The Filipino Seafarers' Lived Experiences Aboard ...

Heart Failure and Short Stature a 43 year-old male Seafarers’ Lived Experiences aboardinShipping Vessels ORIGINAL Filipino ARTICLE

The Filipino Table 1. Initial laboratory ResultsSeafarers’

Lived Experiences Aboard International The Filipino Seafarers’ Lived Experiences Aboard International Shipping Vessels: A Basis Intervention ABG CBC Blood for chem. Health Promotion Urinalysis Shipping Vessels: A Basis for Health Promotion Intervention

WBC RBC HGB HCT MCV MCH MCHC RDW PlT RETIC SEG lYMPH MoNo Eo BASo BlAST

Reference Result Color straw pH 7.408 Reference Result ValueR. Gregorio, Jr. Value Ernesto RBS 3.9-6.1 6.3 Jr. Transp Clear pCo2 49.1 5-10 4.5 Ernesto R. Gregorio, HGBA1C 4.27-6.07 6.4 Sp Gravity 1.010 po2 70 4-6 BUN and Education, 2.6-6.4 5.0 Health, University pH of the Philippines 8.0 HCo3 31.3 Department of90 Health Promotion College of Public Manila 120-150 CREAand Education, 53-115 123 Health, University Sugar of the Philippines NEG o2 sat 93.6 Department of0.27 Health Promotion College of Public Manila 0.38-0.48 AlB 34-50 32 Protein NEG Fio2 21% 80-100 Fl TAG 0.34-1.7 0.82 RBC 0-1 Temp 36.9 27-31 PG maritime HDl 0.91-1.56 than 0.6720% of the world’s WBC 0-2 workforce, the Philippines 320-360 G/l than the maritime workforce, thePBS Philippines lDl 1.1-3.8 4.2120%toofbe Cast 11.5-15.5% remains theworld’s top source country for seafarers. Seafarers ToTAl CHol 4.2-5.2 5.25 Epith cell Rare 200-400 Inc remains to be the top source country for seafarers. Seafarers constitute more than a quarter of the 1.5 Overseas Slightmillion poikilocytosis, AST 15-37 95 Bacteria occ’lof the 1.5 0.005-0.015 constitute more than a quarter million Overseas acanthocytes, ovalocytes, Filipino Workers (OFWs) who helped maintain the stability AlT 30-65 91 Mucus th Rare 50-70% 48 slight toxic the granulation, Filipino Workers (OFWs) who helped maintain stability and184growth ofCrystals the Philippine in 2011. In fact, Alk po4 Rareeconomy 20-44% 50 slight anisocytosis and growth of the Philippine economy in 2011. fact, remittances from sea-based OFWs alone reached aInrecord NA 140-148 136.9 Am urates 2-9% 2 remittances from sea-based OFWs alone reached a record K 3.6-5.2 3.35 0-4% 0 high of US$ 4.34 billion which was 12% higher than what Cl 100-108 0-2% 0 1 high of US$ 4.34 billion which was 12% higher than what was86remitted in 2010. CA++ 2.12-2.52 0% 0 1 was2.37 remitted in 2010. Factors such as low labor costs, competence in the P 2.27 Factors such as labor costs, competence the English language, andlow better work habits contribute in to the MG++ 0.74-1 0.83

Table 2. Thyroid Function Tests Free T4 TSH

Reference Value (0.8-2.0) (0.4-6.0)

Result 0.02 ng/dl 24.75 Uiu/ml

Introduction Figure 1. Electrocardiogram upon admission Introduction Seafarers, also referred to as seamen, are typically male Seafarers, also referred to as seamen, aremonths typically male workers who work for a minimum of six aboard workers who work for a minimum of six months aboard shipping vessels travel incare the high more transferred to thethat intensive unit seas. (ICU)Supplying for ventilatory shipping vessels travel in on the bedside high seas. Supplying more support and closerthat monitoring. cardiac ultrasound, _______________ there was a finding of eccentric left ventricular hypertrophy, _______________ Corresponding author: Ernesto R. Gregorio, Jr., MPH global hypokinesia with depressed overall systolic function Department of Health Education Corresponding author:Promotion Ernesto R.and Gregorio, Jr., MPH with concomitant spontaneous echo contrast on left ventricular College of Public Health Department of Health Promotion and Education (lV) cavity suggestive of rheologic stasis, the ejection fraction University of the Philippines Manila College of Public Health 625 P. Gil St., Manila 1000 Philippines University of Ermita, the Philippines Manila was 25%, with moderate mitral regurgitation, moderate Telephone: +632 5260811 625 P. Gil St., Ermita, Manila 1000 Philippines aortic regurgitation with aortic sclerosis, severe tricuspid Email: [email protected] Telephone: +632 5260811 regurgitation with mild pulmonary hypertension, pulmonary Email: [email protected] regurgitation, and minimal pericardial effusion or pericardial Vol. 46 43 NO. N0. 432009 VOL. 2012

