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The Sinking of the MV Doña Paz – I. An analysis of the event

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 The Sinking ofHeart
CASE REPORT
ORIGINAL ARTICLE Failure
the MV DoñaandPaz
Short
– I.Stature in a 43 year-old
An analysis male
of the event

Heart
Table 1. Initial Laboratory Failure
Results
The Sinking of the MV and Short
Doña Paz Stature in a 43 year-old
– A Critique on Maritime maleDisaster
CBC Blood chem. Urinalysis ABG
Katerina T.Preparedness in the
Leyritana1, Ma. Czarlota Philippines: An
M. Acelajado-Valdenor1 analysis
, Amado of the
O. Tandoc event
III2 and Agnes D. Mejia1
Reference Result Reference Result Color straw pH 7.408
Value Value
1
Department of Medicine, College of Medicine and Philippine General Hospital, University of the Philippines Manila
WBC 5-10 Anthony24.5 RBS 1 Carl Abelardo
R. Perez, 3.9-6.1 T. Antonio
6.3 Transp J. Consunji
2 and Rafael Clear 3,4 pCO2 49.1
Department of Pathology, College of Medicine, University of the Philippines Manila
RBC 4-6 HGBA1C 4.27-6.07 6.4 Sp Gravity 1.010 pO2 70
HGB 120-150 90 BUN 2.6-6.4 5.0 pH 8.0 HCO3 31.3
HCT 0.38-0.48 0.271Division CREA
of Hepatobiliary and53-115 123
Pancreatic Surgery, Department Sugar
of Surgery, NEG O2 sat 93.6
MCV 80-100 FL College of Medicine ALB 34-50 Hospital,
and Philippine General 32University of the
Protein NEG
Philippines Manila FiO2 21%
MCH 27-31 PG TAG 0.34-1.7
2Pasay City Health 0.82
Office RBC 0-1 Temp 36.9
MCHC 320-360 G/L 3DivisionHDL 0.91-1.56 0.67 WBC
of Surgical Critical Care and Trauma, Department of Surgery, 0-2
RDW 11.5-15.5% College of Medicine LDL 1.1-3.8 Hospital,
and Philippine General 4.21
University of theCast
Philippines Manila PBS
PLT 200-400Presentation of theGroup
Inc4Study case
TOTAL CHOL 4.2-5.2 5.25 regularEpith
require cell use. There
laxative
on Injury Prevention and Control, National Institutes of Health,
Rare wasSlight
also a report of two
poikilocytosis,
RETIC 0.005-0.015
This is a case AST
of a 43-year-old male presenting with 15-37
short more95 syncopal Bacteria
episodes. He Occ’l brought
was to another
acanthocytes, doctor
ovalocytes,
University of the Philippines Manila
SEG 50-70% 48 ALT 30-65 91 Mucus th Rare slightwas
toxicstill
granulation,
stature and heart failure. The patient was admitted at the in a private hospital where the assessment a “heart
LYMPH 20-44% 50 Alk po4 184 Crystals Rare slight anisocytosis
medicine
MONO ward 2-9%of the Philippine2 General
NA Hospital (PGH) 140-148 problem”.
136.9 TheAmpatient
urates was again prescribed unrecalled
for
EO dyspnea.0-4% This paper will
0
ABSTRACT investigate
K several issues:
3.6-5.2 medications
3.35
comprises. and the
Given again was lost toto follow-up.
vulnerability This time,
harsh environmental
BASO
differentiating 0-2%congenital from
0 acquiredCL hypothyroidism,
Objective. To discuss the various factors contributory to the 100-108 86
however, symptoms were persistent. He later consulted at
BLAST CA++ 2.12-2.52
conditions and our reliance on boats and ships for inter-
2.37 local hospital, where he was admitted and managed
the 0%
relationship between 0 hypothyroidism and the another
fatalities that resulted from the sinking of the MV Doña Paz. island
P 2.27 travel, Filipinos are somewhat resigned to the
cardiomyopathies, and the therapeutic options in patients as a case of anemia and bronchial asthma. He was discharged
MG++ 0.74-1 0.83
numerous maritime accidents dotting the history of the
with cardiomyopathy
Methods. Review of thesecondary pre-disaster,to hypothyroidism.
disaster and post-disaster slightly improved after four days, only to have recurrent heart
Philippine domestic shipping industry and their toll on
events
Thesurrounding
patient hadthe beensinking
bornoffull MV Doña
the term to a Paz,
thenas31-year-
well as failure symptoms, prompting admission at PGH.
the human life (Table 1).
old subsequent
Gravida 4 Para response by thethe
3 (G4P3), government and responsible
4th of 9 siblings, with an Upon admission the patient was in mild respiratory
agencies
apparently to the disaster.
unremarkable delivery at home facilitated by fat pad. Cardiac
distress, enzymes
with stable wereand
vital signs notnoconsistent with Pertinent
note of fever. an acute
Table 2. Thyroid Function Tests Table 1. Maritime disasters* in the Philippines (1980-2003)
a traditional birth attendant. He was noted to be normal coronary eventfindings
physical exam (Table 3), however,
included intravenous
short (IV)lips,
stature, thick heparin
non-
Results. The Sinking of the MVValue
Reference Doña Paz, along Result
with the loss of
at birth. (overlapping
pitting withedema,
periorbital oral warfarin)
dry skin,was
a still given
displaced to cover
apical for
impulse,
more thanThe
Free T4 4,000patient
precious waslives,
allegedly at par within age
(0.8-2.0) is but a footnote
both
0.02 ng/dLthe long 1980 M/V DON JUAN 180 DEAD/115 MISSING
physically and mentally until eight years old when he was the
1981
presence
crackles on of
both
M/V SAN JUAN
a
lungpossible
fields, LV
and thrombus
bilateral as demonstrated
non-pitting
52 DEAD bipedal
litany
TSH of misfortunes plaguing (0.4-6.0)the Philippine maritime industry.
24.75 Uiu/ml
said to have stopped growing in height. He
A closer look into the events and circumstances leading to this was brought to by1986rheologic
edema. There
M/V DOÑAstasis
was on a cardiac
also
JOSEFINA 3 cm x ultrasound.
3 cm reducible
150 DEAD Medications
umbilical
a privatedemonstrates
tragedy doctor, whose diagnosis was
a confluence undisclosed,
of equipment and and he
system were
1987 shifted
hernia. to IVPAZ
M/V DOÑA
However, diuretics
there was no and inotropes;
pallor, no neckoral
> 4000 DEAD
veindigoxin was
distention,
1988 M/V MARILYN 500 DEAD
was given medications
inadequacy on one hand to increase
and human height,error
whichandthe lack
patient
of started.
no IV antibiotics
apparent congenital were given for
malformations, possible
no cardiac pulmonary
