The ORIGINAL ARTICLE Heart the MVand Short StaturePolicy implications CASE REPORT Sinking of Failure Doña Paz – II. in a 43 year-old male

Table 1. Initial Laboratory Results Heart Failure

recommendations to address these to hypothyroidism. with cardiomyopathy secondary factors. The patient had been born full term to a then 31-yearMethod. ReviewPara 3 (G4P3), the 4th of preparedness in the old Gravida 4 of the state of maritime 9 siblings, with an pre-disaster setting and the post-disaster responsefacilitated the apparently unremarkable delivery at home following by Table 2. Thyroid Doña Paz by the sinking of the MV Function Tests government and responsible a traditional birth attendant. He was noted to be normal agencies. A scrutiny Reference Value preparedness of concerned of the state of Result at birth. and subsequent response to thewith age was agencies The patient was allegedly at par0.02 disaster both Free T4 (0.8-2.0) ng/dL physically and mentally until formulating 24.75 Uiu/ml conducted with the objective of eight years old when he was recommendations TSH (0.4-6.0) said to have stopped growing in height. He was brought to which may lead to prevention and mitigate loss of lives. a private doctor, whose diagnosis was undisclosed, and he Results. Multiple factors to increase for the occurrence patient was given medications accounted height, which the of this tragedy. only one month with no improvement. Through the took for These factors include an inherent risk due to the geography patient was apparently well, although still of short years, the of shipping lanes in the Philippines, the economic problemswith thick lips,shippingfacial features its labor force. stature, besetting the coarse industry and and dry skin. Economic conditions prevent both the industry and government He was notably slow in ambulation. He was said to have agencies from upgrading vessels and communications bronchial asthma at age 15 years, and since then he had been equipment. Lack of enforcement of existing regulations allows taking to sail overloaded occasionally for bouts of dyspnea vessels salbutamol tablets and at times manned by less-thanoccurring one Delayed response and qualified crew. to two times annually. deficient post-disaster The response symptoms started disproportionately was medical patient’s may have led to a in 2001 when he high mortality. to have sudden loss of consciousness. During this reported time, the patient did not have any symptoms of heart failure; no prior seizures, cyanotic episodes, chest pain, headache, or blurring of vision. He regained consciousness shortly after and was brought to a private physician, whose assessment was a “heart problem”. He was prescribed unrecalled medications Figure 1. Electrocardiogram upon admission taken for a few months and eventually discontinued when the syncopal episode did not recur. transferred next four years, theunit (ICU)would develop In the to _______________the intensive care patient for ventilatory support and closer monitoring. On bedside cardiac ultrasound, intermittent, progressive exertional dyspnea and bipedal there was a finding ofwould be accompanied by generalized edema. Later on this eccentric left ventricular hypertrophy, globalweakness, anorexia,depressed overall severe enough to body hypokinesia with and constipation, systolic function with concomitant spontaneous echo contrast on left ventricular Corresponding author: Anthony R. Perez, MD Department of Surgery (LV) cavity suggestive of rheologic stasis, the ejection fraction Philippine General Hospital Corresponding author: Ma. Czarlota Acelajado-Valdenor, M.D. was 25%, with moderate mitral regurgitation, moderate University of the Philippines Manila Department of Medicine aortic regurgitation with Philippines Taft Avenue,GeneralManila 1000 aortic sclerosis, severe tricuspid Philippine Ermita, Hospital Telephone: +639209703622 regurgitation with mild Philippines hypertension, pulmonary Taft Avenue, Manila, 1000 pulmonary Email: tonyperez92@yahoo.com Telephone: +632 554-8488 regurgitation, and minimal pericardial effusion or pericardial
Email: czarlota@yahoo.com

Reference Result Color straw pH 7.408 Reference Result Value Value 1 Department of Medicine, College of Medicine and Philippine General Hospital, University of the Philippines Manila WBC RBS 3.9-6.1 6.3 Clear pCO2 49.1 2 5-10 24.5 Anthony R. Perez,1 Carl College of Medicine, University of theTransp J. Consunji3,4 Department of Pathology, Abelardo T. Antonio and Rafael Philippines Manila RBC HGBA1C 4.27-6.07 6.4 Sp Gravity 1.010 pO2 70 4-6 HGB BUN 2.6-6.4 5.0 pH 8.0 HCO3 31.3 120-150 90 HCT 53-115 123 Sugar O2 sat 93.6 of Hepatobiliary and Pancreatic Surgery, Department of Surgery, NEG 0.38-0.48 0.271Division CREA MCV ALB 34-50 32 Protein NEG FiO2 21% 80-100 FL College of Medicine and Philippine General Hospital, University of the Philippines Manila 2Pasay City Health 0.82 MCH TAG 0.34-1.7 RBC 0-1 Temp 36.9 27-31 PG Office MCHC HDL 0.91-1.56 0.67 WBC 0-2 3Division of Surgical Critical Care and Trauma, Department of Surgery, 320-360 G/L RDW LDL 1.1-3.8 4.21 Cast PBS 11.5-15.5% College of Medicine and Philippine General Hospital, University of the Philippines Manila PLT TOTAL CHOL 4.2-5.2 5.25 200-400 Incof the case require regularEpith cell use. Rare laxative also a report of Presentation4Study Group on Injury Prevention and Control, National Institutes of Health,There wasSlight poikilocytosis, two RETIC is a case of a 43-year-old male presenting with 15-37 AST 95 Occ’l 0.005-0.015 more Manila Bacteria This short acanthocytes, ovalocytes, University of the Philippinessyncopal episodes. He was brought to another doctor SEG ALT 30-65 91 Mucus th Rare 50-70% 48 slight toxic granulation, in a private hospital where the assessment was still a “heart stature and heart failure. The patient was admitted at the LYMPH Alk po4 184 Crystals Rare 20-44% 50 slight anisocytosis problem”. The patient was again prescribed unrecalled medicine ward of the Philippine General Hospital (PGH) MONO NA 140-148 136.9 Am urates 2-9% 2 medications The systems inadequacies of the Philippine for dyspnea.0-4% This paper will investigate several issues: EO K 3.6-5.2 3.35 0 Conclusions. and again was lost to follow-up. This time, ABSTRACT BASO CL 100-108 86 0-2% 0 however,disaster response mechanism are highlighted by the differentiating discuss the from acquired hypothyroidism, congenital various factors contributory to maritime symptoms were persistent. He later consulted at Objective. To BLAST CA++ 2.37 0% another local hospital, where he factors contributing to the the relationship between 0in hypothyroidism the context and 2.12-2.52 Doña Paz tragedy. Many of thewas admitted and managed the maritime disaster preparedness the Philippines, in P 2.27 as a case of anemia and bronchial asthma. He disasters in the disproportionately high incidence of maritime was discharged cardiomyopathies, and the therapeutic options patients of the sinking of the MV Doña Paz and informulate MG++ 0.74-1 0.83

