The early days of Dialysis at Sea began with a small travel agency 31 years ago. The owner used the agency to find travel deals for herself, her husband and another couple, recounted Steve Debroux, president of Dialysis at Sea. "They’d always vacation with this couple, but the friend’s husband went into kidney failure and all of a sudden, the traveling stopped. When the owner of the travel agency heard about this, she said ‘You are going to travel; we’ll just bring the dialysis machine with us’ and would not take no for an answer," he said.
The agency thus morphed into a travel agency that also provided dialysis. The company grew slowly, but dialysis requirements grew larger and the company was undercapitalized, so the company was sold to Bill Boverly, who eventually offered a partnership to Debroux. "I didn’t know anything about the travel business or dialysis, so I said, ‘Let me take a look and see what we have.’ It became apparent that the travel side was primary and the dialysis side was a necessary evil, and I didn’t have a comfort level with the way things were set up," Debroux recalled. "If you’re going to do life- support treatments, the emphasis should always be that the medical side is taken care of first, then the travel side second."
Debroux and the managers went to school to become biomedical-certified by Fresenius and Baxter. "We really didn’t know a whole lot about it. Technicians were talking about proportioning problems, and we were wondering, ‘What the heck are they talking about?’ We had to take the mystery out of this thing, so off to school we all went," he said.
In early years, the company did not meet any standards for dialysis. The service is not covered by Medicare because it is all provided offshore. However, Debroux made it a priority to learn about the standards that governed dialysis centers, and established a new company motto: to meet or exceed all AMI standards. Dialysis at Sea now meets or exceeds these guidelines, and Debroux said, is willing to compare its ship-based service to any land-based units.
Setting up a Clinic at Sea
None of the company’s services are contracted out; Dialysis at Sea owns all the equipment and provides the services itself. The company publishes a new cruise calendar three times a year, listing approximately 100 trips on several cruise lines. The company brings its own dialysis machines and R/O systems on board, as well as its own nurses and nephrologists. Typically, the dialysis center on-board will include four machines with redundant systems available as needed. At the end of the cruise, Dialysis at Sea just takes its equipment off the ship.
The company leases part of the ship’s infirmary to create the dialysis clinic. The nurses and physicians are available to the patients 24 hours a day throughout the length of the cruise, and are put up as passengers on the ship. "We are completely independent from the cruise lines. The only thing the cruise line does is lease us the space," Debroux emphasized.
Setting up the dialysis center is done as in a land-based center—because the ship’s water is potable, it is filtered just as it would be on land and sent through a medical-grade R/O system. Red-bag waste is boxed and taken off the ship with the equipment at the end of the cruise, where it is picked up and disposed of by a biohazard company.
Treatments essentially mirror those provided in traditional dialysis facilities. "We offer a continuum of service," Debroux explained. "Even though we have a nephrologist and the nephrologist does a physical on the patient and makes rounds, the idea is that they’ve already been diagnosed [at home] and their treatments have already been adjusted to a protocol that works for them. We use the Fresenius 2008K machines and duplicate the treatments they get at home."
For several reasons, patients often like their cruise treatments better than those at home. "That’s because a) they see a nephrologist before every treatment, and b) the nurse/patient ratio is two patients to one nurse. And c), it’s better because they’re on vacation, so the atmosphere is different," Debroux stressed.
Patients do not have the luxury of the home pharmacy, so they are required to bring enough of their medications with them for the duration of the cruise. Although Dialysis at Sea will stock the basics—heparin, antibiotics, etc.—there are simply too many dialysis medications for the company to carry them all. But as long as the patients pack sufficient medication, there is generally no limit to how long they can cruise. Some long cruises visit Europe or Alaska. One cruise that originates in Auckland, New Zealand, is a World War II memorial that cruises to the Philippines, throughout the Pacific, and up to Japan. It lasts 35 days.
Removing the chains that restrict patients to a small radius of their homes and dialysis centers is life-changing. Patients and their families are grateful for the ability to go on vacation. "Much of the feedback is about the patients having a sense of freedom," Debroux said. "Once in a while, we get a dialysis patient who’s cranky at times—rightfully so, because they’re pretty courageous people to go through that regimen. But 95 percent of our feedback is pretty complimentary. The most difficult thing for us is, we have a lot of repeat customers, and we know dialysis patients are ill. But they develop friendships with our sales agents— they’re not just clients—and when they pass away, it becomes gut-wrenching for the people here, because it’s like losing a friend. My job is to put things in perspective, saying, ‘You have to think of all the good things we provided for them.’ Not only does the cruise do wonders for the patient, it also does more for the caretaker, because they’re the ones who need it the most," he pointed out.