English language, and better work 2habits to the Hence,contribute the Philippines high demand for Filipino seafarers. 2 Hence, the Philippines high demand Filipino is projected tofor supply this seafarers. demand for seafarers globally in 3 is projected to supply this demand for seafarers globally in the next 10 years. fat Cardiac enzymes were not consistent with an acute 3 the pad. next 10 years. However, several studies have shown that seafaring coronary event (Table 3), however, intravenous (IV)seafaring heparin However, studies have shown that occupation hadseveral a higher mortality compared to other (overlapping with oral warfarin) was still given to cover for occupation had 4,5,6 a higher mortality compared challenges to other They hurdle work-related working groups. the presence of a possible lV thrombus as demonstrated 4,5,6 They hurdle work-related challenges working groups. boredom, such as loneliness, overwork and injuries due to a by rheologic stasis on cardiac ultrasound. Medications such as loneliness, overwork injuries due to a hazardous workingboredom, environment just toand support their loved were shifted to IV diuretics and inotropes; oral digoxin was 7,8 Furthermore, hazardous working environment just to support their loved several studies and reports have ones. started. IV antibiotics several were given for possible pulmonary studies and reports have ones.7,8 Furthermore, likewise shown that Filipino seafarers are more prone to infection. The patient later on showed improvement, and was likewisediseases shown that seafarers are more prone to chronic and Filipino sexually-transmitted infections (STIs) eventually weaned off from ventilatory support, extubated, chronic diseases sexually-transmitted infections This (STIs) was because of their and unique work situation.9,10,11,12 9,10,11,12 Thisdouble was because of their unique work situation. exacerbated by demoralization due to perceived Table 3. Cardiac Enzymes exacerbated by demoralization due to perceived double standards of treatment favoring European crews who standards of treatment favoring European crews work who allegedly have better working andResult regular Reference Rangeconditions (mmoL) 13 allegedly have better working conditions and regular work shifts. Qualitative PoSITIVE 13 shifts. Troponin The Ieconomic contributions and documented workCK-MB 0-6.0 1.14 Theconcerns economic contributions and it documented workrelated of this workforce make imperative to give CK-ToTAl 21-232 543 related concerns of this workforce make it imperative to give attention to their health, safety and well being. attention to their health, safety and well being. There is a dearth of qualitative information available on There is a dearth of qualitative on Filipino seafarers’ perceptions aboutinformation their lived available experiences Filipino seafarers’ perceptions about their lived experiences aboard international shipping vessels. Certain aspects of aboard international shipping vessels. aspects of their work situation such as long periodsCertain of isolation, long their work situation such as long periods of isolation, long working hours, occupational hazards and stress can increase working hours, occupational and stress candiseases. increase their vulnerability to work hazards and lifestyle-related their vulnerability to work and lifestyle-related diseases. Information about their lived experiences may serve as basis Information about theirand lived experiences may servethat as basis for health promotion education intervention can for health promotion and education intervention that was can reduce their vulnerabilities. Therefore, this study reduce their to vulnerabilities. this study lived was undertaken document Therefore, Filipino seafarers’ undertaken intointernational document shipping Filipino vessels, seafarers’ lived experiences specifically experiences international vessels, specifically their health in conditions, accessshipping to available health services theirfacilities, health conditions, access with to available health and their satisfaction these, and theirservices coping and facilities, their satisfaction with these, and their coping mechanisms. mechanisms. Figure 2. Chest radiograph on admission ACTA ACTA MEDICA MEDICA PHILIPPINA PHIlIPPINA 13 1

Filipino Seafarers’ Lived Experiences aboard Shipping CASE VesselsREPORT

Methods were married. The length of work ranged from Heart Failure and Short Stature in a 43 year-old male