and Short Stature in a 43 on Maritime The Sinking of the MV Doña Paz – A Critique year-old maleDisaster CBC Blood chem. Preparedness in the Philippines: Policy Urinalysis III2 and Agnes D.ABG 1 Katerina T. Leyritana1, Ma. Czarlota M. Acelajado-Valdenor1, Amado O.Implications Tandoc Mejia

Philippines and theafter four days,of limb may be preventable. slightly improved resulting loss only to have recurrent heart Recommendations prompting admission at PGH. failure symptoms, on regulation and enforcement, disaster preparedness, search and rescue, and medical response are Upon admission the patient was in mild respiratory discussed. fat pad. Cardiac enzymes wereand no note of fever. Pertinent distress, with stable vital signs not consistent with an acute coronary exam findings3), however, intravenous (IV) heparin physical event (Table included short stature, thick lips, nonKey Words: drowning, Philippines, maritime industry, disaster (overlapping withedema, dry skin, a displaced apicalcover for pitting periorbital oral warfarin) was still given to impulse, response, disaster preparedness the presence of lung fields, and thrombus as demonstrated crackles on both a possible LV bilateral non-pitting bipedal by rheologic was also a cardiacx ultrasound. Medications edema. There stasis on 3 cm 3 cm reducible umbilical Introduction were shifted to IV diureticsno pallor, no neck vein distention, inotropes; oral digoxin was hernia. However, there was and mode of transport between Maritime travel is a major started. IV antibiotics were given for possible pulmonary no apparent congenital malformations, no cardiac murmurs the Philippines’ more than 7,000 islands, owing primarily to infection. The patient later onalso no note of an anterior neck and no clubbing. There was showed improvement, and was its low cost. Regulation of this industry, however, appears to eventually weaned off from ventilatory support, extubated, mass. be inconsistent at best, as can be gleaned from the numerous Laboratory workup showed cardiomegaly history of the maritime disasters and sinkings in the with pulmonary congestion, thoracic dextroscoliosis, and atheromatous aorta by Table 3. Cardiac Enzymes Philippine domestic shipping industry, the worst of which chest radiograph, and left ventricular hypertrophy by 12-lead was the sinking of the MV Doña Paz in 1987, claiming the Reference Range (mmoL) Result electrocardiogram (12-L ECG) (Figures 1 and 2), normocytic lives of more than 4,000 people. Qualitative POSITIVE normochromic anemia (Hgb 90 mg/dL), dyslipidemia, and Troponinfirst paper in this series dissected the events before, The I pre-renal azotemia (serum creatinine 123 mmoL). Electrolytes CK-MBand after the sinking of the Doña Paz, discussing 0-6.0 1.14 during CK-TOTAL 543 on admission showed 21-232 hyponatremia, hypokalemia, slight existing maritime industry regulations and the response and hypochloremia (serum Na 136, K 3.35, Cl 86). Blood gases evoked by the disaster, both in the immediate and long-term revealed partially compensated metabolic alkalosis with mild periods (Table 1). The policy implications of these with hypoxemia. The patient was noted to be hypothyroid based respect to prevention, rescue, and emergency medical on elevated serum thyroid-stimulating hormone (TSH) and response are the focus of the second paper in this series. markedly decreased serum free thyroxine (FT4). The exact values are shown in Tables 1 and 2. Methods Upon admission to the wards, the patient was managed References1,2,3 dealing with disaster management and as having congestive heart failure from cardiomyopathy disaster preparedness were used as bases for the analysis of secondary to acquired hypothyroidism. Oral loop diuretics, the pre-disaster, disaster and post disaster events. The 1st angiotensin-converting enzyme (ACE) inhibitors, betacited reference recommends an analysis of physical factors blockers, statins, and levothyroxine were started. Electrolyte (vessel, equipment and crew) which may have been relevant correction was instituted. The sections of Endocrinology to the occurrence of the event. Emphasis will be placed on and Cardiovascular Diseases were co-managing the patient factors contributing to the occurrence of the event in the together with the General Medicine service. hope of primary prevention. The 2nd cited reference was He soon developed respiratory failure, upon which the used to identify existing systems in the local setting considerations were acute pulmonary congestion, nosocomial Figure 2. Chest radiograph on admission response. Factors established for rule out an acute coronary event. He was later pneumonia, to disaster preparedness and VOL. 43 N0. 4 ACTA MEDICA PHILIPPINA2009 ACTA MEDICA PHILIPPINA 13 1

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The Sinking of the MV Doña Paz – II. Policy implications CASE REPORT

