Pharmacist on the high seas: “The hospital ship functions like a small village”

PZ: What does everyday life look like in a ship’s pharmacy?

Pape: The tasks, workflows, and routines in a hospital ship pharmacy are essentially comparable to those of a land-based hospital pharmacy. Pharmacy management, pharmacists, and PTAs ensure the supply of medications to pre-, post-, and inpatient patients on weekdays between 8:00 a.m. and 5:00 p.m. The international pharmacy team of three to four people processes standard orders from the wards and operating rooms, as well as individual patient prescriptions, on a daily basis. Pharmacists also participate in daily rounds. They are also available to answer clinical-pharmaceutical questions at other times. A licensed pharmacy technician is always available on call, even outside of regular opening hours.

PZ: Given the limited space, can pharmaceuticals also be manufactured?

Pape: While the pharmaceutical supply is focused on finished pharmaceuticals, mostly delivered in bulk from the USA, manufacturing takes place on a small scale, such as the reconstitution of antibiotic dry syrups, the preparation of mouthwashes, or Lugol's solution before thyroid surgery. Dermatological formulations are the exception rather than the rule. However, there are no separate rooms on board for the laboratory testing of drugs and excipients or for drug manufacturing. However, there is a fume hood and a small laminar airflow bench, which can be used to manufacture pharmaceuticals under aseptic conditions, at least on a small scale.

PZ: How are supplies and storage organized?

Pape: Like land-based pharmacies, the ship's pharmacies are equipped with rolling shelves, refrigerators, freezers, and narcotic cabinets, as well as heavy-duty shelving for medication storage. Since the pharmacy facilities on the "Africa Mercy" are significantly smaller than on the "Global Mercy," excess stocks or large-volume medications such as infusion or irrigation solutions are stored in a climate-controlled medication container, which is itself housed in a shipping container, outside the air-conditioned hospital area.

On the wards and in the operating rooms, medication supplies are stored in Omnicell cabinets. These are electronically monitored storage cabinets for medications and medical devices, including automatically generated requisitions. Emergency medications are stored in emergency carts and backpacks. The type and quantity of medications on board are determined by the planned programs, the number of patients to be treated, available storage capacity, and delivery time. During the preparation phase, the pharmacy and all dispensing stations receive their respective basic stocks. The basic stock in the pharmacy is based on consumption data from previous years, combined with adjustments based on the programs and the respective number of elective patients. The on-board supplies ensure drug therapy for several weeks.

PZ: How long does an order take? And is it also blistered if needed?

Pape: From the moment the pharmacy initiates the order to the receipt of the goods via international wholesalers, weeks or even months can pass. Therefore, close monitoring of the pharmacy's inventory and all points of use is essential to ensure continuous availability of the listed medicines. Only in exceptional cases, after consultation with hospital management, will the pharmacy management purchase medicines in the country of deployment.

There is no automated blister packaging on board. To ensure that the medications fit into the compartments of the Omnicell cabinets, many medications, mostly solid oral medications from large containers, must be repackaged into smaller containers. This requires manual labor. On the wards, nurses provide the required medications. Missing medications are requested from the pharmacy for the respective patients via a doctor's prescription. There, the prescribed amount of medication is placed in a suitable container, labeled with the patient and medication information, and picked up from or delivered by the pharmacy.

PZ: How does the delivery of medicines work?

Pape: First thing in the morning, the PTA processes the bulk orders from the wards, operating rooms, and outpatient facilities. These medication orders are generated via the respective Omnicell cabinet, which is located on every ward, in every operating room, and in the supply rooms. Only in the supply room of the operating room on the "Africa Mercy" is manual work still required. There, PTAs or pharmacists check medication stocks on-site Monday through Friday using checklists. Once all bulk orders have been checked and approved, the pharmacy team takes the orders to the ordering locations and immediately stocks the cabinets. Of course, operating hours must be taken into account in the operating room, meaning deliveries take place early in the morning or after the end of daily operating room operations. Because space for medication storage on the wards and in the operating rooms is limited, frequently used medications are often refilled daily if defined minimum stock levels have been reached. Medication orders are usually generated automatically via the Omnicell system. Determining drug consumption and order quantities is a complex matter. Just like on land, an electronic inventory management system supports this process.

PZ: Who takes care of the crew’s health and well-being?

Pape: There's also a "Crew Clinic" on board with a small team of doctors and nurses who care for the crew. During the day, individual prescriptions for patients and crew members are processed. There's also a dental team on board. And there's a rehabilitation area with physical therapists, speech therapists, music therapists, massage therapists, and other healthcare professionals. These departments also regularly request medications. Individual prescriptions for patients are either picked up by the nursing or operating room staff or delivered by the pharmacy. And of course, crew members are also welcome to visit us to pick up prescribed medications or purchase them for self-medication.