1 to 17 years with an average of 9 years. Among those from dry cargo 1 2 1 bulk/tanker vessels, majorityIII worked as able-bodied seaman, Research DesignT. leyritana1, Ma. Czarlota M. Acelajado-Valdenor Katerina , Amado o. Tandoc and Agnes D. Mejia The study used a descriptive phenomenology to followed by oiler, electrician, messman, ordinary seaman, 1 Department of Medicine, College of Medicine Philippinechiefmate General Hospital, University of the Majority Philippines of Manila describe the lived experiences of seafarers while and aboard or an engineer. those working in 2 of Pathology, College of University ofluxury the Philippines Manilaworked as waiters and international shipping vessels.Department Phenomenologic research isMedicine, a passenger liners qualitative research technique developed by Husserl in 1970 stateroom/cabin crews. Most of the informants were to discover the meaning of people’s life experiences. The graduates of maritime degree courses. goal of this inquiry is to fully describe lived experiences and perceptions to which it gives rise.14 Emerging Themes The five major themes that emerged from the informants’ responses were: require regular laxative use. There was also a report of two Presentation of the case Study Site more syncopal episodes. was brought to another doctor This a case of awas 43-year-old presenting with short Datais collection done in male an industrial clinic located Common health He problems experienced by seafarers; in a private hospital wherefor thean assessment stature and port heart area failure. The patient was admitted at and the in Manila during their pre-employment  High propensity unhealthywas diet;still a “heart problem”. The patient was again prescribed unrecalled medicineexamination ward of the Philippine General the Hospital (PGH) medical (PEME). Interviewing informants at  Accessibility of health services and facilities; medications again was to follow-up. time, for dyspnea. This paper willfeasible investigate issues: their actual workplace was not due toseveral logistical and  Highand satisfaction withlost health services andThis facilities; however,and symptoms were persistent. He later consulted at differentiating congenital acquired hypothyroidism, financial constraints. Thisfrom industrial clinic is one of the another hospital, he was and admitted managed the relationship hypothyroidism the biggest providers ofbetween PEME services for Filipino and seafarers  local Strong copingwhere mechanisms otherand psychosocial as a case of anemia and bronchial asthma. He was discharged cardiomyopathies, and the therapeutic options in patients that work in various international shipping companies. It support. slightly improved after four days, only to have recurrent heart with cardiomyopathy secondary to hypothyroidism. was purposively selected based on the approval and failure symptoms, prompting admissionby atSeafarers PGH. The patient had been born full of term a then 31-yearcooperativeness of the management the to industrial clinic. Common Health Problems Experienced Upon admission the patient was in old Gravida 4 Para 3 (G4P3), the 4th of 9 siblings, with an The informants were asked about the mild healthrespiratory problems distress, with stable vital signs and no note of Pertinent apparently unremarkable delivery at home facilitated by common among seafarers. Results revealedfever. a variety of Study Informants, Data Collection and Analysis physical exam findings included short stature, thick lips, nona traditional birth attendant. He was noted to be normal be Purposive sampling was used as it is one of the most occupational and lifestyle-related diseases perceived to pitting periorbital dry skin, a displaced apical impulse, at birth. and The appropriate patient was sampling allegedlystrategies at par with age both common among edema, seafarers. Most admitted personally common in qualitative 15 crackles on both lung fields, and bilateral non-pitting physically and mentally until eight years old when he was experiencing at least one of these health problems bipedal and/or research. The selection of informants was guided by the edema. There was also a some 3 cm problems x 3 cm reducible umbilical said to have stopped growing in height. He was brought to following criteria: male seafarer, must have provided written had personally observed actually occurring hernia. However, thereorwas noattack. pallor, no neck vein distention, aconsent, private at doctor, diagnosis was undisclosed, and he least whose 18 years old, and must have worked as on board e.g. injuries heart no apparent congenital malformations, cardiac murmurs was given medications to increase height, which the patient seafarers for at least six months at the time of the interview. The most frequent health problemsno mentioned by those and no clubbing. There was also no note of anterior neck took for only one month with no improvement. Through the Each informant was approached in between waiting periods working in dry cargo bulk/tanker vesselsan were sexuallymass. years, the patient was apparently well, although still of short of their PEME. Data was collected through in-depth transmitted infections (STIs) such as herpes and gonorrhea. laboratory showedresponses cardiomegaly with pulmonary stature, with thick facialguide features and contained dry skin. interviews with thelips, usecoarse of a topic which Followingworkup were verbatim of informants when congestion, thoracic dextroscoliosis, and atheromatous by He was notably slow in ambulation. He was said to have mostly open-ended questions that pertain to the study asked for the reasons why seafarers get these aorta health chest radiograph, and left ventricular hypertrophy by 12-lead bronchial asthma at age 15 years, and since then he had been objectives. To ensure privacy and minimum interference problems: electrocardiogram ECG) (Figures 1 and[female 2), normocytic takingthe salbutamol tablets occasionally for boutswas of dyspnea with regular clinic activities, each interview done in “Whenever(12-l the ship docks, the women normochromic anemia (Hgb 90 mg/dl), dyslipidemia, and occurring one to two times annually. a secluded area of the clinic during long waiting periods. A sex workers] run after us, the women in Brazil pre-renal azotemia (serum creatinine 123 mmol). Electrolytes The patient’s symptoms started in 2001 when he was total of 12 informants who met the inclusion criteria were look like our local actresses here [in the on admission showed slight hyponatremia, hypokalemia, reported to have sudden loss of consciousness. included in the study. Recruitment was stoppedDuring on the this 12th Philippines]. and hypochloremia (serum K 3.35, Cl 86). gases time, the patient did not have any symptoms of heart failure; informant when informational redundancy or data “Even in local portsNa in 136, the Philippines like Blood in revealed partially compensated metabolic alkalosis with mild no prior seizures, cyanotic episodes, chest pain, headache, or saturation was noted by the researcher during the interview Pangasinan, Cebu, Batangas Cities, there were hypoxemia. The patient was noted to be hypothyroid based blurring of vision. He regained consciousness shortly after and Data was transcribed and preliminary data analysis.16 women who entered the ship and offered on elevated serum thyroid-stimulating hormone (TSH) and was brought a private themes physician, verbatim withtoemerging andwhose actualassessment quotationswas froma commercial sex. The same was true even in markedly decreased serum free thyroxine (FT4). The exact “heart problem”. He was prescribed unrecalled medications the informants were extracted in the succeeding analysis. Singapore and Thailand, in Thailand, women values are shown in Tables 1 and 2. taken for a few months and eventually discontinued when Responses including quotations were collected in the were already queued up as the ship arrives". Upon admission to the wards, the patient was managed the syncopal episode did not recur. vernacular and later translated to English. It was also noted from a number of informants that sex as having congestive heart failure from cardiomyopathy In the next four years, the patient would develop trade on board the ship ceased when maritime rules secondary to acquired hypothyroidism. oral loop diuretics, intermittent, progressive exertional dyspnea and bipedal Results disallowed entry of commercial sex workers following angiotensin-converting enzyme (ACE) inhibitors, betaedema. later on this would be accompanied by generalized September 11 terrorists attacks in the US. However, this blockers, statins, and levothyroxine were started. Electrolyte body weakness, anorexia, and constipation, severe enough to prohibition did not prevent seafarers from acquiring sexual Socio-demographic Data correction was instituted. The sections of Endocrinology There were a total of 12 informants who participated in services in commercial sex establishments at docking points. and Cardiovascular Diseases were co-managing the patient the study. More half (58%) worked in either STIs were commonly mentioned by those who worked Corresponding author:than Ma. Czarlota Acelajado-Valdenor, M.D. dry together with the General Medicine service. Department Medicine cargo/bulk of carriers and tanker vessels while the rest were in dry cargo bulk/tanker vessels but not among informants He soon developed respiratory failure, upon which the Philippine General Hospital employed in passenger luxury liners. Informants’ age from the passenger luxury liners. Apart from STIs, there Taft Avenue, Manila, 1000 Philippines considerations were acute pulmonary congestion, nosocomial ranged from to 51 with a mean of 37 years old. Majority were other health problems mentioned to be common Telephone: +63225554-8488 pneumonia, to rule out an acute coronary event. He was later Email: [email protected]

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Vol.46 43NO. N0. 43 2009 VOL. 2012

Heart Failure and Short Stature a 43 year-old male Filipino Seafarers’ Lived Experiences aboardinShipping Vessels