Table 1. The Haddon Heart Failure Phase-Factor Matrix

and Short Stature in a 43 year-old male

slightly improved after four days, only to have recurrent heart with cardiomyopathy secondary to hypothyroidism. Event (Collision) Number and location of Flammability of vessel Life preservers in locked failure symptoms, prompting admission at PGH. The patient had been born full term to a then 31-year(Will an injury occur?) passengers cargo in cabinets Upon admission systempatient was in mild respiratory old Gravida 4 Para 3 (G4P3), the 4thofof 9 siblings, with an Crew – state inebriation Sprinkler the in ships distress, with present and working and no note of fever. Pertinent stable vital signs apparently unremarkable during the event,home facilitated by delivery at training physical exam findings included short stature, thickpenalties lips, nona Post-Event traditional birth attendant. He swim noted to be normal was Ability to Burning seas Minimal or no pitting periorbital edema, dry skin, a displaced owners for apical impulse, at(Post-event, what will birth. The patient was Crew’s ability at provide allegedly of par with age both Inadequate, and late, for ship the outcome be?) at least basic life support disaster response (i.e. violation of maritime crackles on both lung fields, and bilateral non-pitting bipedal physically and mentally until eight years old when he was regulations edema. Thereorganized search 3 cm x 3 cm reducible umbilical was also a and said to have stopped growing in height. He was brought to rescue team, on-site hernia. However, therecare, no pallor, no neck vein distention, a private doctor, whose diagnosis was undisclosed, and he emergency was no apparent congenital malformations, no cardiac murmurs was given medications to increase height, which the patient on0shore triage, transport from shore to and no clubbing. There was also no note of an anterior neck took for only one month with no improvement. Through the proper hospital) mass. years, the patient was apparently well, although still of short stature, with thick lips, coarse facial features prevention and amelioration of Laboratory workup showed cardiomegaly with pulmonary Source: Haddon W. Jr. The changing approach to epidemiology, and dry skin. trauma: the transition to approaches etiologically rather than descriptively based. congestion, thoracic dextroscoliosis, and atheromatous aorta by He J was notably slow in ambulation. He was said to have Am Public Health Nations Health. 1968 Aug;58(8):1431-8. chest radiograph, and left ventricular hypertrophy by 12-lead bronchial asthma at age 15 years, and since then he had been electrocardiogram (12-L increased risk and 2), normocytic taking salbutamol tablets occasionallylivesbouts likewise be for will of dyspnea contributing to the immense loss of vessels at significantly ECG) (Figures 1 of storm damage, normochromic anemia (Hgb 90 outright dyslipidemia, and occurring to minimize loss annually. in similar events in the one to two times of lives analyzed vessel grounding, overturning ormg/dL), sinking. pre-renalmajority of navigational aids, includingElectrolytes The (secondary prevention). Equal 2001 when willwas patient’s symptoms started in emphasis he be future The azotemia (serum creatinine 123 mmoL). buoys and on admission the Philippines are obsolete, non-functioning reported to have sudden loss casualties, both in During this of consciousness. addressing placed in the medical care of lighthouses in showed slight hyponatremia, hypokalemia, and hypochloremia (serum Na will require an increase in time, the patient did not have in prevention of furtherfailure; any symptoms of heart injury actual medical problems and or defective. Correcting these136, K 3.35, Cl 86). Blood gases revealed partially compensated metabolic which sorely mild no prior seizures, cyanotic episodes, chest pain, headache, or and possible sequelae (tertiary prevention).3 budgetary allocation of the Coast Guard, alkalosis with lacks hypoxemia. The patient was noted to be hypothyroid based blurring of vision. He regained consciousness shortly after and ships and equipment not only for patrolling the seas but for on elevated serum thyroid-stimulating hormone was brought to a private physician, whose assessment was a Results and Discussion mounting search and rescue operations as well.1 (TSH) and markedly vessels, the Doña free thyroxine MT Vector, exact “heart problem”. of the Titanic palesunrecalled medications He was prescribed in comparison to the Both decreased serum Paz and the (FT4). The were The sinking values are shown in Tables 1 and 2. taken for a fewthe MV Doña eventually discontinued of the months and Paz, and yet the history when definitely not state of the art ships. Steel-hulled ships in the tragedy that is Upon admission to the wards, the patient was managed the syncopal episode did not recur. Philippines average 22 years of age. The Doña Paz was 24 maritime industry in the Philippines is notable for numerous as having congestive heart failure from cardiomyopathy In the next four years, the patient would develop years old at the time of the accident.4 Though it is easy to mishaps, and this tragedy is but a footnote in a long litany of secondary to acquired hypothyroidism. Oral loop diuretics, intermittent, progressive exertional dyspnea and bipedal recommend that only new, seaworthy ships should be misfortunes. In fact, from 1972 to the time of the Doña Paz, angiotensin-converting enzyme (ACE) inhibitors, betaedema. Later on this would be accompanied by generalized allowed to carry cargo and passengers, the Conference of there were 80 collisions, 177 sinkings and 53 shipboard fires blockers, statins, and levothyroxine were started. Electrolyte body weakness, anorexia, and constipation, severe enough to Interisland Shipowners and Operators (CISO) will resulting in the deaths of more than 4,000 people. correction was instituted. The sections of Endocrinology immediately contend that the poor economic conditions in A lot of factors will account for this dismal record, and and Cardiovascular Diseases were co-managing the patient the country, in addition to the high tariffs imposed on them, many of these can be corrected. Acelajado-Valdenor, M.D. Corresponding author: Ma. Czarlota The geography and location together with the General Medicine service. Department of Medicine will render refleeting with new ships impractical from an of the Philippines within the typhoon belt and frequent but He soon developed respiratory failure, upon which the Philippine General Hospital economic and return-on-investment (ROI) standpoint. difficult to predict tropical storms puts its domestic maritime Taft Avenue, Manila, 1000 Philippines considerations were acute pulmonary congestion, nosocomial Telephone: +632 554-8488 pneumonia, to rule out an acute coronary event. He was later
Email: czarlota@yahoo.com