murmurs
1994 M/V CEBU CITY 66 DEAD/ 76 MISSING
took for onlyon
preparedness onethemonth
other.with no improvement. Through the infection.
and
1995no M/VThe patient
clubbing.
VIVA later
There
ANTIPOLO wasonalso
VII showed improvement,
no note and neck
of an anterior
62 DEAD was
years, the patient was apparently well, although still of short eventually
mass.
1995 M/V weaned
KIMELODY off from ventilatory
CRISTY support,
17 DEAD/ extubated,
20 MISSING
Conclusion.
stature, with Multiple factors
thick lips, account
coarse forfeatures
facial the occurrence
and dryofskin.
this 1996 M/L GRETCHEN I
Laboratory workup showed cardiomegaly51 DEAD
with pulmonary
tragedy, along with other maritime disaster incidents dotting the 1996 M/V DAVID JR. 7 MISSING
He was notably slow in ambulation. He was said to have congestion,
Table
1996 3.M/B thoracic
Cardiac dextroscoliosis,
Enzymes
NICKADEL and atheromatous
4 MISSING aorta by
long maritime history of the Philippines. A cursory analysis of
bronchial
these factorsasthma
may at leadageto15recommendations
years, and since then that he
canhad been
prevent chest
1996 radiograph, and left ventricular hypertrophy
M/V PENAFRANCIA by 12-lead
2 THROWN OVERBOARD
Reference Range (mmoL) Result
taking salbutamol tablets occasionally
similar occurrences in the future and mitigate damage to for bouts of dyspnea electrocardiogram
1997 (12-L ECG) (Figures
M/B FISH HUNTER 1 and 2), normocytic
3 DEAD
Qualitative
1997 F/B ANNIE PAULINE POSITIVE
4 MISSING
occurring
property andone to of
loss twolife.times annually.
The policy implications of these findings normochromic
Troponin
1997 M/V
anemia
I KALIBO STAR
(Hgb 90 mg/dL), dyslipidemia, and
17 DEAD/ 13 MISSING
The patient’s
are discussed symptomspaper.
in a subsequent started in 2001 when he was pre-renal azotemia (serum
CK-MBM/V PRINCESS OF THE
1998 creatinine
0-6.0
ORIENT 123 mmoL). Electrolytes
70 DEAD/ 801.14
MISSING
reported to have sudden loss of consciousness. During this on admission
M/V ASIAshowed
CK-TOTAL
1999 slight hyponatremia,
21-232
SOUTH KOREA 58 DEAD hypokalemia,
543
time,
Key the patient
Words: maritime did not have
industry, any symptoms
Philippines, of heart failure;
disaster preparedness and
2001hypochloremia
M/L ANNAHADA (serum Na 136, K 3.35, Cl 86).
124 DEAD/ Blood gases
14 MISSING
2002 M/V MARIA CARMELA 39 DEAD / 6 MISSING
no prior seizures, cyanotic episodes, chest pain, headache, or revealed
2002
partially compensated
M/V NILODE- A
metabolic alkalosis
19 DEAD
with mild
blurring of vision. He regained Introduction
consciousness shortly after and hypoxemia.
2003 The patient
M/V SAN NICHOLAS was noted to43 DEAD/ 21 MISSINGbased
be hypothyroid
was The
broughtPhilippines
to a private is physician,
a maritimewhose country by force
assessment wasofa on elevated serum thyroid-stimulating hormone (TSH) and
geography owing to its archipelagic layout. Hundreds of *Maritime
markedly disasters refer to events
decreased serum occurring at sea that result
free thyroxine to “aThe
(FT4). mismatch
exact of
“heart problem”. He was prescribed
Figure 1. Electrocardiogram upon admission unrecalled medications
casualties seeking medical care and the availability of such care.” (Eischen J. Maritime
ferries
taken for carry many
a few thousands
months of workingdiscontinued
and eventually people and whenrural values In: areHogan
shown in Tables 1 and 2. medicine, 2nd ed. Philadelphia, PA:
disasters. DE, Burstein JL, eds. Disaster
poor between
the syncopal the more
episode did not than 7,000 islands the country
recur. Upon
Lippincott admission
Williams to2007.
& Wilkins; the pp.
wards, the patient was managed
332-338.)
transferred
In the next to thefourintensiveyears,care theunit (ICU)would
patient for ventilatory
develop as having congestive heart failure from cardiomyopathy
_______________
support and closer monitoring. On bedside cardiacand
ultrasound,
intermittent, progressive exertional dyspnea bipedal secondary
On theto morning
acquired ofhypothyroidism.
December 21, Oral1987,loop
the diuretics,
Filipino
there
edema. was a finding
Later on thisofwouldeccentric left ventricularbyhypertrophy,
be accompanied generalized angiotensin-converting
people were given a rudeenzymeawakening(ACE)
wheninhibitors, beta-
the news broke
global hypokinesia
body weakness, with depressed
anorexia, overall severe
and constipation, systolicenough
functionto blockers,
that statins,
the lives of and
morelevothyroxine were started.
than 4,000 people hopingElectrolyte
to spend
with concomitant spontaneous echo contrast on left ventricular correction in
Christmas was instituted.
Manila Theforever
were lost sections
in aof
seaEndocrinology
of fire off the
Corresponding author: Anthony R. Perez, MD
(LV) cavity suggestive of rheologic stasis, the ejection fraction
Department of Surgery and Cardiovascular Diseases were co-managing
coast of a remote province in Mindoro. The theensuing
patient
Corresponding
was 25%, withauthor: Ma. Czarlota
moderate mitral Acelajado-Valdenor, M.D.
regurgitation, moderate
Philippine General
Department of Medicine
Hospital together with the General Medicine service.
response from concerned agencies focused on finger
aortic regurgitation
University
Philippine
of the Philippines
General Hospital with aortic sclerosis, severe tricuspid
Manila He soon
pointing, developed
putting respiratory
the blame failure, upon
on organizations whichwith
concerned the
Taft Avenue, Ermita, Manila 1000 Philippines
regurgitation with mild
Taft Avenue, Manila, pulmonary hypertension, pulmonary
1000 Philippines considerations were acute pulmonary congestion, nosocomial
safety and enforcing regulations governing the Philippine
Telephone: +639209703622
Telephone: +632and
regurgitation, 554-8488
minimal pericardial effusion or pericardial Figure 2. Chest
pneumonia, radiograph
to rule on admission
out an acute coronary event. HeHouses
was later
Email: tonyperez92@yahoo.com maritime industry. Several bodies, including both of
Email: czarlota@yahoo.com