Table Initial laboratory Results accidents such as burns, among1. seafarers. These included hypertension, heart attack, fever, homesickness/boredom, CBC Blood chem. asphyxia and common colds. It was also noted that Result complacency Reference of some seafarers actually placed them atReference risk Value Value for accidents as claimed by one informant below: WBC RBS 3.9-6.1 5-10 4.5 Asphyxia level below RBC 4.27-6.07 4-6 is caused by low oxygenHGBA1C HGB 2.6-6.4 [the 120-150 ship]. Seafarers 90 knew how BUN to detect if HCT 53-115 0.38-0.48 0.27 was alsoCREA oxygen level is low, there a gauge to MCV AlB 34-50 80-100 Fl measure oxygen level. However, sometimes the MCH TAG 0.34-1.7 27-31 PG did not look at the gauge MCHC seafarers HDland just 0.91-1.56 320-360 G/l the oxygen level because they were RDW estimated lDl 1.1-3.8 11.5-15.5% PlT ToTAl CHol 4.2-5.2 used 200-400 to such practice.”Inc RETIC AST 0.005-0.015 Informants mentioned other health problems15-37of SEG AlT 30-65 50-70% 48 seafarers but of lesser frequency and these included: muscle lYMPH Alk po4 20-44% 50 and back pains, “Tanker skin MoNo NAEffect”, burn,140-148 2-9%diarrhea, fatigue, 2 asthma, etc. When the informant who mentioned “Tanker Eo K 3.6-5.2 0-4% 0 BASo was asked Cl 100-108 0-2% to describe 0 the condition, Effect” he mentioned BlAST CA++ 2.12-2.52 0% 0 that… P “The illness was common among MG++ those 0.74-1 chronically exposed to fumes, usually those who have been working as seafarers for a long time. It was said to be manifested by absentmindedness, irritability Table 2. Thyroid Function Tests and having blank stares, or showing signs of insanity.” Reference Value Result those working in passenger FreeOn T4 the other hand,(0.8-2.0) 0.02 ng/dl luxury liners TSH reported hypertension, (0.4-6.0) back, knee, and 24.75muscle Uiu/ml pains due to prolonged standing or lifting of heavy objects as well as SGPT elevations. Other ailments mentioned included diarrhea due to Norwalk Virus, varicose veins, high blood sugar, etc. Some of the actual responses pertaining to illnesses or health conditions common among seafarers were quoted as follows: “Boredom, stomach problem, cough, fever, STIs, swollen sex organ, cold air penetrating the stomach which sometimes led to nausea, and accident. Just like what happened to the second cook, whose finger was accidentally cutoffduring food preparation, what he did was to wash the finger, put it back and wrapped with gauze pad, then he waited to be brought to the nearest hospital after docking which took weeks later that caused his cut finger to Figure 1. rot.” Electrocardiogram upon admission “Heart attack, back and hip pain, accidents like decapitation of lower limb, getting stuck in transferred to the intensive care unit (ICU) for ventilatory ropes, and high cholesterol.” support and closer monitoring. on bedside cardiac ultrasound, Hypertension was commonly mentioned in both groups there was a finding of eccentric left ventricular hypertrophy, and informants were also aware that the disease was due to global hypokinesia with depressed overall systolic function high dietary meat and fat as well as lack of alternative food with concomitant spontaneous echo contrast on left ventricular choices while on board. (lV) cavity suggestive of rheologic stasis, the ejection fraction was 25%, with moderate mitral regurgitation, moderate High for an unhealthy aorticpropensity regurgitation with aortic diet sclerosis, severe tricuspid Seafarers were found to be more vulnerable to regurgitation with mild pulmonary hypertension, pulmonary unhealthy diet because of the circumstances they are in. regurgitation, and minimal pericardial effusion or pericardial Vol. 46 43 NO. N0. 432009 VOL. 2012

Contributory factors identified included unlimited amount of food servings available and the lack of control over food Urinalysis ABG choices. Most of the time, a buffet is served where there were Color straw 7.408 no Result restrictions in the amount that theypHcould eat. Some informants also mentioned that the attitude of the chief 6.3 Transp Clear pCo2 49.1cook is 6.4 also contributory perceived po2 high number of Sp Gravityto the1.010 70 5.0 pH chief cook8.0were lazy, HCo3 hypertension. If the he would31.3 always 123 Sugar sat propensity 93.6 to prepare meaty and fatty food.NEG Perceivedo2 high 32 Protein NEG Fio2 21% hypertension is explained in the following quotations: 0.82 RBC 0-1 Temp 36.9 to food that we were 0.67 “Hypertension WBC is due 0-2 4.21 served with, Cast if the chief cook is lazy, he would PBS 5.25 alwaysEpith Rare in vinegar servecell us adobo (pork and soy Slight poikilocytosis, 95 Bacteriato tenderness), occ’l sauce boiled steak, pata-timovalocytes, acanthocytes, 91 Mucus th Rare granulation, (pork legs cooked in Rare vinegar &slight soy toxic sauce), 184 Crystals slight anisocytosis “Jollibee” which means chicken, we call those 136.9 Am urates 3.35 types of food as ‘killing me softly.” 86 2.37 2.27 0.83

Another informant mentioned, “Arthritis comes first before hypertension, this is because of the greater amount of meat in the diet, there were vegetables but limited, sometimes other seafarers do not like vegetables. You have no fat pad. Cardiac enzymes not consistent choice because the were food served is adobo, with pork an acute coronary bone event (Table 3), however, intravenous (IV) heparin marrow, and entrails”. (overlapping with oral warfarin) was still given to cover for Interview responses also revealed that vegetables were the presence of a possible lV thrombus as demonstrated usually consumed first just before they begin to show signs by rheologicHence, stasisfrozen on cardiac ultrasound. Medications of spoilage. meats and fishes will be served were shifted to IV diuretics and inotropes; oral digoxin was for the rest of voyage unless there is a chance to purchase started. IV antibiotics were given for possible pulmonary fresh vegetables in the markets from ports where the ships infection. The patient later on showed improvement, and was dock throughout the journey. eventually weaned off from ventilatory support, extubated, Few informants from the dry cargo bulk/tanker vessels also related personally witnessing a case of heart attack Table 3. Cardiac Enzymes happening on board. The informants were aware that heart attack is related to Reference high blood pressure Range (mmoL) and excessive Result alcohol intake. Qualitative PoSITIVE Elevation in liver enzymes specifically SGPT was Troponin I CK-MB 0-6.0 1.14 mentioned by several informants from passenger luxury CK-ToTAl liners but not among 21-232 those from dry cargo543bulk/tanker vessels. But hepatitis and other liver problems were mentioned by informants from the latter. Some informants from luxury liners attributed SGPT level elevation to high alcohol and fat intake. Some of the verbatim comments were given below. “Elevated SGPT was because of alcohol and fat intake.” “Drinking alcohol is part of our pastime, it is done simply for fun, 90% of seamen drink alcohol.” Accessibility of health services and facilities Health Services The informants were asked about their perceptions related 2. toChest the accessibility services and facilities on Figure radiographof onhealth admission ACTA ACTA MEDICA MEDICA PHILIPPINA PHIlIPPINA 13 3

