High-quality case management for ill crew: A West Nile virus case study

In the maritime industry, the health and safety of crew members are of paramount importance. When a crew member presents with a high fever after traveling to a vessel, it highlights the critical need for effective case management, stresses Arthur Diskin, Global Chief Strategy Officer, AP Companies.

This article discusses the significance of high-quality case management in such scenarios, focusing on the challenges of differential diagnosis, accessing medical care, and the specific case of a crew member ultimately diagnosed with West Nile virus.

A 45-year-old Turkish crew member arrived at the ship after a 12-hour flight. He tested negative for Covid before deployment. Within several hours after boarding, he began experiencing vomiting, a headache, and gradually deteriorating mental status. He was taken to the ship’s medical facility, where he reported having mild upper respiratory symptoms for a week, despite the negative Covid test. His initial examination showed normal vital signs, but he appeared disoriented, complained of chills, intermittent fevers, cough, congestion, and headache. His neurological exam was normal, except for the disorientation. Approximately 30 minutes later, he experienced a grand mal seizure, his heart rate increased, his blood pressure dropped, and his temperature rose significantly.

At this point, the ship contacted a local port agent to have the crew member transferred to a medical facility. The port agent arranged for an ambulance to take the patient to a small private hospital. However, the hospital had only one ICU bed, which was occupied, and significant delays occurred in transferring the patient to a larger facility. The larger facility also struggled to diagnose the patient, who eventually had to be evacuated to another country, where he was diagnosed with West Nile virus and managed in an ICU.

At the hospital, x-ray revealed bilateral pneumonia. The patient developed respiratory failure and had to be intubated and placed on a ventilator. The hospital’s only ICU bed was already occupied. Blood work was drawn but did not reveal the cause of the patient’s illness. There were significant delays in getting the patient to the larger local medical facility. They were also unable to make a diagnosis and the patient eventually had to be evacuated to a large medical center in another country where he was diagnosed with West Nile virus and managed in the ICU.

This case highlights the importance of engaging a high-quality external case management medical company, such as AP Companies, from the moment a crew member is still on the ship. Such reliable medical assistance companies could have directed the crew member to the most appropriate medical facility, engaged medical expertise via telemedicine to manage a complex clinical situation, and initiated arrangements for transfer to a tertiary facility, potentially resulting in a better outcome for the crew member.

High-quality, reliable  case management, as provided by AP Companies, is vital in ensuring that crew members receive timely and appropriate care. It involves coordinating medical assessments, diagnostics, treatment plans, logistics, transfers and evacuations, medical escorts, and continuous monitoring. Effective case management becomes even more critical when the patient is at sea or in remote locations where access to healthcare services can be limited.

Key Components of Quality Case Management

1. Assessment: A thorough assessment of the patient’s condition is the first step. This includes gathering a medical history, performing a physical examination, and understanding the travel and exposure history. For example, in a case like this, it would have been crucial for AP Companies’ medical team to consider the crew member’s recent travel to regions endemic with certain diseases.

2. Differential Diagnosis: Fever is a nonspecific symptom that can result from various infectious diseases, especially in individuals who have traveled internationally. AP Companies’ case management approach involves considering a range of potential diagnoses, from viral infections like West Nile virus and Dengue fever to bacterial and parasitic infections.

3. Accessing Medical Care: One of the significant challenges in maritime medicine is accessing quality medical care. With AP Companies’ extensive network, case managers can direct the crew member to the most appropriate medical facility for their condition and plan for evacuation if necessary. Understanding the logistics involved—such as the vessel’s position, nearest port, and available healthcare facilities—is essential for timely intervention.

4. Timely and Appropriate Medical Evacuation: AP Companies ensures that, when needed, medical evacuation is conducted swiftly and efficiently, using the most suitable mode of transport, whether by air or sea, to a facility equipped to handle the patient’s condition. This patient needed a facility with advanced diagnostic capabilities and critical care management in an intensive unit care setting. With a dedicated team of experienced flying doctors and nurses, AP Companies is uniquely positioned to offer cost-effective evacuation solutions tailored to each patient’s needs.

5. Ensuring Payment and Financial Guarantees: AP Companies also plays a crucial role in securing appropriate and timely payment for services. By negotiating competitive rates and providing financial guarantees, AP Companies ensures that there are no interruptions in the patient’s care, thus maintaining the highest standard of treatment.

Recognition and Management of West Nile Virus

In our case, the crew member was ultimately diagnosed with West Nile virus (WNV). Recognizing WNV early is crucial for effective management.

The signs and symptoms after an incubation period of 2 to 14 days following exposure can range from mild to severe and include: fever, headache, body aches, joint pains, rash, and fatigue.  In severe cases, such as our crewmember, neurological symptoms such as confusion, seizures, or paralysis may occur.  The diagnosis is made clinically and confirmed with serology (detecting antibodies) and polymerase chain reaction (PCR) testing to identify viral RNA in blood or cerebrospinal fluid at a facility capable of performing the tests. There is no specific antiviral treatment for West Nile virus. Management focuses on supportive care, including intensive care unit (ICU) management in severe cases.

I have used this case to highlight an example of the difference high quality case management can make.  This crewmember could have been assessed by a case manager while still onboard the ship, engaging a telemedicine provider familiar with the possible infectious disease risks to the crew member based on origin and travels.  The case manager could have arranged transport directly to the most appropriate local facility, already considering the need to arrange for evacuation to a tertiary medical facility by air ambulance based on the crewmember’s condition.  Simultaneously, arrangements for payment and guarantees are underway to not interfere with optimal care.

Conclusion

High-quality case management is essential in addressing the health needs of seafarers, particularly when dealing with serious conditions such as high fever and potential infectious diseases like West Nile virus.

Ensuring a systematic approach to assessment, differential diagnosis, and treatment is vital for optimizing outcomes. The challenges associated with accessing medical care must be addressed proactively, as timely intervention can significantly impact recovery. 

Through effective case management and awareness of conditions like West Nile virus, crew members can receive the care they need, ultimately ensuring their safety and health while at sea.

AP Companies remains committed to providing comprehensive and efficient case management services, ensuring that seafarers receive the highest quality of care, no matter where they are in the world.

source : safety4sea