VOL.
VOL. 43 NO.
12 ACTA
45 N0. 432009
MEDICA2011 PHILIPPINA VOL.
ACTA MEDICA
ACTA MEDICA 43 N0. 4 2009
PHILIPPINA
PHILIPPINA 13
1
The Sinking of the MV Doña Paz – I. An analysis of theCASE
event REPORT

Congress displayed Heart extraordinary Failure eagernessandtoShort conductStature in athe

controlling 43 majority
year-old of themale shipping industry in the
hearings on the sensational issue in front of national media. Philippines. It had a declared capacity of 1,518 passengers
Katerina
Proposals T. Leyritana
to improve maritime
1
, Ma.safety
Czarlota by M. Acelajado-Valdenor
enforcing the and was 1
, Amado
manned O. byTandoc a crew III2 of
and 60.Agnes D. Mejia1 by
1 It was acquired

implementation of strict standards were bannered by Sulpicio Lines in 1975. 8

Department oforganizations
legislators and 1concerned Medicine, Collegeimmediately
of Medicine andafter
Philippine General
TheHospital, University629-ton
steel-hulled, of the Philippines Manila the other ship
MT Vector,
the incident.
2
Department of Pathology, College of Medicine, University
involved inofthe
the accident,
Philippinescarried
Manila a crew of 13. At the time of
The reality is that months after the incident interest died the incident, the Vector was on lease to Caltex Philippines,
down, with families of the victims left without or with only tasked with transporting its cargo of 9,000 barrels of
minimal compensation, with blame being put on agency gasoline, kerosene and crude oil from Bataan to Masbate.5,8
officials not capable of defending themselves. Questions on Most of the vessels plying the major Filipino domestic
the effectiveness of the proposed measures were quickly shipping routes are secondhand cargo and passenger ships
answered when another Presentation
passengerof the ship,
case the MV Marilyn require regular
bought cheap fromlaxative use. There
Japanese was alsowhich
shipyards, a report areof then
two
This is atocase
belonging the ofsame
a 43-year-old
shipping male company presenting withLines),
(Sulpicio short more syncopal in
reconditioned episodes. He was brought
local shipyards, given to new another
names doctor
and
stature
also sank,and hearthundreds
killing failure. The patient people
of innocent was admitted at the
a year later. in a privateas
advertised hospital
luxurywhere passengerthe assessment
liners. All wasthe still
seven a “heart
major
medicine wardofoftwo
This first the papers
Philippine will General
dissect and Hospital
analyze (PGH)
the problem”.
liners The Lines,
(Sulpicio patientSweet was Lines,
again Aboitiz
prescribed unrecalled
Shipping Corp,
for dyspnea. This
circumstances leadingpaper to, willduring,
investigate and several issues:
immediately medications
Hijos de Escano and Inc.,
againNegroswas lost to follow-up.
Navigation, CarlosThis time,
Gothong
differentiating
following, congenital
the worst peacetimefrommaritime
acquireddisasterhypothyroidism,
in modern however,
Lines, and symptoms
William were Linespersistent. He later
Inc.) maintain consulted
ships with an at
the relationship
history, in the process betweenreconstructing
hypothyroidism and the
the events as another local
average age of hospital,
22 years, where with he 20%
was admitted
of these more and managed
than 30
cardiomyopathies,
accurately as possible.and A thecomprehensive
therapeutic options in patients
understanding of as a case
years old.ofAccording
anemia and to bronchial asthma. He procurement
shipping companies, was discharged of
with cardiomyopathy secondary to hypothyroidism.
the incident, the factors contributing to the tragedy, the new ships coupled with high maintenance recurrent
slightly improved after four days, only to have costs andheart low
The patient
immediate had been
response to theborn full term
tragedy and to thea acute
then 31-year-
medical failure symptoms,
revenues will render prompting
business admission
non-viable.at1 PGH.
old Gravida 4 Para 3 (G4P3), the 4th
care provided to the victims will lead to recommendationsof 9 siblings, with an Upon admission the patient
In the Philippines, water transportation was in mild respiratory
is still the best
apparently unremarkable delivery at
for improving our preparedness to deal with and prevent home facilitated by distress, with stable vital signs and
mode of cargo carriage and transport between its moreno note of fever. Pertinent
than
a traditional
similar birth attendant.
catastrophes in the future. He was noted to be normal physical
7,000 exam findings
islands. Passengers included shortboth
traveling stature,
forthick lips, non-
business and
at birth. The patient was allegedly at par with age both pitting periorbital
pleasure to various edema, dry skin,
locations a displaced
within apical impulse,
the archipelago still
physically and mentally until Methods eight years old when he was crackles
favor water on both
travel lung
duefields,
to lowerandfares
bilateral
and non-pitting bipedal
unlimited baggage
said Ato comprehensive
have stopped growing search in andheight.
review He of wasallbrought to
available edema. There
allowances, was also
especially whena 3 compared
cm x 3 cmwith reducible umbilical
air travel.
a private doctor, whose diagnosis was
records on the sinking was performed. Relevant published undisclosed, and he hernia. However, there was no pallor, no
The travel conditions along the routes being plied by neck vein distention,
was given regarding
materials medicationsthe to increase
events were height, which the
gathered patient
