurysm,³ 70% thermal burns,⁴ and intestinal haemorrhage requiring a multinational rescue operation.⁵ Although the health needs of workers in Antarctica have been documented, little is known of the requirements of unscreened tourists. I report the death of an Australian tourist on an Antarctic cruise.

Clinical record

An 82-year-old Australian man boarded a Russian ice-strengthened vessel in Ushuaia, at the southern tip of Argentina, for a two-week cruise to the Antarctic Peninsula. During traverse of the notoriously rough Drake Passage on Day 2, he took dimenhydrinate and hyoscine for motion sickness. On Day 3, he had a minor fall while disembarking from an inflatable boat, leaving him with back pain which he treated with paracetamol and dextropropoxyphene. His only complaint to the ship's doctor (myself) at the time was wheezing induced by the cold air.

On Day 5, he missed breakfast and was found lying on the floor of his single cabin. He explained that he had been unable to get up after a fall 12 hours before. I examined him carefully, with the only positive findings being dry mucosae and exquisite localised midline vertebral tenderness elicited at T9. He had a past history of smoking-related chronic airflow limitation, treated with bronchodilators and corticosteroids, and osteoporosis. The working diagnosis was a crush fracture of a lower thoracic vertebra, for which I gave him further analgesia.

The following afternoon, subtle disorientation was noted, progressing over four hours to stupor with hypotension, poor peripheral perfusion and tachypnoea. Examination revealed left basal crackles and right-sided wheeze. The right calf had become tender. Intravenous resuscitation with 10% hydroxy-ethyl starch increased his blood pressure to 125/65 mm Hg, and urine output to 40-50 mL/h. Ceftriaxone (1 g) and gentamicin (320 mg) were administered with dexamethasone (4 mg intravenously) in lieu of regular bronchodilator therapy.

On Day 8, the stupor persisted. Lung auscultation revealed left basal crackles correlating with a region of dullness to percussion. There was profuse purulent sputum. The patient's insurer agreed to meet the expense of evacuation, but a plan to fly him from the nearby Russian base on King George Island to Punta Arenas in Chile was abandoned when the weather deteriorated. After discussion, the Russian captain's initial plan to leave the patient at the Russian base, which was apparently less well equipped than the ship's hospital, was dropped in favour of returning to Ushuaia at full speed.

That evening, the patient developed bilateral ocular deviation to the right, poor peripheral perfusion and periodic respirations. Crystalloid was administered to treat poor perfusion and falling urine output. Lansoprazole, for stress-ulcer prophylaxis, and aspirin, for a probable left leg venous thrombosis, were also given.

On Day 9, the patient remained febrile, with normal heart rate and blood pressure. Enteral fluids (2000 mL per day) with sucrose (80 g) and sodium chloride (4 g) were tolerated, with gastric aspirates under 20 mL and normal bowel sounds. That afternoon, his breathing became intermittent, he developed oliguria and bradycardia, and died at 1730 hours. The ship reached Ushuaia 16 hours later. No autopsy was performed, and the body was cremated in Argentina.

Discussion

The final diagnosis was septic shock secondary to lower respiratory tract infection. The patient may also have had a deep venous thrombosis with possible pulmonary embolism. Contributing factors were chronic airflow limitation, back pain due to a thoracic crush fracture complicating osteoporosis secondary to frequent corticosteroid use, immobilisation and dehydration. Cold air exacerbating bronchospasm probably also contributed, while impairment of balance and cognitive function by anticholinergic medications may have been a factor in the patient's falls.

This case illustrates the fundamental principle of incident analysis — a number of seemingly minor factors can combine to produce a disaster that was not predicted from any one precipitant alone.⁶ The case also raises issues for Antarctic tourism:
Medical stocking of ships: As the areas explored can be several days' journey from modern healthcare facilities, there is an argument that ships' hospitals should be able to provide life support for 72 hours. This is not the case on most Antarctic cruise ships, despite travel companies advertising medical supervision as a feature. In contrast, the major "tropical" cruise lines provide advanced medical facilities appropriate to the elderly and infirm nature of many of their clientele.