Physical Social Pre-Event Qualification of vessel Seaworthiness of Gangway obstruction Lax enforcement of 1 Department of Medicine, College of Medicine and Philippine General Hospital, University of the Philippines Manila (Will an injurious event crew (i.e. license, training) maritime vessels: Passenger density maritime regulations (i.e. 2 Department of Pathology, College of Medicine, University of the Philippines Manila occur?) Passenger density Navigational (radar, Frequent typhoons along passenger load, non(overloading and rudder) and shipping lanes sailing of vessels found overcrowding) Inconsistent weather communications (radio) unseawoarthy) Capability of passengers equipment. reports Lack of government to swim Inadequate or nonsupport to the shipping functional navigational industry (i.e. low budget aides (i.e. buoys, allocation for Coast lighthouses) Guard rescue require regular laxative use. There was also a report of two Presentation of the case equipment). more syncopal episodes. He was brought to another doctor This is a case of a 43-year-old male presenting with short High coast of refleeting/purchase of in a private hospital where the assessment was still a “heart stature and heart failure. The patient was admitted at the new vessels problem”. The patient was again prescribed unrecalled medicine ward of the Philippine General Hospital (PGH) No safety culture (premedications and again was lost to follow-up. This time, for dyspnea. This paper will investigate several issues: boarding safety and however, symptoms were persistent. He later consulted at differentiating congenital from acquired hypothyroidism, security instructions ignored, and managed another local hospital, where he was admittedpassengers the relationship between hypothyroidism and the purchasing tickets from as a case of anemia and bronchial asthma. He was discharged cardiomyopathies, and the therapeutic options in patients scalpers)

Environment Katerina T. Leyritana1, Ma.Individual M. Acelajado-Valdenor1, Amado O. Tandoc III2 and Agnes D. Mejia1 Human Czarlota Agent and Carrier

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Heart Failure Doña Paz – II. in a 43 year-old male The Sinking of the MVand Short StaturePolicy implications

Table 1. Initial Laboratory Results have often figured in Poor communication systems previous sea disasters. Not only does this hamper CBC Blood chem. communications between ships, this also delays the Reference Reference Result emergency response to disasters when they occur.1 Value Value The National Telecommunications RBS Commission (NTC) WBC 3.9-6.1 5-10 4.5 has difficulty going after ships without functional radio RBC HGBA1C 4.27-6.07 4-6 HGB BUN 2.6-6.4 equipments. A 1988 NTC report cited inadequately trained 120-150 90 HCT CREA 0.38-0.48 0.27 personnel, underequipped radio monitoring stations53-115 and MCV ALB 34-50 80-100 FL lack of police power to implement radio laws. The lack of MCH TAG 0.34-1.7 27-31 PG communication compounded the problems from the 0.91-1.56 time MCHC HDL 320-360 G/L the two ships sailed to the time theLDL survivor 1.1-3.8 last was RDW 11.5-15.5% PLT TOTAL CHOL 4.2-5.2 200-400 Inc rescued.5 RETIC AST 15-37 Another 0.005-0.015 that frequently compounds loss of practice SEG ALT 30-65 50-70% 48 lives during sea mishaps is overloading. Overloading occurs LYMPH Alk po4 20-44% 50 due to laxity on the part 2 of those NA tasked to enforce MONO 140-148 2-9% regulations and the ship-owners’ desire for profit. Coast EO K 3.6-5.2 0-4% 0 BASO CL 100-108 0-2% 0 Guard officials are required by law to inspect all ships before BLAST CA++ 2.12-2.52 0% 0 they sail. Unfortunately, even some Coast Guard personnel P acknowledge that corruption at times causes officials to0.74-1 turn MG++ a blind eye to overloading. Some bend rules to allow as many passengers as possible. Ship personnel allow children to board without listing them in the manifest. Passengers boarding without tickets are Table 2. Thyroid Function Tests allowed to pay personnel selling unregistered tickets on the ship. It is no surprise that Reference Value Result the Doña Paz may have(0.8-2.0) carrying 4,0000.02 ng/dLwhen it been people Free T4 sank that fateful night.1 (0.4-6.0) TSH 24.75 Uiu/ml The Coast Guard is tasked to inspect the ships and attest to their seaworthiness and to make sure they are not overloaded. It was remiss in all its duties in the case of the Doña Paz. It was allowed to sail grossly overloaded, with an expired certificate of inspection and with defective communications equipment. Unfortunately, the impact of law enforcement is only as strong as the law itself. The biggest fine that can be imposed on a ship-owner for sailing an unregistered vessel is 1,000 pesos. The maximum fine for sailing without a valid inspection certificate is 200 pesos. The fine for overloading is 100 pesos for every passenger in excess of the authorized capacity. A Navy Coast Guard commander admitted that they allow as many passengers as possible for as long as the water does not reach the loadline mark, a line along a vessel’s hull which drops below water level when a ship is overloaded. It becomes clear that even if Figure 1. Electrocardiogram upon admission can clearly get the laws are strictly imposed, ship-owners away with violations with minimal consequences to them. Unfortunately, the consequences for the unknowing transferred to the intensive care unit (ICU) for ventilatory passengers are uniformly fatal.6 support and closer monitoring. On bedside cardiac ultrasound, Although the role of human error in the occurrence of there was a finding of eccentric left ventricular hypertrophy, this particular catastrophe is debatable, prevention of future global hypokinesia with depressed overall systolic function mishaps will definitely involve the people riding these with concomitant spontaneous echo contrast on left ventricular vessels, both crew and passengers. Coast Guard Chief (LV) cavity suggestive of rheologic stasis, the ejection fraction Commodore Carlos Agustin and the CISO agreed that at was 25%, with moderate mitral regurgitation, moderate least regurgitation with aortic sclerosis, severe tricuspid aortic80 percent of all sea accidents between 1984 and 1990 involved human error and the limited competence of regurgitation with mild pulmonary hypertension, pulmonary crewmen. A study of the Maritime Industry Authority regurgitation, and minimal pericardial effusion or pericardial VOL. 43 N0. 3 2011 VOL. 45 NO.4 2009