including no apparent
these ships can congenital malformations,
best be described no cardiac murmurs
as unpredictable, at worst
took for only one month with no improvement.
newspaper articles from the most widely distributed daily Through the and no clubbing. There was
hazardous. In many parts of the country, also no note of antyphoons
anterior neckand
years, the patient
newspapers was apparently
that extensively well,the
covered although
incident.stillAofformal
short mass.
hurricanes regularly batter shipping lanes. The maritime
stature, was
request with made
thick tolips,
thecoarse facialDaily
Philippine features and dry
Inquirer, andskin.
the Laboratory
industry oftenworkup
has toshowed rely on cardiomegaly with pulmonary
weather advisories from
He was notably slow in ambulation. He
authors were given access to several archived articles on the was said to have congestion, thoracic dextroscoliosis, and
government agencies with aging and obsolete forecasting atheromatous aorta by
bronchial asthma
incident.1,2,3,4 at age
Official 15 years,
reports fromand since then
agencies he had been
concerned with chest radiograph,
equipment, and left
the batting ventricular
average of whichhypertrophy by 12-lead
can be described as
taking salbutamol tablets occasionally
the accident were secured and reviewed when available. A for bouts of dyspnea electrocardiogram (12-L ECG) (Figures
inconsistent at best. This is compounded by inadequate 1 and 2), normocytic
occurring
formal one tofrom
request twothe times annually.
MARINA office allowed the authors normochromic of
dissemination anemia
available (Hgb 90 mg/dL),
accurate weather dyslipidemia,
forecasts. Other and
The patient’s symptoms started in
to secure a copy of the report, "MARINA Report on the Doña 2001 when he was pre-renal azotemia (serum creatinine 123
aids to navigation appear to be equally inadequate. Of the mmoL). Electrolytes
reported
Paz to have
Tragedy". sudden loss from
5 Proceedings of consciousness.
congressional During this
hearings on admission
308 lighthousesshowed lining the slight
36,289 hyponatremia,
km coastline, hypokalemia,
less than half
time, the patient did not have any symptoms
were secured through the Senate Secretariat’s Office of heart failure; are operational. Only 42 of theK 120
and hypochloremia (serum Na 136, 3.35, charted
Cl 86). Blood
buoysgasesin
no prior seizures, cyanotic episodes,
Websites of government agencies concerned with the chest pain, headache, or revealed partially compensated metabolic
Philippine waters are in position. Government navigational alkalosis with mild
blurring ofindustry
maritime vision. He regained
were accessedconsciousness
and searched shortly
for after and
relevant hypoxemia.
charts have The patient
not been was noted
updated sinceto1980
be hypothyroid based
to reflect present
was brought
information.6 to a private physician, whose assessment was a on elevated serum thyroid-stimulating
sea conditions, such as vessel wreckage and non-functional hormone (TSH) and
“heart problem”. He was prescribed unrecalled
A direct interview with a survivor and another victim's medications markedly decreased serum free thyroxine
lighthouses. The numerous vessels plying these routes have (FT4). The exact
taken for were a few conducted.
months and Documentaries
eventually discontinued values are shown in Tables 1 and 2.
relative producedwhen by to rely on many occasions on the crewmen’s experience and
the syncopal episode 7did not recur. Upon admission to the wards, the patient was managed
National Geographic and GMA News Network8 were also instinct, referred to as “dead reckoning”. The Doña Paz and
In the next four years, the patient would develop as having congestive heart failure from cardiomyopathy
reviewed. the Vector set out on their respective voyages armed only
intermittent, progressive exertional dyspnea and bipedal secondary to acquired hypothyroidism. Oral loop diuretics,
A thorough review and cross referencing of the above with these navigational tools, as had always been the case in
edema. Later on this would be accompanied by generalized angiotensin-converting enzyme (ACE) inhibitors, beta-
sources of information were conducted to reconstruct the the numerous trips they had taken.5
body weakness, anorexia, and constipation, severe enough to blockers, statins, and levothyroxine were started. Electrolyte
circumstances surrounding the incident. Several government agencies and institutions oversee
correction was instituted. The sections of Endocrinology
the Philippine maritime industry and each has its own set of
and Cardiovascular Diseases were co-managing the patient
Corresponding author: Results and Discussion
Ma. Czarlota Acelajado-Valdenor, M.D. operating procedures. For every ship and every sailing,
Department of Medicine together with the General Medicine service.
Pre-disaster Events. The MV Doña Paz was a steel- clearances have to be obtained from at least eight agencies,
Philippine General Hospital He soon developed respiratory failure, upon which the
hulled liner built in 1963 weighing 2,215 tons and was including the Philippine Ports Authority (PPA), Bureau of
Taft Avenue, Manila, 1000 Philippines considerations were acute pulmonary congestion, nosocomial
owned
Telephone: by+632Sulpicio
554-8488 Lines, one of seven major companies Customs (BoC), Bureau of Posts (BoP) and Bureau of Plant
pneumonia, to rule out an acute coronary event. He was later
Email: czarlota@yahoo.com

