Cruise Ship Medicine

Gary Podolsky MD

When I first decided to talk about my job as a cruise ship physician I simply told my experiences as they had unfolded to me. There are many popular misconceptive views of work on a cruise ship and I had to reconciliate these with my experiences and the stories I heard from my fellow crew members.

Furthermore there are many authorities on the state of health aboard cruise ships. Many of the testimonials were from physicians solely praising the merits of working afloat and did not mention any of the significant problems I found myself confronted with. After I has returned and was able to refer other physicians from my city and found them similar jobs I still had radically different experiences. I found it hard to believe we worked on the exact same ships yet had very variable positive and negative experiences. I have reviewed the medical and legal literature to highlight some of the problems with cruising.

The travel industry barely mentions any form of medical risk in their pamphlets or guides to cruising put out by large travel critics. In preparation for this talk I read several recent guidebooks on cruising and other than a description of the facilities they offered nothing on practiced safety issues. The people we hear the most about cruising are in fact those who have the most to gain by selling packages.

Several watchdog groups have raised many serious concerns about human rights violations, lack of safety and risky behaviors aboard. Many successful lawsuits have been won against the cruise industry to give further credibility to these claims. It is generally difficult to sue a cruise shop company because often people live outside the port of jurisdiction and there is also a time and effect. The number of completed lawsuits may represent the tip of an iceberg.

I have included statements from ACEP and the CDC on their guidelines towards Cruise Medicine. It should be noted though that they are only guidelines and not always watched. Hopefully by forcible acknowledgement problems within the Cruise Industry will reform towards progressive actions. This is unlikely to evolve by itself and will have to enforced from without as watchdog organizations enforce existing and proposed guidelines.

I will discuss the basic operations of a cruise ship and explain how the doctors and nurses fit into the hierarchy.

Injuries and illnesses that occur can be divided into those that will occur when any large group of people are congregated together as well as the types of problems specific to a remote marine environment.

Cruise ships are popular type of leisure travel with people having images of the "Loveboat". The reality can be quite different. I have worked as Chief Medical Officer on several large cruise ships. The following is a brief description of what it is like, for both passenger and doctor. Descriptions may change from company to company

Your Staff Aboard the Cruise Ship

The captain is the master of the ship and runs the ship according to International Law and the rules of the cruise line. He is also in charge of medical evacuations not the physician who must convince the Captain of the necessity of evacuation. Most lines employ people from all over the world. We had crew from China, Philippines, Indonesia, Caribbean countries, South America, Europe, and Australia. Even though we sailed from a U.S. port, most crew (including many officers) spoke little English. The captain and other officers were Italian; apparently the cruise line had an agreement with the Italian government. Language was a major problem as many senior officers could barely speak English. On routine day-to-day events this was merely an inconvenience but during emergent and urgent situations this as a major obstacle.

The Medical Department

Depending on the size of the ship there is one or more doctor(s) and at least 2 nurses. Medical staff may be from anywhere in the world but generally speak English. There has been criticism in the past about the medical qualifications of medical staff since not all are not all are board certified (see reference). Although the American College of Emergency Physicians (ACEP) has made guideline (see Table) the cruise ship is not under obligation to follow these. (See reference)

The infirmary is open during regular office hours for both passengers and crew, and 24 hours for emergencies. Each ship's infirmary has different capabilities, but generally there are IV fluids, splints, ACLS medications and a defibrillator. (See table 2 for a suggested equipment list)

Medical staff can perform minor procedures, treat accidents, dispense medications and begin treatment for cardiac problems. Most ships have capabilities to communicate with backup experts on shore. Our ship had a satellite phone to communicate with an on call Miami Emergency Physician to provide medical backup advice. This was useful for both medical and legal considerations. In general the consulting physician would generally agree that an evacuation was advisable if there were any suspected serious pathology. This was exceptionally useful when I had to advise patients to be evacuated since both the patients and Cruise Officers did not want to organize an evacuation. The cost of an evacuation being over 10,000 dollars and the logistics in the evacuations being time consuming.

Infirmary beds are available for quarantine or observation of ill patients. Our ship had used an empty cabin for a chickenpox outbreak. Both chickenpox (personal experience) and rubella (see reference) have been reported aboard cruises. Passengers are responsible for infirmary costs, and these can be significant. Medical insurance with evacuation coverage is strongly recommended. Prices for medications are usually higher when compared with home. On our ship minor medications -analgesics, cough and flu medications, and anti-nauseants were for purchase in the gift store by passengers.

Anyone requiring an assessment or refill was required to see a physician.