(MARINA) by the Barlindhaug Og Fuglum A/S of Norway supports this observation. Of the 27 maritime schools in the Urinalysis ABG country, most are ill-equipped and use substandard teaching Result Color straw pH methods to instruct the thousands of ill-prepared 7.408 seamen 7 they graduate yearly. 6.3 Transp Clear pCO2 49.1 Juan Nolasco, Vice President of the Philippine Merchant 6.4 Sp Gravity 1.010 pO2 70 5.0 pH 8.0 HCO3 31.3 Marine School, the biggest marine school in the country, 123 Sugar NEG 93.6 however, dismissed the claim. Most O2 sat graduates of local 32 Protein NEG FiO2 21% maritime schools land jobs abroad and most major 0.82 RBC 0-1 Temp 36.9 international shipping companies at one time or another 0.67 WBC 0-2 employ Filipinos Cast as crewmen. CISO president acknowledges 4.21 PBS 5.25 Epith cell Rare that PRC records show passing rates as high as 90 percent Slight poikilocytosis, 95 Bacteria Occ’l plus for seamen. It is acknowledged that Filipino ovalocytes, acanthocytes, seafarers 91 Mucus th Rare slight toxic granulation, are known worldwide and are major revenue earners for the 184 Crystals Rare slight anisocytosis country.7 136.9 Am urates Unfortunately, a lot of these qualified seamen leave for 3.35 86 greener pastures, leaving the local shipping industry to 2.37 newcomers and less skilled crewmen. In the case of the 2.27 Vector, the vessel’s crew at the time of the accident was led 0.83 by a seaman with a 2nd mate’s license instead of a chief mate’s license. The exodus of qualified seamen can only be stemmed by improving economic conditions. In this fat pad. Cardiac enzymes were enforcement with an acute particular case however, simplenot consistent on the part of coronary event (Table 3), however, intravenous (IV) owners authorities and compliance on the part of the Vector’s heparin (overlapping with oral outcome. could have affected the warfarin)3 was still given to cover for the presence of utilizing water thrombus as demonstrated The public a possible LV transportation must do its by rheologic stasis mustcardiac ultrasound. Medications share. Self-discipline on be exercised so that overloading wereovercrowding diuretics and inotropes; oral digoxin was and shifted to IV can be avoided. Attention must be given started. IV antibiotics and security for possible pulmonary to pre-boarding safety were given instructions, commonly infection. The patient later on showed improvement, and was ignored in the mayhem of trying to find comfortable spaces eventually weaned off from ventilatory support, extubated, in the crowded ships. A culture that puts a premium on safe rather than swift and/or cheap travel must be created Table 3. Cardiac Enzymesmaritime market. They must be amongst the domestic educated that it is Reference Range (mmoL) their basic right to demand Result safe travel that meets international standards from all domestic maritime Qualitative POSITIVE industry stakeholders. Troponin I CK-MB Much can be said 0-6.0 about the response 1.14 maritime to CK-TOTAL 21-232 disasters when they occur. In the case of 543 Doña Paz, a coordinated response to the accident on board the ship was virtually nonexistent. No one directed evacuation efforts on board and this was compounded by the unavailability of life vests–they were under lock and key in deck lockers. No one among the crew had the time to react to the collision, and no distress signal was sent out. These maritime disasters have a high mortality, with very few long-term sequelae in terms of having to deal with health problems resulting from the initial incident. The majority of the fatalities died on the spot. In incidents such as these, injuries come in the form of burns, drowning, smoke inhalation, blunt trauma and occasionally penetrating trauma. Secondary injuries may theoretically come from shark attack. In this particular incident, although the ships sank in shark-infested waters, there was no way to verify the Figure 2. Chest radiograph on admission ACTA MEDICA PHILIPPINA 13 ACTA MEDICA PHILIPPINA 3