12 ACTA MEDICA
2 ACTA MEDICA PHILIPPINA
PHILIPPINA VOL.45
VOL. 43NO.
N0. 43 2009
2011
 The Sinking ofHeart Failure
the MV DoñaandPaz
Short
– I.Stature in a 43 year-old
An analysis male
of the event

Table
Industry1. Initial
(BPI).Laboratory
Inspection by Results
the National Quarantine Office is also expected to constantly intercept and prevent pirates,
is aimed at ensuring sanitary conditions inside passenger terrorists and rebels from taking advantage of the country’s
CBC Blood chem. Urinalysis ABG
ships.6 porous coastlines to engage in a multitude of nefarious
ReferenceCoast Guard Result(PCG) is tasked to inspect Reference Result 6 Color straw pH 7.408
The Philippine activities.
Value Value
the
WBCships yearly5-10
to ensure 4.5
their safety.
RBS Ships found
3.9-6.1 6.3Such were Transp the conditions Clearof the Philippine
pCO2 Maritime
49.1
seaworthy
RBC are
4-6issued certificates of inspection,
HGBA1C while those 4.27-6.07 Industry
6.4 whenSp both the Doña 1.010
Gravity Paz and the pO2 Vector set out 70 from
HGB unseaworthy
found 120-150 are taken90to the docks BUN for repairs.2.6-6.4
The 5.0 respective points
their pH of origin. 8.0 Though HCO3
the history31.3 of the
HCT Paz, at the
Doña 0.38-0.48
time of her last 0.27voyage, CREA
was said to have 53-115
all 123 travel in the
water SugarPhilippines NEG has always O2 sat
been marked 93.6 by
MCV ALB 34-50 32 Protein NEG FiO2 21%
the necessary80-100 FL
inspection papers from all these agencies. The mishaps and accidents, both manmade and natural, never
MCH 27-31 PG TAG 0.34-1.7 0.82 RBC 0-1 Temp 36.9
Vector,
MCHC on its320-360last G/L
PCG inspection, was HDL found to have a
0.91-1.56 had0.67a tragedy WBC of this magnitude 0-2 and human toll ever
steering
RDW defect and
11.5-15.5% some other deficiencies.
LDL Based on
1.1-3.8 occurred
4.21 in the history
Cast of civilian shipping. PBS
PLT
available 200-400 its radioInclicense had
documents, TOTAL CHOLnearly
expired 4.2-5.2
18 5.25 Epith cellOn December
Disaster Events. Rare 20,Slight
1987, people from
poikilocytosis,
RETIC earlier.
months 0.005-0.015
It sailed without a certificateAST 15-37
of inspection 95
Samar and Leyte Bacteria
and various Occ’l areas acanthocytes,
from the ovalocytes,
southern
SEG 50-70% 48 ALT 30-65 91 Mucus th Rare
and the papers it submitted to the Coast Guard were found Philippines were joining the mad rush toslight boardtoxicthe
granulation,
Doña Paz
LYMPH 20-44% 50 Alk po4 184 Crystals Rare slight anisocytosis
toMONO
be fake.5,8 2-9% 2 NA 140-148 on 136.9
its voyage to AmManila,
urates hoping to join their families, others
EO Seamen 0-4% in the Philippines 0 areK licensed by3.6-5.2 the bringing
3.35 their families to the big city, in time for the
BASO
Professional 0-2%
Regulation Commission, 0 CL are all crewmen
as 100-108 86
Christmas holidays. It was set to sail from Tacloban City in
BLAST 0% waters and 0manning internationalCA++ 2.12-2.52 2.37
plying Philippine vessels. Samar to Manila. The 675 people who boarded the Doña Paz
P 2.27
The Philippines in fact controls nearlyMG++ 20 percent of0.74-1 the in Tacloban
0.83 were all listed in its passenger manifest. Another
officer and rated positions in the world’s fleet with more 908 boarded the liner when it stopped in Catbalogan to pick
than 180,000 seafarers. It is said that among seafarers up more passengers. The declared number of passengers
worldwide, Filipinos have the most training, assessment and was placed at 1,583, along with a crew of 58. The declared
certification. It isFunction
a valid premise fat pad. Cardiac enzymes wereonly not 1,518
consistent with anand acute
Table 2. Thyroid Tests that the crewmen of both capacity of the Doña Paz was passengers 60
ships were part of this trained group.2 coronary event (Table 3), however, intravenous
crew members; based on the listed passengers alone the ship (IV) heparin
Reference Value Result (overlapping with oral warfarin) was still andgivenit to cover not
for
The Philippine Rescue
Free T4
Coordinating Center
(0.8-2.0)
(PRCC), as
0.02 ng/dL was already loaded beyond its capacity should
mandated internationally, is the lead agency when maritime the presence of a possible LV thrombus
have been allowed to proceed by the Coast Guard and/or the as demonstrated
TSH (0.4-6.0) 24.75 Uiu/ml
disasters occur. Although the National Disaster by rheologic
shipping line stasis
and its on crew.
cardiacAccounts
ultrasound. fromMedications
survivors,
Coordinating Council is responsible for disaster were shifted to IV diuretics and
however, described a ship packed to the railings,inotropes; oral digoxin was
four deep
management during natural or manmade calamities, the started. IV antibiotics were given for
in the bunks with no place to move in the common areas. possible pulmonary
PRCC is tapped for its technical competence in handling infection.
Others The patient
claim that thelater shiponwasshowed improvement,
visibly listing to one andside,
was
eventually weaned off from ventilatory support, extubated,
aeronautical and maritime disasters. It has at its disposal the even before it left its moorings in Tacloban; a visual
resources of the Philippine Air Force for its Search and testament to its state of overload.8 At the points of boarding,
Rescue (SAR) operations. This is where the Air Force plays a Table 3. Cardiac
hundreds Enzymes
more came aboard as the ship was leaving port. It
vital role, along with the Navy through the Coast Guard. was estimated by Reference those on Range
board(mmoL)that the Doña Paz left port
Result
Aside from these resources, the PRCC can tap planes and with around
Qualitative 3,000 to 4,000 passengers. AccountsPOSITIVEfrom those
choppers of the US Air Force stationed in the country tasked with experience
Troponin I with other liners confirm that in the
to assist in civil emergencies when they occur.9 CK-MB
Philippines, discrepancies 0-6.0
between the manifest 1.14and actual
Of the numerous government agencies concerned with CK-TOTALload easily run
passenger 21-232
up to thousands. 543

making policies and overseeing the Philippine maritime The difference will be accounted for by several factors.
industry, none play a more direct and important role than Children are usually not listed in the manifest. On this
the PCG. Although some agencies overlap its functions, it is particular trip, hundreds of children, excited to go to Manila,
concerned with maritime security, maritime safety, maritime were brought along by their parents. It is an acknowledged
Figure 1. Electrocardiogram
environmental protection and upon admission
maritime search and rescue. practice that tickets to the ships are sold by scalpers, and this
Aside from doing its part in enforcing rules and regulations trip was no different, with many trying to get valuable slots
to ensure the seaworthiness of vessels carrying passengers for the Doña Paz.3
transferred to the intensive care unit (ICU) for ventilatory
and cargo, it has the enormous responsibility of patrolling The Vector, with its crew of 13, set out to sea from
support and closer monitoring. On bedside cardiac ultrasound,
Philippine sea waters. This entails monitoring 500,000 square Batanes, carrying 9,000 gallons of petroleum products
there was a finding of eccentric left ventricular hypertrophy,
miles of territorial waters and a coastline twice that of the including gasoline, kerosene and oil. The most senior
global hypokinesia with depressed overall systolic function
United States. As is the case with other government agencies navigator on deck serving as captain was a seafarer with a
with concomitant spontaneous echo contrast on left ventricular
severely hampered by limited resources, the PCG has very license of 2nd mate. The crew, as is customary during long
(LV) cavity suggestive of rheologic stasis, the ejection fraction
meager equipment given the task at hand. The PCG only has holidays in the Philippines, was already in a festive mood,
was 25%, with moderate mitral regurgitation, moderate
two
aorticsearch and rescue
regurgitation cutters
with andsclerosis,
aortic 23 Worldsevere
War II-vintage
tricuspid drinking and merrymaking during the trip.
boats
regurgitation with mild pulmonary hypertension,does
for patrolling a very large area. Not only it have
pulmonary Based on available accounts of the incident, there were
to contend with vessels with questionable seaworthiness,
regurgitation, and minimal pericardial effusion or pericardial it no reported
Figure 2. Chest weather disturbances
radiograph on admission at the time the Vector and