The company’s greatest challenge is delivering excellent care in every location. The logistics of supply and demand can make that difficult. "We operate on a global basis and have departures from Auckland, San Diego, Barcelona, Vancouver, Copenhagen, New York, the Caribbean, Miami, Fort Lauderdale and Tampa. Since 9/11, security in the ports has tightened up, and that makes things very difficult. Also, there is the need to provide the same level of care anywhere we go. It’s like McDonald’s—everywhere you go, it’s supposed to taste the same. So how do we provide all the support and logistics? If it’s in Tampa and 20 minutes from our office, that’s fairly easy to do, but how do we do the same thing in Copenhagen? Or if we have to resupply in Osaka, Japan, how do we do that? Dialysis is a fairly complicated system, but the logistics are probably the most challenging part of this business."
All of the dialysis supplies come from the United States and are planned far in advance. "Although we could probably supply from other places, we’re not really sure what we’d be getting," Debroux pointed out. "For the cruise from Auckland—the WWII memorial cruise— all of the equipment and supplies were loaded on the ship at the beginning of September last year. On departure, our technicians will fly to Auckland, board the ships, and get the system set up and ready to go. Obviously, we don’t have an infinite amount of equipment, so we have to make sure the equipment is at the right place at the right time for the cruise patients."
Running out of supplies when far from home is not an issue; the company has learned to factor in "extras" as a matter of course. "In the past 10 years, we’ve never run out of anything. We’re keenly aware that if a ship in Japan runs out of bloodlines, it’s not good business to have someone spend $5,000- $7,000 to fly to Osaka on the same day to bring a dozen bloodlines worth three bucks apiece. It’s just cheaper to put a couple dozen extra bloodlines on the ship before it leaves," he said.
Formulas programmed into the company’s internal computer system calculate a safety factor for each supply, and take into account how far away the ship will be. Coming back from San Diego to Hawaii takes four days, and running out of a supply when the ship is out of helicopter range would be an enormous problem. "That is when we get nervous, and that is when the logistics get checked and double-checked. But for everything we do, there are always two people looking at the counts, and the vice president of operations does a final inspection on everything that goes out, to make sure the counts are correct," he added.
Home Away From Home
To make the experience on-board more enjoyable, each cruise will accept no more than 16 dialysis patients. "It’s not that we couldn’t do more, but the idea is for the dialysis patients to get away from dialysis—to become an unknown—and if we take more than 16 patients, it becomes noticeable. We never seat the patients or their families with the nurses or doctors or with each other; they’re always at different tables, and if they want to tell somebody they’re on dialysis, that’s their business. But we are very private, and very few people know we’re on board," Debroux pointed out.
"What we do sometimes interferes with the travel, but our emphasis is that the medical side is always first, and we do not negotiate with the medical phase of the business," he said. "We set times for dialysis and we match the treatments, and we will not cut treatment short to accommodate their being able to go to a particular event. Being on dialysis means you may have to miss something. Some people complain, ‘I paid all this money, and I’m going to miss X.’ We tell the patients, if you stay compliant while you’re on the ship, do your full treatments, you’re going to have a wonderful trip. You may miss a couple things. But if we start juggling around the treatment, we know from experience that the first part of your cruise might be great, but during the last part of the cruise, you’re going to run into problems.’ We are sticklers for the medical side first. Keep them healthy, keep them well treated, and they’ll have a wonderful vacation."
One reason for sticking to a non-negotiable treatment time is the ship’s logistics. When the dialysis center provides treatments, the ship is informed, and the ship’s engineer knows they have to maintain certain levels of water pressure. There cannot be testing of the emergency generators, for example, while dialysis is going on. "There are windows in which we do dialysis, and all the technical people on the ship know that we’re doing that. They’re under requirements to maintain water pressure, electricity, etc. There are a lot of things going on behind the scenes for the patient’s safety that people don’t know about it, so the schedules are chipped in granite. The patients sometimes think we’re crazy, but you have to look at the bigger picture," Debroux concluded.