Medical equipment on Antarctic cruises should include intravenous fluids for resuscitation and maintenance and, ideally, a portable ventilator and monitoring device, such as a pulse oximeter. Ships' doctors require a high level of critical care skills to undertake advanced life support at sea. Many ship's doctors now working in Antarctica are Australian emergency physicians.

Furthermore, the risks of anticholinergic medications for motion sickness, especially in the elderly, need to be better appreciated. Disturbed balance, sedation and cognitive impairment are a deadly combination in an unfamiliar environment. NASA (the National Aeronautics and Space Administration) advises promethazine for microgravity motion sickness.⁷ It is believed that promethazine, unlike hyoscine, dimenhydrinate and other common anti-motion-sickness agents, relieves symptoms without impairing adaptation. Therefore, during prolonged exposure, promethazine can be ceased as travellers get their "sea legs".

Screening and education of prospective passengers: Factors that increase risk during Antarctic travel include:

Moderate to severe reactive airway disease, especially if precipitated by cold air. Caution should be advised for those with chronic airway disease with severe fixed obstruction (FEV₁ < 1.0 L/s) or requiring frequent courses of corticosteroids.
Decreased mobility or balance problems, because of the need to negotiate steep companionways in heavy seas.⁸
Conditions with potential complications that would be difficult to treat in a remote environment, such as coronary artery disease, pregnancy and insulin-dependent diabetes.
Poorly controlled mental illness.

Provision of information on motion sickness, cold environment risks, and hazards such as falls may help passengers look after their own health. Appropriate health and accident insurance should be mandatory.

A nihilistic philosophy that requires tourists to accept their own risks does not take into account the impact of illness or injury on other passengers, who may seek legal remedy from the tour operator.

Improved surveillance of passengers travelling alone: Passengers in single cabins appear to be at increased risk of adverse events. The failure to detect my patient's predicament until 12 hours had elapsed may have been a crucial factor in his death. A simple system of surveillance would be possible, with passengers on their own reporting to a nominated crew member twice daily.

The increase in adventure tourism by the elderly is a significant health challenge. Tour companies should consider developing a standard to equip ships for life support. A well-prepared aeromedical evacuation plan would mitigate this responsibility. Physicians advising prospective passengers should consider the rigorous screening that scientific expeditions apply to participants, and the equipment and training they provide in preparation for medical emergencies.⁹

Tourists swimming in an active volcano, Deception Island, Antarctic Peninsula.

References

Prociv P. Health aspects of Antarctic tourism. J Travel Med 1998; 4: 210-212.
Priddy RE. An "acute abdomen" in Antarctica. The problems of diagnosis and management. Med J Aust 1985; 143: 108-111.
Pardoe RA. A ruptured intracranial aneurysm in Antarctica. Med J Aust 1965; 1: 344-350.
Alcorn GB. My Antarctic practice. Med J Aust 1992; 157: 253-258.
Poki MT, Semmens K. Intestinal haemorrhage in Antarctica: a multinational rescue operation. Med J Aust 1979; 2: 275-277.
Mendick M. What went wrong? Analysis. the little things add up. Flight Safety Aust 2001; 5(4): 14.
Cowings PS, Toscano WB, DeRoshia C, et al. Promethazine as a motion sickness treatment: impact on human performance and mood states. Aviat Space Environ Med 2000; 71: 1013-1022.
Carter JW. Shipboard medicine on package cruises. BMJ 1972; 1: 553-556.
Lugg DJ. Antarctic medicine. JAMA 2000; 283: 2082-2084.

Authors' details

Department of Emergency Medicine, Canberra Hospital, Canberra, ACT.
Paul G Lamberth, FACEM, Emergency Physician, and Consultant, Shock Trauma Service.

Reprints will not be available from the author.
Correspondence: Dr P G Lamberth, Canberra Hospital, Yamba Drive, Garran, ACT 2606.
palamATozemail.com.au

Clinical record

Discussion

References

Authors' details

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