The Sinking of the MV Doña Paz – II. Policy implications CASE REPORT

cause of death of the fatalities since those who were rescued perform a 43 will save male Heart Failure and Short Stature in triage year-oldprecious time and prevent only had minimal injuries.2,3 secondary injuries. Patients who have to be brought to This brings to the fore1,the response to the disaster. Manila can be attended to III2 and by informing those Katerina T. Leyritana Ma. Czarlota M. Acelajado-Valdenor1, Amado O. Tandoc properly Agnes D. Mejia1 in There was no coordinated response at the time of the Manila of the precise nature of the injuries. The capabilities 1 Department other maritime disasters in the General Hospital, in the provinces in proximity incident, as with many of Medicine, College of Medicine and Philippineof the hospitalsUniversity of the Philippines Manila to the shipping 2 country. The ships that wereDepartment of Pathology, College of Medicine, University ofbe Philippines ManilaThere are several hospitals in the vicinity of the disaster lanes must the well defined. conducted the only search and rescue effort that bore fruit capable of attending to victims, which will negate the need and this is directly attributable to a breakdown in for transport to Manila. There are primary and secondary communication. Improving the communication systems will hospitals capable of rendering immediate care to drowning, not only contribute immensely to prevention of these burns and trauma. Upgrading the capabilities of these accidents, but also to the rapidity of response when they hospitals may not necessarily mean spending for additional occur. One thingPresentation of the the capability of the to focus on is case require regular simply holding workshops for report of two equipment but laxative use. There was also a preparedness more syncopal victims of He was brought to another doctor This is a units to 43-year-old male presenting with short responding case of a extract as many survivors as possible in attending to episodes. these disasters. Local governments in a be tasked with creating teams capable of establishing the staturethe water and to The patient any immediate lifefrom and heart failure. attend to was admitted at the can private hospital where the assessment was still a “heart problem”. units for initial evaluation prescribed unrecalled medicine ward of the among them. This will entail a wellthreatening conditions Philippine General Hospital (PGH) camps or The patient was again and treatment. There medications and again was lost to follow-up. Thisas the for dyspnea. This paper will investigate several issues: equipped Coast Guard with ships and aircraft capable of must likewise be a point person or agency (such time, however, symptoms were persistent. He or PDCC) that will differentiating congenital from acquired hypothyroidism, extracting survivors from hostile environments and with Philippine Disaster Coordinating Council later consulted at another local the receiving hospitalsadmitted and managed the relationship and trained hypothyroidism and them sufficient facilities between personnel to provide the transmit to hospital, where he was the condition of the as a case of anemia and bronchial asthma. He was discharged cardiomyopathies, emergency care. Search and rescue teams and the therapeutic options in patients with the necessary victims. slightly this particular four days, we canhave recurrent heart with cardiomyopathy secondary resuscitation since many of must be capable of conducting to hypothyroidism. In improved after incident, only to only surmise that failurecould have prompting admission at PGH. search and Thewho will bebeen born full term to site may have patient had extracted from the a then 31-yearthose more symptoms, been saved if an organized Upon admission dispatched was in mild respiratory old Gravida 4 Para 3 (G4P3), the 4th of 9 must at least an siblings, with be survivable injuries. Personnel on board rescue mission was the patient immediately. It is being distress, with stable vital signs andships are available to the apparently unremarkable delivery at Training if not higher home facilitated by certified with Basic Life Support (BLS) claimed by the government that no note of fever. Pertinent physical exam findings included short stature, thick lips, nona traditional birth attendant. He was noted to be normal levels of expertise. Coast Guard along with air support provided by the US Air pittingin the formedema, dry skin, a displaced apical impulse, at birth. worth notingwas allegedly the par with age both It is The patient that many of at maritime disasters Force periorbital of helicopters and reconnaissance planes. crackles on communications and bilateral non-pitting of these physically and mentally until eight from the shores of cities years old when he was actually happened a few kilometers Improving both lung fields, will allow optimal use bipedal edema. There was alsodoes cm x 3 cm reducible survivors said have hospitals and that it in height. He was brought to to have stopped growing is usually local fisherfolk, in that resources. Saving lives a 3 not end with finding umbilical hernia.Immediatethere wasattention must be vein distention, a private doctor, whose diagnosis was responders" to these undisclosed, and he indigenous bancas, who are the "first alone. However, medical no pallor, no neck made available no attend to the needs of the injured and tocardiac murmurs was given medications Another strategy which the patient to increase height, that is worth maritime incidents. to apparent congenital malformations, no resuscitate those and no clubbing. saved. was also no note of an anterior neck took for onlyis themonth with no improvement. Through the one establishment of medical units or camps considering who may yet be There This will entail providing Basic Life mass. years, the patient was apparentlybe capable of receiving the well, although still of short very near the shore which will Support training for people on the ground, and Advanced Laboratory workup showed in the hospitals receiving the stature, with thick lips, coarse facial features and providing survivors extracted by first responders and dry skin. Trauma Life support for those cardiomegaly with pulmonary congestion, thoracic dextroscoliosis, and atheromatous aorta by He was notably slow in ambulation. He was said to serve have immediate emergency care for victims. They can also injured if feasible. Post-incident counseling must be made chest radiograph, and left ventricular hypertrophy by 12-lead bronchialcenters from which victims will bethen he had local as triage asthma at age 15 years, and since directed to been available to the victims. electrocardiogram (12-L ECG) (Figures 1 and 2), normocytic taking salbutamol tablets occasionally for to other specialty hospitals, to tertiary centers in Manila or bouts of dyspnea Much has been said about the socioeconomic, political normochromic anemia (Hgb 90 mg/dL), dyslipidemia, and occurring one towith times annually. centers. Those two minimal injuries can be directed to and legal factors surrounding this case. Focus on improving pre-renal azotemia (serum creatinine 123be givenElectrolytes The patient’s symptoms started in 2001 when he was centers where they can undergo counseling and be provided the medical standpoint must now mmoL). attention, on admission complexity of trying to address the other reported to have suddenrelatives consciousness. During This loss of and/or acquaintances. this assistance for contacting knowing the showed slight hyponatremia, hypokalemia, and hypochloremia (serum Na 136, K 3.35, Cl 86). Blood gases time, thewill necessitate rapid any symptoms of heart failure; patient did not have transport from the site, ideally strategy issues. A coordinated medical response will necessitate that revealed partially compensated metabolic alkalosis with their no prior high-speed Coast Guard vessels or via air transport. through seizures, cyanotic episodes, chest pain, headache, or all involved have a thorough understanding of mild hypoxemia. The patientinterdependence of these roles. based blurring of vision. He regained consciousness shortly after and Such transports are actually available at present. particular roles and the was noted to be hypothyroid on elevated serum thyroid-stimulating hormone (TSH) and was brought to majority of the victims of maritime accidents, a private physician, whose assessment was a Unfortunately, Initial knowledge of the incident must trigger a markedly decreased serum free thyroxine (FT4). The exact “heart problem”. He was prescribedbe ferried all the way to as in the Doña Paz tragedy, have to unrecalled medications mechanism that relays information to the PDCC. The Coast values are shown in Tables 1 and 2. taken for a few months and eventually discontinued when Manila. The victims who were brought to Manila were not Guard will be dispatched immediately for search and rescue Upon admission to the wards, the patient was managed the syncopal episode did not recur. received by an organized emergency medical team. Those operations. The responding ships will be the site of first as having congestive heart failure from cardiomyopathy In the next four years, the patient would develop who were ambulatory had to secure their own transport and contact between the victims/patients and the secondary to acquired hypothyroidism. Oral loop diuretics, intermittent, progressive exertional dyspnea and bipedal proceed to their destinations on their own. Those who were responders/caregivers. The initial triage unit will necessarily angiotensin-converting enzyme (ACE) inhibitors, betaedema. Later on this would be accompanied by generalized found to have injuries had to be transported to tertiary be aboard the responding ships. Responding teams must blockers, statins, and levothyroxine were started. Electrolyte body weakness, anorexia, and constipation, severe enough to hospitals on private ambulances contracted by relatives, or immediately notify the receiving medical teams of the nature correction was instituted. The sections of Endocrinology by public transportation. In fact, even the injured passengers of injuries they should be expecting. If feasible, it would be and Cardiovascular Diseases were co-managing the patient received very minimal medical attention prior to ideal to have a doctor or other medical personnel on board Corresponding author: Ma. Czarlota Acelajado-Valdenor, M.D.being together with the General Medicine service. Department of the hospitals where they were brought for brought to Medicine the responding vessels. However, knowing the usual He soon developed respiratory failure, upon which the Philippine General Hospital definitive medical care. Establishing a system whereby those problems of manpower shortage, workshops may be Taft Avenue, Manila, 1000 Philippines considerations were acute pulmonary congestion, nosocomial involved +632 the actual conducted to provide some amount of training to nonTelephone:with 554-8488 search and rescue can immediately pneumonia, to rule out an acute coronary event. He was later
Email: czarlota@yahoo.com