There is a good proportion of occupational medicine among the crew, especially musculoskeletal overuse problems. If a crewmember is very sick the medical staff may recommend evacuation. For less urgent problems consultation with portside consultants in the USA and in other countries can be made while a ship is in port. This included referrals to dentists, physiotherapists, internists and sub specialists and gynecologists. Interestingly cruise physicians were forbidden to do gynecology exams on female crew except in emergencies. No reasons were given for this but undoubtedly reflect prior boundary issues.

The general crew was multinational and made up of members of all 6 continents and many had variable states of health care, some of which claimed to me as never having seen a doctor in their life. Members from developed countries claimed to have had a pre-boarding crew physical as well as an HIV test. I myself had no physical or confirmation of prior vaccinations. As a Family physician I have since filled such forms out for applicants to cruise employment.

All crewmembers were compelled to complete a Panamanian physical on the ship that I worked on that was registered in Panama. This consisted of a simple history and physical checklist and cursory review of systems to satisfy the Panamanian authorities. All crew had to pay $50 US for this procedure. This examination had very low predictive value in determining any type of illness and was more of a financial incentive for the company than anything else. Visits for the crew were free and the infirmary was open for them twice per day. The company also covered analgesics, antibiotics and other basic medication. Crew could have their dental needs looked at in Mexican ports and this was also covered. Condoms were widely available for the crew from a box in he infirmary although I did not ever see anyone checked for an STD in my whole contract. Birth control pills for women were not encouraged and female members had to seek treatment from a shore side gynecologist if they wished them.

Flags of Convenience

Our cruise line had its ships registries under Panamanian or Liberian registrations, as this was significantly cheaper than being US registered and we were not subject to US laws while at sea. These registries under "Flags of Convenience " enable companies to avoid paying taxes and establishment of unions and are crucial to the high profitability of the cruise industry.

I had noted that while on a Liberian registered vessel our home country was in the middle of a violent civil war.

Case study:

Luis, the ideal worker

I had noticed that one of the older cooks aboard had been particularly subdued and pleasant to everyone. He had attended the clinic with a translator because he only spoke Spanish. A week later, the Food and Beverage Manager had praised him on what a great worker he had been and all he ever did was get up and go to work and then go back to sleep causing no problems and always being reliable. This sounded very suspicious to me and I couldn't t stop thinking about it. I remembered that one entry in his chart had mentioned he was on digoxin and I started to think- if I had been there for a week who else could have given him any? I immediately called him in and found that he hadn't taken either his digoxin or Lasix for a few months and was fluid overloaded with CHF. After resuming his medication after a week he had a normal affect and even took to wearing a print Hawaiian shirt apart from his cook's uniform during his time off.

Many of the Crew Staff had regular medical conditions and quite a number were over 55 years. My impression was that the Company doctor was there for them to see twice a day between or during their shifts but this was not encouraged by previous physicians.

Our cruise line had a strict policy that if female employees became pregnant, they were sent home. And the employee's superior must report the pregnancy to the company, or lose their job as well. Requests for abortions were referred off shore and not recorded by the medical department. The infirmary did not recommend birth control pills because our cruise lines did not officially endorse the pills. I had spoken with the Medical Director specifically and he confirmed this. Clearly there may be a conflict in doing what is best for the patient while following the company's guidelines.

Although cruise lines have guidelines for accepting passengers with advanced pregnancy or other serious severe medical problems we encountered several people who "pushed the envelope" of what was acceptable safe travel by being

Common Medical Problems Aboard Ship

Traveler's Diarrhea

This condition can generally be averted by careful attention to what you eat, especially on shore. The cruise doctor is responsible for doing a weekly "diarrhea log" of all affected and passengers and crew. If the ship has an incidence of 0.5%, it is considered significant and must be submitted to the U.S. Centers for Disease Control. They generally investigate large outbreaks. The green sheet is made from these statistics.

The cruise line tries to regulate its employees and people with significant diarrhea are told to report to the infirmary immediately. On the one hand this may be a good thing for the employee since they are off work until they get better but at other times when they have shore leave coming up it would be bad since they weren't allowed to go ashore if still sick. One musician had told me that much to my surprise many of the crew were able to obtain their own medications without a doctor's prescription and self medicate themselves.

Since not everyone reported their own diarrhea I suspect that the ship's diarrhea log may under report actual incidences.

Sea Sickness

The disequilibrium associated with the sways of the boat makes many people nauseous and it usually takes a few days to get their "sea legs". We saw more of the severe cases among those who had excessive alcohol and sunburn. Medications such as gravol, meclizine, and phenergan, all help in controlling symptoms (during the first few days). Intramuscular injections of Phenergan were very effective in treating even severe seasickness.

Pregnant women may have prescriptions from their own doctors (for gravol or diclectin) or may try ginger.