Filipino Seafarers’ Lived Experiences aboard Shipping CASE VesselsREPORT

board. There were noHeart medical nor even paramedical staff onStature there isin a person from the crewmale who monitors its utilization. Failure and Short a 43 year-old board the dry cargo bulk/tanker vessels. Thus, health Nevertheless, there were some who admitted poor 1 second mate who trained on 1 1 services were provided by the compliance in using earmuffs informant Katerina T. leyritana , Ma. Czarlota M. Acelajado-Valdenor , Amado o. Tandoc III2and andearplugs. Agnes D.An Mejia how to manage the common health needs of the seafarers on mentioned that: Medicine, College of Medicine and Philippine General Hospital, of the Philippines board such as1Department first aidof and basic medical care. In “ThereUniversity were goggles, earmuffs Manila for too much 2 Department Pathology, of Medicine, University of the Manilautilized because of the complicated cases, they usually call of the nearestCollege hospital noise butPhilippines are not being where instructions on how to manage patients were received difficulty of use, others just use cotton plugs through telephones. For emergency medical situations that as they were perceived to be better than may lead to serious or fatal injuries, the captain or second earplugs, earplugs cause pain in the ears. mate could call on the nearest hospital and a helicopter will Helmets were required when grinding but be sent to fetch the patient for appropriate medical were not always used because of the hot management. Following from the require regular laxative use. There was also a report of two Presentationwere of thequotations case sensation it causes.” more syncopal episodes. He was brought to another doctor This is aregarding case of a 43-year-old male presenting with short informants health services: in a private hospital where the assessment wasfacilities still a “heart stature and failure. Theforpatient was admitted at the “Weheart have medications all types of diseases, High satisfaction with the health services and problem”. The patient unrecalled medicinewe ward theaidPhilippine General haveoffirst kits, a complete set Hospital of PPE (PGH) The informants were was askedagain to rateprescribed their satisfaction with medications and again was lostontoboard follow-up. for dyspnea. ThisProtective paper will investigate several [Personal Equipment], we also have issues: the health services and facilities using aThis scaletime, of 1 however, were persistent. later consulted at differentiating congenital from acquired hypothyroidism, safety briefings on how to use these PPEs. We to 5, with symptoms 5 as the highest. Majority ofHe informants from dry another local hospital, where he was admitted and managed the relationship between have a second mate whohypothyroidism serves as our doctorand the cargo bulk/tanker vessels gave a mean rating of 4 which as a case ofa anemia and bronchial asthma. He was discharged cardiomyopathies, options in patients on board. Ifand therethe weretherapeutic serious or fatal injuries indicates high satisfaction with the health services and slightly improved after four days, only to have recurrent with cardiomyopathy secondary to hypothyroidism. like fractures, we contact the nearest hospital facilities on board. The mean satisfaction ratingheart of failure symptoms, prompting PGH. The patient been born a then and thenhad a helicopter will full pick term up theto patient to 31-yearinformants from luxury liner admission was only 3atand the following th Upon the given: patient was in mild respiratory old Gravida 4 Para 3 (G4P3), the 4If of 9case siblings, be given proper management. the can be with an were someadmission of the reasons distress, with stable vital signs and no of to fever. apparently unremarkable delivery at home facilitated by managed on board, we could receive “I only rated health services onnote board be 2Pertinent physical exam findings included short stature, thick a traditional birth attendant. He was noted to be normal instruction from the doctor through phone on because the nurse dispenses medicine which islips, nonpitting periorbital edema, dry skin,for a displaced apical impulse, at birth. how The to patient was allegedly at par with age both manage emergency cases like heart not effective like Ibuprofen tooth ache.” crackles on both lung fields, and bilateral non-pitting physically and mentally until eight years old when he was attack”. “3 only because of absence of x-ray, then we bipedal edema. There was also awho 3 cm 3 the cm ship reducible said Seafarers to have stopped growing in height. He was brought to working in luxury passenger liners were had one colleague diedx in becauseumbilical hernia. However, there was no pallor, no neck vein distention, a private doctor, whose diagnosis was undisclosed, and he allowed to use the medical facilities and services available of appendicitis.” no apparent congenital malformations, no cardiac murmurs was given medications to increase height, which the patient for the medical staff when these were needed. Medical and no clubbing. There was also no note of an anterior took for only one month with no improvement. Through the doctors and nurses were on board for free consults anytime. High coping mechanisms and other psychosocial supportneck mass. years, the patient was apparently well, although still of short There were a variety of leisure activities that seafarers Facilities have a complete supply of emergency drugs. laboratory showed cardiomegaly with pulmonary stature, with thickiflips, coarse features and dry skin. engage in to workup cope with boredom, loneliness and other When asked there werefacial occasions where seafarers congestion, thoracic dextroscoliosis, and atheromatous by He was notably slow in ambulation. He was said to have problems. Off duty, informants from the dry cargoaorta vessels were not able to get the health services needed while on chest radiograph, and left ventricular hypertrophy by 12-lead bronchial asthma at age 15 years, and since then he had been spend most of their time in their cabins sleeping, relaxing, board, majority of informants from both groups claimed that electrocardiogram (12-l ECG) (Figures 1 and 2), normocytic taking salbutamol tablets occasionally for bouts of dyspnea watching DVDs, listening to music, play video games and health services needed were always readily available. normochromic anemia (Hgb 90 mg/dl), dyslipidemia, and occurring one to two times annually. singing. They also engaged in sports like ping-pong, pre-renal azotemia (serum creatinine 123 mmol). Electrolytes The patient’s symptoms started in 2001 when he was basketball, softball, and swimming. Sometimes they go to Health Facilities and Equipment on showed slight hyponatremia, hypokalemia, reported haveofsudden consciousness.which Duringcould this the admission gym to workout. Gym facilities like barbells, dumbbells, Both to types vesselsloss haveofmini-hospitals and hypochloremia (serum Na 136, K 3.35, Cl 86). Blood gases time, the patient did not have any symptoms of heart failure; treadmills, stationary bikes, table soccer and mobile bicycles accommodate a few patients at a time. Passenger luxury revealed partially compensated metabolic alkalosis with mild no prior seizures, cyanotic episodes, chest pain, headache, or were present and were always available, but, seldom used liners have a helicopter that could be used to transport hypoxemia. The patient was noted to be hypothyroid based blurring of vision. He regained consciousness shortly after and because of fatigue experienced after work. Drinking sessions patients during emergency cases which was not present in on elevated serumduring thyroid-stimulating hormone and was brought to a private physician, whose assessment was a were also done off duty hours. When(TSH) boredom dry cargo bulk/tanker vessels, however, they can always call markedly decreased serum free thyroxine (FT4). The exact “heart problem”. He was prescribed unrecalled medications comes, they could also go fishing in some areas where it was for helicopter assistance during emergency cases. values are shown in Tables 1 and 2. taken for a few months and eventually discontinued when allowed. In this manner, the seafarers did not only get to Seafarers in both vessels have access to their own gym Upon admission to the wards, the patient was managed the syncopal episode did not recur. ease their boredom and loneliness but also had gotten to facilities which have a complete set of work out equipment. as having congestive heart failure from cardiomyopathy In the next four years, the patient would develop taste fresh seafood from their catch. See some of the However, majority of the informants from dry cargo secondary to acquired hypothyroidism. oral loop diuretics, intermittent, progressive exertional dyspnea and bipedal quotations below. bulk/tanker admitted not using these facilities because they angiotensin-converting enzyme (ACE) inhibitors, betaedema. later on this would be accompanied by generalized “When on board, we just sleep, watch movies, were often too tired to use them after work. Many would blockers, statins, and levothyroxine were started. Electrolyte body weakness, anorexia, and constipation, severe enough to play video games, or sing. We have videoke and rather sleep, rest, watch movies in their cabins than work out correction was instituted. The sections of Endocrinology magic sing. When in port, we unwind and at the gym. and Cardiovascular Diseases were co-managing the patient visit friends, go to beerhouses, watch strip All of the seafarers from Acelajado-Valdenor, the dry cargo bulk/tanker Corresponding author: Ma. Czarlota M.D. together with the General Medicine service. Department of Medicine shows and sometimes, we take our women/sex vessels claimed that they have a complete set of Personal He soon developed respiratory failure, upon which the Philippine General Hospital workers.” Protective Equipment (PPE) on board. Majority of the Taft Avenue, Manila, 1000 Philippines considerations were acute pulmonary congestion, nosocomial informants+632 claimed that utilization of PPE is high because Telephone: 554-8488 pneumonia, to rule out an acute coronary event. He was later Email: [email protected]