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Heart Failure Doña Paz – II. in a 43 year-old male The Sinking of the MVand Short StaturePolicy implications

medical personnel responding to these emergencies. In the Table 1. Initial Laboratory Results these training in basic life medical personnel responding person, emergencies. In the absence of a medically trained to absence becomes a necessity. person, training in permits, support of a medically trainedIf logistical support basic life CBC Blood chem. support for resuscitation like logistical support permits, facilities becomes a necessity. If ambubags, oxygen tanks, Reference Result facilities for Reference resuscitation like ambubags, hand. tanks, intravenous fluids and a code cart must be onoxygen Splints, Value Value intravenous fluids and a codeshould be available to Splints, cart be cervical collars and warmers 4.5 must RBSon hand. prevent WBC 3.9-6.1 5-10 cervical collars and warmers should be HGBA1C to initial available secondary injury. Those directly involved in theprevent RBC 4.27-6.07 4-6 HGB 2.6-6.4 secondary rescue will likewise play aBUN 120-150 90 search and injury. Those directly involved in role in the crucial the initial HCT 53-115 0.38-0.48 0.27 search and rescue will likewise play aCREA crucial role in dissemination of information. These teams will need the MCV ALB 34-50 80-100 FL dissemination of the situation, determine the logistical skills to assess information. These teams will need the MCH TAG 0.34-1.7 27-31 PG skills to assess the situation, determine the logistical requirements, process and relay the necessary information to MCHC HDL 0.91-1.56 320-360 G/L requirements, process and relay the relevant receiving parties. the necessary information to RDW LDL 1.1-3.8 11.5-15.5% PLTMedical 200-400 will play a TOTAL CHOL 4.2-5.2 the relevant receiving parties.Inc crucial part after the initial teams RETIC 15-37 Medical teams will play a crucial AST search and 0.005-0.015 operations. The part after the initial rescue National Disaster SEG ALT 30-65 50-70% 48 search and rescue operations. The National Disaster Coordinating Council must come up with a list of hospitals LYMPH Alk po4 20-44% 50 Coordinating2-9% Council must come up with a the event 140-148 that are capable of handling casualties in list of hospitals of a MONO NA 2 that are disaster. The Department of Health may assist in of a maritime capable of handling casualties in the event 3.6-5.2 EO K 0-4% 0 BASO 100-108 maritime disaster. hospitals 0 mapping out 0-2% The Department of Health capabilities in these and rating CL their may assist BLAST 2.12-2.52 mapping out 0% injuries expected in CA++ capabilities in these and rating maritime accidents. their handling specific hospitals 0 P handling specific injuries expected in MG++ maritime that0.74-1 These hospitals will be tasked to organize teamsaccidents. will These hospitals will be tasked to may be situated very near receive the casualties. These teams organize teams that will receive in makeshift stagingteams maymay receive patients shores the casualties. These areas or be situated very near shores in their hospitals. Workshops may receive patients directlyin makeshift staging areas or must be conducted to directly in certain level of preparedness in the hospitals maintain atheir hospitals. Tests Table 2. Thyroid Function Workshops must be conducted to maintain as receiving areas preparedness in the Medical identified a certain level of for maritime casualties.hospitals Reference Value Result identified as receiving areas for maritime that no secondary transport must be arranged to ensure casualties. Medical Free T4 (0.8-2.0) 0.02 ng/dL transport must be arranged to ensure that hospitals will injuries are sustained during transport. These no secondary TSH (0.4-6.0) 24.75 Uiu/ml injuries be expected to serve as triage in hospitals will likewiseare sustained during transport. These multiple/mass likewise be expected to serve as whether multiple/mass casualty accidents. Medical teams, triage in situated in the casualty accidents. the hospital itself, will situated in to staging areas or in Medical teams, whether be expectedthe staging triage, in the hospital itself, will be expected to perform areas or initial resuscitation and treatment (if not perform the initial resuscitation and treatment injury done on triage, rescue vehicles), onsite care, and (if not done on evaluation.the rescue will provide definitive care if the A team vehicles), onsite care, and injury evaluation. A team will provide definitive care if the capabilities of the hospital permit. Previous experience with capabilities of the hospital permit. Previous experience with maritime disasters have shown that victims of maritime maritime disasters have shown that burns, of maritime disasters sustain injuries secondary to victims asphyxiation, disasters sustain injuries secondary to burns, asphyxiation, drowning, blunt thoracoabdominal trauma, and potentially drowning, blunt thoracoabdominal trauma, and potentially infected traumatic wounds. Assessment of the capabilities of infected traumatic wounds. Assessment of the capabilities of the hospitals and the staff in handling mass casualties and the hospitals and the staff in handling mass casualties and providing definitive care to victims will have to put these providing focus. Doctors and support staff must undergo injuries in definitive care to victims will have to put these injuries through Doctors and support staff must undergo training in focus. short courses or workshops to be prepared training through short courses or workshops to be prepared to handle the initial management of patients sustaining these Figure 1. Electrocardiogram uponof patients sustaining these to handle the initial definitive admission injuries, providing managementcare when possible, and injuries, providing for referral and transport as needed. recognizing the needdefinitive care when possible, and recognizing the need on Basic Life Support and Advanced Staff must be updated for referral and transport as needed. transferred to the intensive care unit (ICU) for ventilatory Staff must be updated on Basic Life Support and Advanced Cardiac Life Support when possible. support and closer monitoring. On bedside cardiac ultrasound, Cardiac Life Support when possible. there was a finding of eccentric left ventricular hypertrophy, global hypokinesia with depressed overall systolic function with concomitant spontaneous echo contrast on left ventricular (LV) cavity suggestive of rheologic stasis, the ejection fraction was 25%, with moderate mitral regurgitation, moderate aortic regurgitation with aortic sclerosis, severe tricuspid regurgitation with mild pulmonary hypertension, pulmonary regurgitation, and minimal pericardial effusion or pericardial VOL. 43 N0. 3 2011 VOL. 45 NO.4 2009