VOL. 45
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2011 ACTA MEDICA
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3
The Sinking of the MV Doña Paz – I. An analysis of theCASE
event REPORT

the Doña Paz crossedHeart paths atFailure

Tablas Strait, and40kms Short fromStaturesuch as inthis,a 43 year-old
a full eight hours maleafter the collision. Details
Oriental Mindoro and about 175kms from Manila. Much of from secondhand information were allegedly insufficient
what Katerina
happenedT.can Leyritana , Ma. Czarlota
be reconstructed
1
M. Acelajado-Valdenor
from accounts of the and thus,1
, Amado
a search O.andTandoc
rescue IIIoperation
2
and Agnes wasD. notMejia
initiated
1 at
survivors and those within the vicinity of the incident. Those this point. After another eight hours, information was
who were awake 1
Department
at the oftime Medicine, College
of the of Medicine
incident and Philippine
heard an General Hospital,
deemed adequate University
and the of the
PCG,Philippines Manila
Philippine Air Force and US
explosion that jarred the Doña
2
Department
Paz. Oneofsurvivor
Pathology,claimed
College of to
Medicine,
AirUniversity
Forceof the Philippines
were Manila
mobilized. US choppers and a
had just talked to the captain and the chief mates of the Doña reconnaissance plane that arrived first at the scene initially
Paz who were drinking liquor at a party on the bridge a few failed to locate the site. They later noted an area where
minutes before the explosion. Upon going up the deck, debris was floating all around, with no survivors in sight.
survivors saw the ocean turn into a sea of flames. Many of All vessels and aircraft arrived at the point of the collision at
those who survived can only recall jumping into the water, least 16 hours later, long after both ships had sunk.
leaving behind people Presentation
wailing of the
andcase screaming in pain. require
Theregular laxative
Don Claudio, use. There
despite having was also a report
practically of two
nonexistent
This is acries
Children’s case echoed
of a 43-year-old
in the night.maleApresenting
man whowith was short
with more syncopal
medical supplies, episodes.
was ableHe was brought
to safely to another
bring all of thedoctor
26
stature
his and was
family heartawakened
failure. The bypatient
the loud was explosion
admitted at the
while in a privatethey
survivors hospital wherefrom
rescued the assessment
the site towas still a “heart
Manila North
medicineinward
sleeping one of ofthe
thebunks
Philippine
of the DoñaGeneral Paz.Hospital
He went(PGH) to the problem”.
Harbor, 175The patient from
kilometers was theagainareaprescribed
of the collisionunrecalled
even
for dyspnea.
cabinet containing Thisthe paper will only
life vests investigate
to find themseveral issues:
locked. He medications
before and again
an organized, was lost
credible to follow-up.
search and rescue This time,
operation
differentiating
jumped into the congenital
burningfrom waters acquired
to escape hypothyroidism,
the flames however,
was mounted. symptoms
Waiting were
at thepersistent.
harbor were He later
a fewconsulted
ambulances at
the relationship
engulfing the Doña Paz, between never hypothyroidism
knowing what happened and the to another
sent local hospital,
by those who receivedwherecalls
he wasfrom admitted
the Donand managed
Claudio. The
cardiomyopathies,
his wife and two daughters and the therapeutic
who accompanied options him in patients
on the as a case ofwho
survivors anemia
wereand bronchial
able to walkasthma.
and hadHe nowas discharged
gross signs of
with cardiomyopathy secondary to
trip to Manila. One survivor remembers seeing people hypothyroidism. slightly improved after four days, only
injury made their own arrangements for transportation. to have recurrent heart
The patient had been born
burning afloat on the open seas, with many othersfull term to a then 31-year- failure symptoms, prompting admission
Some were picked up by relatives, others took taxis while at PGH.
old Gravidaand
swimming 4 Para 3 (G4P3),
shouting the 4thofofrelatives
the names 9 siblings,andwith an
crying thoseUpon
having admission
nowherethe to gopatient
stayedwas for ainlong
mild respiratory
period of time
apparently
out for help. unremarkable
4 delivery at home facilitated by distress, with stable vital signs
waiting for the Department of Social Welfare and no note of fever. Pertinent
and
a traditional
Evidence birth attendant.
gathered He was noted
by subsequent inquiries to be normal
concluded physical exam(DSWD)
Development findings to included short4 stature, thick lips, non-
assist them.
at birth.
that the The
Vector patient
rammed was the allegedly
port side at parof with
the Doña age both
Paz, pitting
The periorbital
survivorsedema, who dryhadskin,
grossa displaced
signs ofapical impulse,
injuries were
physically and mentally until eight years
immediately disabling the engine and setting the two ships old when he was crackles on both lung fields, and bilateral
brought individually to various hospitals in Manila non-pitting bipedal
and
said to have
on fire. stopped
Both ships sank growing
in aboutin545 height.
meters Heofwas brought to
shark-infested edema.treated
were There was also a injuries.
for burn 3 cm x 3Some cm reducible
were brought umbilical to
awaters
private doctor,
within a whose
matter diagnosis
of minutes. wasThe undisclosed,
crew of the andshiphe hernia. However,
Metropolitan there was
Hospital, othersno pallor,
to Sanno neck
Juan deveinDios distention,
Hospital
was given
sailing medications
within a few miles to increase
of theheight,