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Vol.46 43NO. N0. 43 2009 VOL. 2012

Heart Failure and Short Stature a 43 year-old male Filipino Seafarers’ Lived Experiences aboardinShipping Vessels

Table 1. Initial “Therelaboratory is a gym,Results we can play basketball, softball. There is a swimming pool, dumbbells, CBC Blood chem. treadmills, stationary and mobile bicycles. Reference TheseReference were available Result anytime, however, we Value Value seldom use them because we wereRBS tired after WBC 3.9-6.1 5-10 4.5 work4-6 and drinking sprees.” RBC HGBA1C 4.27-6.07 HGB 2.6-6.4 “It is120-150 only in one’s attitude, just BUN believe that 90 HCT 53-115 0.27want to CREA you 0.38-0.48 could cope, if you aspire for a MCV AlB 34-50 80-100 Fl higher position and financial growth, you can MCH TAG 0.34-1.7 27-31 PG MCHC do it.” HDl 0.91-1.56 320-360 G/l The coping mechanisms of those lDl working in luxury RDW 1.1-3.8 11.5-15.5% PlT were almost ToTAl 4.2-5.2 200-400similar to those Inc from the liners dryCHol cargo/tanker RETIC except AST occasions,15-37 0.005-0.015 vessels that the former, on some had SEG AlT 30-65 50-70% 48 opportunities to attend parties for the crews, going to disco lYMPH Alk po4 20-44% 50 orMoNo even to spas. NA 140-148 2-9% 2 Eo

0-4%

0

K

3.6-5.2

BASo Cl 100-108 0-2% 0 Informational Support BlAST 2.12-2.52 0% from the dry 0 Informants cargo CA++ bulk/tanker vessels P indicated that guidebook like self-care MG++and HIV/AIDS 0.74-1 information were available on board. There were also materials on hypertension, cholesterol and healthy diet. Informants also indicated that these were read when they already out ofFunction something to read. Table 2. ran Thyroid Tests ‘We have reading materials about high blood, Reference Value Result food to eat. We read Free T4 cholesterol, and(0.8-2.0) 0.02these ng/dl materials when (0.4-6.0) we ran out of something to TSH 24.75 Uiu/ml read or after reading FHM.” Materials on safety, first aid were available in the mess hall and in the hospital/clinic. There were times that the captain would casually remind seafarers to reduce weight when needed. There was one who mentioned that if the captain was a Filipino, safety meetings where topics like disease prevention for diseases such as STIs/AIDS on top of work-related problems and concerns were included. Use of condoms to prevent STIs was likewise mentioned to be taught on board. Most of the informants from luxury liners mentioned that they had access to materials such as posters on STD/AIDS, hypertension, and condom use. There were also lectures or seminars on alcohol and drug awareness, hygiene, health diet, basic safety, vaccination, and pregnancy. Condoms and pamphlets were mentioned to be Figure 1. Electrocardiogram upon admissionwere as follows: available in the infirmary. Some quotations “We were taught on how to use condoms to prevent HIV, there were pamphlets about transferred to the intensive care unit (ICU) for ventilatory pregnancy .There were too many lectures on support and closer monitoring. on bedside cardiac ultrasound, safety but health issues were not always there was a finding of eccentric left ventricular hypertrophy, included, very focused on service and safety.” global hypokinesia with depressed overall systolic function “We have posters in bulletin boards, there with concomitant spontaneous echo contrast on left ventricular were advertisements about flu and vaccination (lV) cavity suggestive of rheologic stasis, the ejection fraction during seasons. mitral We were taught aboutmoderate was 25%, with flu moderate regurgitation, condom use.” aortic regurgitation with aortic sclerosis, severe tricuspid

regurgitation with mild pulmonary hypertension, pulmonary regurgitation, and minimal pericardial effusion or pericardial