PZ: What challenges are there regarding quality management on board?

Pape: We have clear protocols and common standards to ensure consistency. There's also a strong mentoring culture on board. This means everyone learns from each other to achieve the highest quality standards. This creates a safe, collaborative environment where learning and excellence go hand in hand. Effective quality management on board is the foundation for treatment effectiveness and patient safety. With so many crew members from different countries, harmonization of procedures is essential to ensure low-risk collaboration within teams and across departments for the best possible treatment outcome.

Therefore, before assignments, you complete an online training program, which also familiarizes you with the contents of the electronic QM manual, both for your own area of responsibility and for the departments you work with. Once you're on board, you quickly gain confidence by applying binding standard operating procedures, even if the on-board processes differ from your own national standards and best practices, such as units of measurement or legal requirements.

PZ: Have there been any situations during your deployments that required pharmaceutical emergency management? If so, what were they, and what specific precautions need to be taken?

Pape: I've experienced twice how an urgently needed medication became scarce during complicated operations. When the pharmacy is informed, precise information about the type, strength, and dosage of the medication, the amount needed to meet demand, and the point of use are important. And then clarity and speed are essential. A look at the inventory management system provides information about the various storage locations and stock levels. If stocks are available in other operating rooms, a phone call to the operating room supervisor can quickly close the gap. If only the pharmacy has the medication in stock, the required quantity of the medication is quickly assembled, everything is packed securely in a transport container, and off we go on foot to the operating room. Once there, either a member of the operating room team receives the medication at the airlock, or the patient quickly slips into surgical clothing and runs down the operating room corridor to the operating room and hands it over.

However, it can also happen that the pharmacy has sold out of stock and only the inpatient wards still have the medication in stock. Here, too, a preparatory phone call helps so that the medication can already be ready on the ward while you are on the way there. Regardless of where and between whom the medication is handed over, accuracy should always be double-checked using the R rule: the right patient, the right medication, the right dose, the right route of administration. Especially when communicating in a non-native language and, given the variety of English accents, do not know all the expressions or are only hearing them in a hurry, asking questions and repeating information is essential to reduce errors caused by language restrictions. This is an important contribution to medication safety.

PZ: How many patients can Global Mercy treat at the same time?

Pape: Our capacity depends on the current staffing situation. We generally have six operating rooms, 102 acute care beds, seven intensive care or isolation beds, and 90 nursing beds. We're always looking for support. Anyone interested in volunteering will certainly find a welcome welcome.

PZ: How important is interdisciplinary cooperation in these missions?

The ship functions like a small village—and, as in any functioning community, every task is important. It is precisely this shared goal and the strong collaboration between all professional groups that enable us to provide surgical assistance of the highest standard where it is needed most.

Interdisciplinary collaboration is extremely important in this setting to achieve the best possible treatment outcome for each patient. It follows a holistic approach that includes medical, nursing, pharmaceutical, and laboratory-diagnostic specialists, as well as chaplains, catering, and cleaning staff. These always include local staff who provide mental and spiritual support to patients, assist with language barriers, and offer practical assistance with organizational problems. It's understandable that bedside rounds can sometimes get quite busy.

PZ: Medical professionals also receive training on board. Did you also train pharmaceutical staff during your deployments?

Pape: During my six-week deployment aboard the "Africa Mercy" from October to December 2024, I worked with a young Malagasy pharmacist. I thoroughly enjoyed sharing my knowledge with her, exchanging experiences, and gaining firsthand insights into the pharmacy and healthcare systems in Madagascar.

PZ: When will you next be traveling with the “Global Mercy”?

Pape: It would be great if we could deploy again on the "Global Mercy" or "Africa Mercy" in 2026. Whether that will happen depends on the personnel requirements on board and my availability during the requested periods.

PZ: In what ways do such on-site missions enrich your personal life and the work of a German reserve medical officer?

Pape: Through my career and my further training in public health and epidemiology, a few years ago, I developed the desire to use my skills on a voluntary basis in the service of global healthcare. Volunteering is a valuable opportunity for me to make a meaningful contribution to the health of disadvantaged people and to address the needs of this world with my medical expertise.

But I personally also benefit enormously. Not only can I keep my clinical-pharmaceutical knowledge in inpatient care up to date and further expand it alongside my regular work in outpatient care, the deployments also allow me to train the pharmaceutical and logistical skills I need on board as a reserve officer in the German Armed Forces' Naval Medical Service. This isn't just about specialist knowledge. Another key aspect is the "how to," i.e., interacting in multidisciplinary teams and consistently reliable interoperability with regard to ensuring high-quality medical care in a multinational setting. In general, spending time together with people from different nations is very inspiring; new friendships are formed; life experiences I wouldn't want to miss.