collisionwhichheardthe patient
a loud no apparent
and Jose Reyes congenital
Memorial malformations,
Medical Center. no cardiac
No listing murmurs
of the
took for only one month with no improvement.
explosion and a ball of fire towering several hundred meters Through the and no clubbing. There was also no note
survivors who required medical treatment could be obtained of an anterior neck
years, the patient was apparently well, although
was seen. It will never be ascertained what transpired on the still of short mass.
from government agencies involved in the management of
stature,
bridge of withthethickDoñalips, Pazcoarse
and facial
the Vectorfeatures andbefore
right dry skin.
the thisLaboratory
accident.4 workup showed cardiomegaly with pulmonary
He was notably slow in ambulation.
incident. It is likewise acknowledged that no distress callHe was said to have congestion, thoracic dextroscoliosis,
The subsequent government and atheromatous
response to this aorta
tragedyby
bronchial asthma at age 15 years, and
was sent from the radios of either vessel. No one receivedsince then he had been chest radiograph, and left ventricular hypertrophy
involved mainly retrieval operations for the many corpses by 12-lead
taking
the SOSsalbutamol
call, if evertabletsthere occasionally
was one. Thefor bouts went
answer of dyspnea
down electrocardiogram
left at sea. Hundreds (12-L ECG)
of bodies(Figures 1 and ashore
washed 2), normocytic
on the
occurring one to two times annually.
along with all 58 crewmen of the Doña Paz, and 11 of the 13 normochromic anemia (Hgb 90 mg/dL),
coastlines of Oriental Mindoro, leaving the local villagers dyslipidemia, and
The patient’s symptoms started
seafarers on board the Vector. The two survivors from thein 2001 when he was pre-renal azotemia (serum creatinine 123
with the grim task of spraying them with sanitizers and mmoL). Electrolytes
reported
Vector neverto have
had an sudden
inklingloss of theof consciousness.
imminent collision. During5 this on admission
covering them up showed slight hyponatremia,
with makeshift structures to hypokalemia,
minimize the
time,Thethe patient did not have any symptoms
MV Don Claudio, a cargo ship plying a route of heart failure; and hypochloremia (serum
smell. Some were forced to bury the Na 136, K 3.35,
deadCl 86).
withoutBloodhaving
gases
no prior seizures, cyanotic episodes, chest
bringing it close to the scene of the collision, witnessed the pain, headache, or revealed partially compensated metabolic
them identified to prevent them from rotting near houses alkalosis with mild
blurring of vision. He regained consciousness
explosion and the ball of fire lighting up the sky. They shortly after and hypoxemia. The patient was noted to
lining the shore. Outbreaks of diarrhea and respiratory be hypothyroid based
was brought
reached to a private
the scene withinphysician,
a few hours whose of assessment
the collision was a
but on elevated
illness wereserum notedthyroid-stimulating
in these villages. hormone The Coast (TSH) and
Guard
“heart problem”. He was prescribed unrecalled
never saw either of the two ships. Debris was all around the medications markedly decreased serum free thyroxine
enlisted the help of banca (boat) owners, shipping (FT4). The exact
taken for values are shown in Tables 1 and 2.
ocean anda they
few months
searchedand for eventually
survivors. discontinued
They were able whento companies and private boat operators to help them in the
the syncopal episode did not recur. Upon admission to the wards, the patient was managed
rescue 26 people, 24 of them were passengers of the Doña retrieval operations. A little over 500 bodies were
In the next four years, the patient would develop as having congestive heart failure from cardiomyopathy
Paz and two were from the Vector. This act of heroism was subsequently recovered and many were left unidentified.
intermittent, progressive exertional dyspnea and bipedal secondary to acquired hypothyroidism. Oral loop diuretics,
the only bright spot in this tragedy, for subsequent search The true number of casualties to this day remains unknown
edema. Later on this would be accompanied by generalized angiotensin-converting enzyme (ACE) inhibitors, beta-
and rescue operations would only confirm the magnitude of as thousands remain entombed in the Doña Paz and its
body weakness, anorexia, and constipation, severe enough to blockers, statins, and levothyroxine were started. Electrolyte
the tragedy, with the recovery of hundreds of bodies and environs.
correction was instituted. The sections of Endocrinology
leaving behind thousands more trapped in the depths of Initial public reaction to the incident was one of extreme
and Cardiovascular Diseases were co-managing the patient
Tablas Strait.5 author: Ma. Czarlota Acelajado-Valdenor, M.D.
Corresponding outrage towards Sulpicio Lines. Relatives of the casualties
Department of Medicine together with the General Medicine service.
Post-disaster Events. News of the collision reached the lined up outside the offices of Sulpicio Lines crying for the
Philippine General Hospital He soon developed respiratory failure, upon which the
Philippine Rescue Coordinating Council (PRCC), the lead heads of officials. Sulpicio Lines immediately blamed Caltex
Taft Avenue, Manila, 1000 Philippines considerations were acute pulmonary congestion, nosocomial
government
Telephone: +632 agency
554-8488tasked to handle maritime emergencies Philippines for contracting the Vector to carry highly
pneumonia, to rule out an acute coronary event. He was later
Email: czarlota@yahoo.com