Vol. 46 43 NO. N0. 432009 VOL. 2012

Family Support With the advent of modern technology, communication Urinalysis ABG with family members has become relatively easier. This was Result Color straw pH 7.408 especially true for those in the luxury liners as most of the times, they had access to communication like mobile phones 6.3 Transp Clear pCo2 49.1 and, could talk with1.010 their families 6.4therefore,Sp Gravity po2 and loved 70 ones 5.0 8.0 could also HCo3make use 31.3 anytime they werepHallowed. They of the 123 Sugar NEG sat corresponding 93.6 communication facilities of the ship but o2 with 32 Protein NEG Fio2 21% charges. Informants working in dry cargo bulk/tanker 0.82 RBC 0-1 Temp 36.9 vessels easy access 0-2 to communication on board, 0.67 also haveWBC but4.21 they have to pay Cast about US$ 24 per 27 minutes. PBS They can Epith cell Rare use5.25 their mobile phones if telephone receptions or signals Slight poikilocytosis, 95 available. Bacteria occ’l were acanthocytes, ovalocytes, 91 Mucus th Rare slight toxic granulation, 184 Crystals Rare slight anisocytosis Discussion and Recommendations 136.9 Am urates The objective of this study was to document the Filipino 3.35 86 seafarers’ lived experiences amidst the circumstances in 2.37 international shipping vessels, specifically those related to 2.27 their 0.83health conditions, access to and satisfaction with the

available health services and facilities, as well as their coping mechanisms. Seafaring workforce is one of the occupational groups fat pad.receive Cardiac were not consistent an acute which a enzymes substantial amount of health-with information. coronary event (Table 3), however, intravenous (IV) Health-information was received at various stages heparin of their (overlapping oral warfarin) was still givenand to cover for work - from with the PDOS, during their physical medical the presence of a possible lV thrombus as demonstrated examinations, and until they are finally employed. This cycle byrepeated rheologic stasis ontheir cardiac ultrasound. Medications is throughout lifetime until retirement which were shifted to IV diuretics and inotropes; oral digoxin was is determined not by age but by physical fitness to work. started. IV antibiotics were given for possible pulmonary HIV/AIDS-related information is mandated by law to be infection. The patient later Furthermore, on showed improvement, and was given during the PDOS. they also have free eventually weaned off from ventilatory support, extubated, and regular access to health services and facilities either on board or during their medical examinations. TableDespite 3. Cardiac Enzymes receiving health-information at various work stages, results still showed a preponderance of lifestyleReference Range (mmoL) Result related conditions and STI-risk behaviors among this Qualitative PoSITIVE population Troponin I group which is consistent with what was found 0-6.0conditions were either 1.14 observed inCK-MB other studies.8,9,11,12 These 21-232co-workers or were 543personally toCK-ToTAl have happened to their experienced by at least one of them. This seeming inconsistency between good knowledge and poor practice could be explained by the fact that good knowledge of a health condition is not always translated into an ideal practice or behavior and that providing access to health services and facilities does not always equate to its utilization. It is important to study other factors that could influence this knowledge-behavior gap in order to improve the health of the seafarers. An example of this is how to improve the utilization of on-board health and wellness facilities such as the use of incentives and linking good/positive indicators to adherence to healthy lifestyle programs. Seafarers from both types of vessels were able to cope up with the different work-related stresses on board. Coping Figure 2. Chest radiograph on admission ACTA ACTA MEDICA MEDICA PHILIPPINA PHIlIPPINA 13 5