Conclusions and Recommendations Conclusions and Recommendations It has been several years since the Doña Paz sank, taking Urinalysis ABG It has 4,000 lives. Several more maritime accidents have more than been several years since the Doña Paz sank, taking Result 7.408 more than 4,000 Color Severalstraw maritime for everyone lives. more occurred since that time, highlighting the pH accidents have need occurred and for all takehighlighting the need formanmade to 6.3 once since that time, a harder look at this everyone Transp Clear pCO2 49.1 to 6.4 once and Prevention a harder lookpO2 this manmade at phenomenon. for Gravity will need to involve not only the Sp all take 1.010 70 5.0 pH HCO3 31.3 phenomenon. Prevention the need topublic asnot only the government agencies but will 8.0 riding involve well. Laws 123 NEG 93.6 government agencies must be strictlySugar but the riding public as well. Laws implemented, people O2 sat educated and well 32 Protein NEG FiO2 21% must be spent resources strictlytoimplemented, people and systems already improve equipment well educated and 0.82 RBC 0-1 Temp 36.9 resources spent to improve equipment and well organized, in place. Response to these incidents must besystems already 0.67 WBC 0-2 in place. Response involve incidents must be well organized, and this will again to these not only the government agencies 4.21 Cast PBS Epith well. They and this public as cell only the Slight poikilocytosis,such but5.25 will again involve notRaremust government agencies the be wary that but95 the may Bacteria as well. They when these happen they be wary ovalocytes, incidents publicand do occur, Occ’lmust acanthocytes, that such and 91 Mucus th Rare slight toxic react. The incidents may and do as to and they shouldgranulation, must be well orientedoccur, Rare when these happen they how 184 Crystals slight anisocytosis must be well Am to as to how must likewise be The oriented medical response uratesthis disaster they should react. well 136.9 medical response to this disaster must likewise be well 3.35 organized. Response must be initiated at the scene of rescue 86 organized. Response must be initiated at the scene of rescue if possible, or at nearby centers established to accommodate 2.37 if possible, or at nearby centers established to accommodate survivors. Personnel, both medical and paramedical, must 2.27 survivors. Personnel, boththese disasters paramedical,occur, be 0.83 trained to respond to medical and when they must be trained to respond to more competent when they occur, and transfer of victims to these disasters centers facilitated and transfer of victims to more competent centers facilitated when necessary. Care of these victims must be continuous, when necessary. Care primary medical attention to involve extending beyond the of these victims must be continuous, fat pad. Cardiac enzymes were not consistent with involve extending beyond the primary medical attention all aspects including post-traumatic counseling. toan acute coronaryhave by no post-traumatic intravenous (IV) heparin all aspects includingmeans heard the last of these Philippine We event (Table 3), however, counseling. (overlapping with oral can only hope last of these Philippine We have by no means heard the still given to cover for maritime disasters. We warfarin) was that the next time such the incident occurs,We can lives hope thatsaved and wesuch presence of a possibleonly thrombusthe next time are maritime disasters. more LV will be as demonstrated an by rheologic stasis on lives ultrasound. and we are an incident occurs, more cardiacour be saved Medications better prepared to take care of will Filipino brothers who were prepared to take care of our Filipino brothers was bettershifted to IV to ride and vessels that may be sailing have no choice butdiureticsthese inotropes; oral digoxin who started. were given for that may be sailing have lastIV antibiotics ride these vesselspossible pulmonary their no choice but to voyages. infection. The patient later on showed improvement, and was their last voyages. eventually weaned off from ventilatory support, extubated, ___________
___________ References Table 3. Cardiac Enzymes 1. Bateman References S. Ferry Safety: A neglected aspect of maritime security? Institute of Defence Safety: A neglected Commentaries. 2006 May 3. Reference Range (mmoL) Result 1. Bateman S. Ferry and Strategic Studies aspect of maritime security? 2. Qualitative of Defence and Strategic Studies Commentaries. 2006 May 3. Heide EAD. Disaster Response – Principles of preparation and POSITIVE Institute coordination. Disaster Response – Principles of preparation and 2. Troponin I EAD. Baltimore (MD): CV Mosby Company; 1989. Heide 3. CK-MB Lumley JSP, Baltimore Baxter PJ, Kirby N. Handbook of coordination. Ryan JM, (MD): CV Mosby Company; 1989. the Medical 0-6.0 1.14 Care of Catastrophes. Baxter PJ, Kirby N. Handbook Medicine Press 3. CK-TOTAL JSP, Ryan JM, London: The Royal Society of543 the Medical Lumley of 21-232
4. 4. 5. 5. 6. 6. 7. 7. Limited; 1996. Care of Catastrophes. London: The Royal Society of Medicine Press Ronquillo M. Limited; 1996.Ships 20 years or older ply island routes. Philippine Daily Inquirer. 1988 Ships1. years or older ply island routes. Philippine Daily Ronquillo M. Nov 20 Esplanada J. DOTC grounds 17 more vessels. Philippine Daily Inquirer. Inquirer. 1988 Nov 1. 1988 Nov 10. DOTC grounds 17 more vessels. Philippine Daily Inquirer. Esplanada J. MARINA Report on the Dona Paz Tragedy. Manila: Maritime Industry 1988 Nov 10. Authority; 1999 March. MARINA Report on the Dona Paz Tragedy. Manila: Maritime Industry Perpena E. Sulpicio’s mariners flunked board exams. Philippine Daily Authority; 1999 March. Inquirer. 1988 Nov 11. Perpena E. Sulpicio’s mariners flunked board exams. Philippine Daily Inquirer. 1988 Nov 11.

Figure 2. Chest radiograph on admission ACTA MEDICA PHILIPPINA 13 ACTA MEDICA PHILIPPINA 5