12 ACTA MEDICA
4 ACTA MEDICA PHILIPPINA
PHILIPPINA VOL.45
VOL. 43NO.
N0. 43 2009
2011
 The Sinking ofHeart Failure
the MV DoñaandPaz
Short
– I.Stature in a 43 year-old
An analysis male
of the event

Table 1. Initial
dangerous cargo Laboratory Results
on a grossly inadequate and unseaworthy other maritime disaster incidents dotting the long maritime
vessel. history of the Philippines.
CBC Blood chem. Urinalysis ABG
The various branches of the government initiated The tragedy of the Doña Paz sinking may have resulted
Referenceinto the Result Reference Result Color straw pH 7.408
separate inquiries accident and independently from ships of questionable seaworthiness being manned by
Value Value
released
WBC their5-10
findings. The Board 4.5
of Marine
RBS Inquiry, Senate
3.9-6.1 less-than-qualified
6.3 Transp mariners.Clear ThesepCO2 factors 49.1were
Committee
RBC on4-6National Defense, Coast Guard HGBA1C and Congress
4.27-6.07 compounded
6.4 byGravity
Sp an archaic1.010 communication
pO2 system 70 that
allHGBconducted investigations.
120-150 90 BUN
A congressional 2.6-6.4
probe 5.0
contributed to thepH 8.0
delay in response. HCO3
This delay, along 31.3 with
HCT
committee 0.38-0.48 that both0.27
declared the DoñaCREA 53-115
Paz and the Vector the123 Sugar
perennial problem NEG
of overloading O2
of satpassengers93.6 and
MCV 80-100 FL ALB 34-50 32 Protein NEG FiO2 21%
should be blamed for the collision. After conducting 13 inadequate medical response, contributed immensely to the
MCH 27-31 PG TAG 0.34-1.7 0.82 RBC 0-1 Temp 36.9
public
MCHChearings andG/L
320-360 listening to the testimony
HDL of 55 expert
0.91-1.56 unprecedented
0.67 loss
WBC of lives. 0-2
witnesses,
RDW the committee concluded LDL
11.5-15.5% that the crewmen 1.1-3.8 Strict enforcement
4.21 Cast of existing laws and formulation
PBS of
PLT
manning ships were notIncqualified TOTAL
both200-400 to do CHOL
so. They4.2-5.2
also new5.25ones may Epith cell
prevent Rare maritime
future accidents
Slight poikilocytosis, and
RETICthe government’s
cited 0.005-0.015 overall apathyASTtoward the 15-37 local 95
decrease Bacteria
morbidity Occ’l whenacanthocytes,
and mortality such events occur.
ovalocytes,
SEG 50-70% 48 ALT 30-65 91 Mucus th Rare
maritime industry as the real culprit behind the collision. The shipping industry must exert anslight toxic to
effort granulation,
upgrade
LYMPH 20-44% 50 Alk po4 184 Crystals Rare slight anisocytosis
The
MONOMarine Board
2-9% of Inquiry2report putNA the blame squarely
140-148 vessels
136.9 and equipment,
Am urates and improve compliance with
onEOthe Vector.0-4% Based on their0 reconstruction K of events,3.6-5.2
the existing
3.35 regulations. The government must take a proactive
BASO sailed 0-2%
Vector with hazardous0 cargo without CL 100-108
the necessary 86 and provide support to the industry while exerting its
stance
BLAST CA++ 2.12-2.52 2.37
permits, was 0%unseaworthy, and 0 was manned by incompetent power to ensure that laws on maritime safety are strictly
P 2.27
and unqualified crewmen. The Senate inquiry MG++ blamed 0.74-1 both followed.
0.83
ships and the government for its lack of support to the
shipping industry.3,5,6 ____________
Sulpicio Lines was mandated by the government to
compensate the families fat pad. Cardiac enzymes were not consistent with an acute
References
Table 2. Thyroid FunctionofTests
the victims amounting to 30,000
pesos per family. A processing center was set up in Manila coronary
1. event
Ronquillo (Table
M. Ships 3), however,
20 years or older plyintravenous (IV) heparin
island routes. Philippine Daily
Reference Value Result Inquirer. 1988 Nov 1.
(overlapping with oral warfarin) was still given to cover for
byFree
theT4government, manned (0.8-2.0)
by personnel of Sulpicio Lines
0.02 ng/dL 2. Perpena E. Sulpicio’s mariners flunked board exams. Philippine Daily
and the presence
Inquirer. 1988ofNov
a 11.
possible LV thrombus as demonstrated
TSHgovernment workers. Though Sulpicio
(0.4-6.0) Lines
24.75 stuck to
Uiu/ml
their claim that passengers were limited to the 1,583 listed in by
3. rheologic
Acosta O. Doña stasis on cardiac
Paz overloaded; ultrasound.
inquiry set. PhilippineMedications
Daily Inquirer.

the manifest, representatives of the liner declared that their were1987 Dec 23.to IV diuretics and inotropes; oral digoxin was
shifted
4. Petilla D. Doña Paz syndrome deepens kin’s misery. Philippine Daily
company is willing to process the claim of whoever can started. IV 1988
Inquirer. antibiotics
Dec 20. were given for possible pulmonary
produce documents to prove their family went down with infection.
5. MARINA TheReport
patient later
on the DoñaonPaz
showed
Tragedy. improvement,
Manila: Maritimeand was
Industry
eventually
Authority;weaned off from ventilatory support, extubated,
1999 March.
the Doña Paz. In fact, the company processed claims of more 6. Session No. 29, Thirteenth Congress, Second Regular Session. Journal of
than 3,000 families. Some of these claims however turned the Senate of the Republic of the Philippines. 2005 Oct 10.
out to be fraudulent. Some families on the other hand were Table
7. 3. Cardiac
National Enzymes
Geographic Channel. Asia’s Titanic [Internet]. [place
unknown]: National Geographic Channels International (NGCI); 2009
too poor to have any documents on hand. The relatives of Reference
[cited 2010 Mar 18]. Range (mmoL)
Video: 19 min. Result Available from:
the victims resorted to legal remedies, including filing a class Qualitative POSITIVE
http://www.youtube.com/watch?v=jl3ef1cambU&feature=related.
action suit. They were, however, unable to raise the six 8. Troponin
Case I Unclosed: The MV Doña Paz Tragedy [Internet].
million pesos required as a filing fee. The survivors were CK-MB
Quezon City, Philippines: 0-6.0 GMA Network; 20091.14Dec 17 [cited
2010
CK-TOTAL Mar 18]. Video:
21-232 15 min. Available
543 from:
sent home without any compensation or even post-event http://www.youtube.com/watch?v=5F18nso5l1Y&feature=related.
counseling. Those who suffered injuries and received 9. Esteban R. Philippine Disaster Management System. 2004 June 3.
treatment in hospitals were assisted by the company in 10. Sulpicio willing to pay victims. AFP News. 1987 Dec 23.
11. Justice eludes kin of Doña Paz victims. Philippine News and Features.
settling their medical expenses.10 Families filed cases
1991 Nov 1.
individually hoping to get just compensation from Sulpicio
Figure 1. Electrocardiogram
lines. Those who accepted the upon admission
30,000 were required to sign a
waiver. Although attempts at providing enforcement
through punitive action to accompany standing maritime
transferred to the intensive care unit (ICU) for ventilatory
safety regulations have been repeatedly exerted, to this day,
support and closer monitoring. On bedside cardiac ultrasound,
no one has been held liable for the maritime disasters that
there was a finding of eccentric left ventricular hypertrophy,
followed after the Doña Paz.11
global hypokinesia with depressed overall systolic function
with concomitant spontaneous echo contrast on left ventricular
Conclusions and Recommendations
(LV) cavity suggestive of rheologic stasis, the ejection fraction
The sinking of the Titanic pales in comparison to the
was 25%, with moderate mitral regurgitation, moderate
tragedy that is the MV
aortic regurgitation withDoñaaorticPaz,sclerosis,
and a lot of factors
severe can
tricuspid
account for the occurrence of such a tragedy,
regurgitation with mild pulmonary hypertension, pulmonary along with
regurgitation, and minimal pericardial effusion or pericardial Figure 2. Chest radiograph on admission

VOL. 45
VOL. 43 NO.
N0. 432009
2011 ACTA MEDICA
ACTA MEDICA PHILIPPINA
PHILIPPINA 13
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