Filipino Seafarers’ Lived Experiences aboard Shipping CASE VesselsREPORT

7. Collins A, Matthews V, McNamara R. SIRC/Center for Occupational and mechanisms were made easier betterStature Heartrelatively Failure andwith Short in a 43 year-old male Health Psychology. Fatigue, health and injury among seafarers and communication facilities and equipment, availability of workers on offshore installations: A Review. September 2000; pp. 22-23. 1 leisureKaterina facilities, materials 1, and gadgets, M. informational T. leyritana Ma. Czarlota Acelajado-Valdenor , Amado o. Tandoc III2 and Agnes D.Prevalence, Mejia1 Risks 8. Saniel OP, Tolabing CC, Lebanan-Dalida MO. HIV and Vulnerabilities of Cavite Overseas Filipino Workers, Their Spouses support available on board and family support provided by 1 andHospital, Their Children: Baseline Research for Programme Department of Medicine, Collegethe of Medicine and Philippine General University of the Philippines Manila Area 1 of the Joint the their loved ones. This finding reflects adaptability of UN Program onPhilippines HIV and Migration, Manila: DOH. 2010a. pp. 81-90. 2 Department of Pathology, College of Medicine, University of the Manila Filipino seafarers amidst difficult circumstances which is 9. Kaerlev L, Dahl S, Nielsen PS, et al. Hospital contacts for chronic consistent with what was found by other authors.2,8 diseases among Danish seafarers and fishermen: A population-based cohort study. Scand J Public Health. 2007; 35(5):481–9. In light of the above findings, it is recommended that an 10. Armstrong W. Noumea, New Caledonia: Secretariat of the Pacific integrated healthy lifestyle policy be formulated and Community. HIV/AIDS and STD among Seafarers in the Pacific Region. implemented by the shipping management. This policy can In: Proceedings of the 1st Pacific Regional HIV/AIDS and STD Conference (1st: 23-25 February, 1999: Nadi, Fiji) Noumea, New include provisions that promote healthy diet among Caledonia. 2000. pp. 34-36. seafarers within the context ofofthe environment require regular laxative use. There was also a report of two Presentation theseafaring case 11. Suñas L. Remedios AIDS Foundation, Inc., The vulnerabilities of moreFilipino syncopal episodes. He[Online]. was brought to2012 another doctor is aperiod case ofofa travel 43-year-old with short e.g.This long at sea,male etc. presenting The healthy lifestyle seafarers to HIV/STIs 2003 [cited July]. Available in a private hospital where the assessment was still a “heart stature and heart Theprovisions patient was at the policy should alsofailure. include thatadmitted will promote from http://www.remedios.com.ph/html/mk3q2003_tvof.htm. 12. Dulay HB. Of patient kilatis, women Filipino seafarers: perceptions of problem”. The was and again prescribed unrecalled medicine ward of Philippine General (PGH) physical activity andthe exercise among the staffHospital and crew with Filipino seafarers on sexually-transmitted disease, its prevention and medications and again was lost to follow-up. This time, for This paper investigate several due dyspnea. regard to the work shiftwill environment in the ship. issues: treatment. A Master’s Thesis. Faculty of Social and Behavioral Sciences, however, symptoms were persistent. He later consulted at differentiating acquired hypothyroidism, This policycongenital should befrom supported by more appealing, Universiteit van Amsterdam. 2004. 13. Binghay VC.hospital, School of Labor and Relations,and University of the another local where heIndustrial was admitted managed the relationship between hypothyroidism and the durable and culturally appropriate information, education Philippines, Ensuring occupational health and safety for overseas as a case of anemia and bronchial asthma. He was discharged cardiomyopathies, and the therapeutic options in patients and communication (IEC) materials which can be provided Filipino seafarers [Online]. [cited 2012 July]. Available from slightly improved after four days, only to have recurrent heart with cardiomyopathy to hypothyroidism. in strategic locations secondary such as mess halls and crew cabins. http://www.freewebs.com/upsolair/Ensuring%20Occupational%20Healt failure symptoms, prompting admission at PGH. The patient had been born full term to a then 31-yearMaterials in video format can be distributed to seafarers to h%20and%20Safety%20for%20Overseas%20Filipino%20Seafarers.pdf. th 14. Polit D, Beck C. Nursing 7th ed. Upon admission the Research: patient Principles was in and mildMethods, respiratory old Gravida 4 Para 3 (G4P3), the 4 of 9 siblings, with an be viewed during assemblies and in their cabins. Philadelphia: Lippincott Company; 2004. p.note 253. of fever. Pertinent distress, with stable vital signs and no apparently unremarkable delivery at home facilitated by The above conclusions and recommendations should be 15. Family Health International, Qualitative Research Methods: A Data physical exam findings included short stature, thick lips, nonataken traditional attendant. He was noted to be normal in the birth light of the study’s possible limitations. The Collector’s Field Guide. Module 1 Qualitative Research Methods pitting periorbital at birth. The patient was allegedly at par with age both Overview. p. 5. edema, dry skin, a displaced apical impulse, selection of only one industrial clinic as the study site raises 16. Sandelowski Sample size in qualitative research. Res Nurs Health. crackles on bothM.lung fields, and bilateral non-pitting bipedal physically and mentally until eight years old when he was the question on whether or not the data gathered in this 1995; 18(2):179-83. edema. There was also a 3 cm x 3 cm reducible umbilical said to have stopped growing in height. He was brought to particular clinic is representative of the common seafarers hernia. However, there was no pallor, no neck vein distention, aexperience. private doctor, diagnosis was and he Since whose this industrial clinic is undisclosed, one of the biggest in no apparent congenital malformations, no cardiac murmurs was given medications to increase height, which the patient Metro Manila and caters to various international shipping and no clubbing. There was also no note of an anterior neck took for only one month with no improvement. Through the companies, it is also possible that the lived experiences of the mass. years, the patient was apparently well, although still of short study informants do not vary much with those from other laboratory workup showed cardiomegaly with pulmonary stature, with thick lips, coarse facial features and dry skin. industrial clinics. It is the goal of this qualitative study to congestion, thoracic dextroscoliosis, and atheromatous aorta by He was notably slow in ambulation. He was said to have provide more depth and breadth in the ongoing discussion chest radiograph, and left ventricular hypertrophy by 12-lead bronchial asthma at age 15 years, and since then he had been of these important issues so that we can better understand electrocardiogram (12-l ECG) (Figures 1 and 2), normocytic taking salbutamol tablets occasionally for bouts of dyspnea the lived experiences of Filipino seafarers. normochromic anemia (Hgb 90 mg/dl), dyslipidemia, and occurring one to two times annually. pre-renal azotemia (serum creatinine 123 mmol). Electrolytes The patient’s symptoms started in 2001 when he was ___________ on admission showed slight hyponatremia, hypokalemia, reported to have sudden loss of consciousness. During this and hypochloremia (serum Na 136, K 3.35, Cl 86). Blood gases References time, the patient did not have any symptoms of heart failure; 1. Pinoyseizures, sailors remit over US$ 4 billion chest in 2011pain, [Online]. 2012 [cited revealed partially compensated metabolic alkalosis with mild no prior cyanotic episodes, headache, or 2012 Feb]. Available from http://www.gmanetwork.com/news/ hypoxemia. The patient was noted to be hypothyroid based blurring of vision. He regained consciousness shortly after and story/249538/pinoyabroad/pinoy-sailors-remit-over-4-billion-in-2011. on elevated serum thyroid-stimulating hormone (TSH) and was brought to a private physician, whose assessment was a 2. Swift O. Flexible Filipinos: myths and realities about Filipino seafarers: Understanding of seafarers’ partners in retaining quality crew. markedly decreased serum free thyroxine (FT4). The exact “heart problem”.the Herole was prescribed unrecalled medications University of London. values are shown in Tables 1 and 2. takenAnthropology, for a few Goldsmiths months and eventually discontinued when 3. BIMCO/ISF Manpower 2005 Update. The world demand for and supply Upon admission to the wards, the patient was managed the syncopal episode did not recur. of seafarers, Institute for Employment Research, University of Warwick, as having congestive heart failure from cardiomyopathy InDecember the next four years, the patient would develop 2006. 4. Hansen HL.progressive Surveillance ofexertional deaths on board Danish and merchant ships, secondary to acquired hypothyroidism. oral loop diuretics, intermittent, dyspnea bipedal 1986:implications for prevention. Occup Environ Med. 1996; 53(4):269angiotensin-converting enzyme (ACE) inhibitors, betaedema. later on this would be accompanied by generalized 75. blockers, statins, and levothyroxine were started. Electrolyte body weakness, anorexia, and constipation, severe enough to 5. Roberts SE, Hansen HL. An Analysis of the causes of mortality among correction was instituted. The sections of Endocrinology seafarers in the British merchant fleet (1986-1995) and recommendations for their reduction. Occup Med (Lond). 2002; 52(4):195-202. and Cardiovascular Diseases were co-managing the patient Corresponding Acelajado-Valdenor, M.D.due to 6. Nielsen D, author: Hansen Ma. HL, Czarlota Gardner BM, Jungnickel D. Deaths together with the General Medicine service. Department of seafarers Medicine disease of on board Singapore ships. Int Marit Health. 2000; He soon developed respiratory failure, upon which the Philippine General Hospital 51(1-4):20-9. 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: [email protected]

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Vol.46 43NO. N0. 43 2009 VOL. 2012