Our suggestions to avoid seasickness were to stay in the middle of the ship (near the center of gravity and there is less sway); avoid reading; and if above deck, focus on far away objects.

Sexual Transmitted Diseases (STDs)

Many of the crew, especially officers, were openly promiscuous with passengers. The crew appeared to have little knowledge of STD prevention, which is very worrisome considering the prevalence of HIV in many parts of the world. The crew is not regularly tested for STD's. Both male and female crewmembers will be fired if they are found in a women's cabin unless they are working there. There have been incidences of rape or other forms of assaults against crew or other passengers. Such incidences can generally be avoided by using one's common sense. If there is an occurrence, seek out a security officer and they will deal with the dispute. Remember, depending on where actions occur, there may be "no law" and the ship is under the Captain.

Accidents

Incidences, whether on or off the ship, should be reported and documented by the ship's security staff as well as medical personnel. Many passengers try to get a free cruise by pressing claims when they report to the infirmary with an injury.

Disabilities

Cabins specifically designated for people with disabilities are not always available. One of our passengers, a 21-year woman with metastatic spinal cancer, had requested such a cabin and became severely injured when a malfunctioning door crashed into her, further limiting her mobility. Although the cabin was designated as "handicap accessible," it had not been properly maintained as such and stewards responsible for this cabin did not have the proper training to do so.

Evacuations

Evacuation is indicated for patients that are very ill, badly injured or need of immediate testing. But evacuation is not always practical, and always very expensive. The Captain and Chief Medical Officer will make arrangements to evacuate patients to the nearest appropriate hospital. The ship's doctor can only recommend evacuations, not order them, but no reasonable captain would go against their doctor's medical opinion. Some of the medical emergencies we encountered included myocardial infarcts, strokes, deep vein thrombosis, and open fractures.

The U.S. Coast Guard will evacuate passengers from ships that are within 100 miles of the U.S. coast. Many cruises, obviously, travel much further than that. And there are watershed areas where there is about one to one and a half days between ports. When passing through these watersheds, evacuation becomes difficult for many reasons, including: logistics, many passengers/patients are reluctant to leave the ship; and changing course if necessary, angers lots of passengers. Sometimes the ship is reversed to the last port or sped up past its cruising speed. Although in the Caribbean the arrival time between islands is usually given as a day, it can usually be accomplished in a few hours. This is not widely done, in part because the company benefits more from keeping the passengers in international waters longer so they can gamble more in the casinos.

Vaccinations for Cruise Ships

We recommended the following vaccines for travel aboard cruise ships, as well as the port destinations. For short cruises: a booster tetanus, diphtheria, and polio, hepatitis A, typhoid, influenza and possible hepatitis B (for those exposed to high risk situations). Outbreaks of influenza occur on cruises. Ports of call may be in developing countries, and people often eat on shore. Also, the ship's food handlers come from many developing countries and sanitation is not always optimal. (I was a little upset when I found a gnawed toothpick in my salad one night).

Passengers usually embark on day trips to shore and are usually back ashore before nightfall. They usually will not require antimalarial medications. They may be exposed to insect borne diseases like yellow fever and dengue fever among others. This is something we did not directly address with passengers, as they should receive this type of advice with their pre trip check up.

I did see one bad case of jellyfish envenomation although we did not identify the species. Hazards like marine animal encounters and SCUBA related problems are possible since many vacationers also embark on a variety of activities at port.

We had 2 crewmembers with chickenpox while I was working. Passengers and crew should be immune. Adults who come from equatorial countries are apt to be susceptible. Those crew members had to be carefully quarantined which is not simple aboard ship. Pregnant women should be immune to rubella since outbreaks have occurred.

Man Overboard

People do go overboard and it is important to know the proper ways to respond to emergencies. Passengers are shown the proper safety measures and responses when boarding and while participating in lifeboat drills. For man overboard situations, witnesses should point at the spot where the person was last seen while someone runs to stop the boat. By maintaining a bearing it becomes easier to find the lost person.

"One of the passengers had been standing on the upper rails, urinating while intoxicated, and fell into the sea. Many cruise ships and rescuers were diverted to that area. Roughly 12 hours later, he washed up on shore alive and well! Back on his ship everyone who had been mourning him, now wanted to kill him for ruining their cruise!"

Working with Shore Doctors in Foreign Countries

Ships try to maintain list of doctors at ports of call that seem to provide reasonable treatment. But sometimes patients chose their own doctors, with variable results. For example, we visited to whom we had been referring crew to and found him and his facility acceptable but some patients returned with prescriptions for multivitamins or very lame advice. When interacting with shore doctors its best to work with people you know best. Often the local Embassy of your country can provide a list of practitioners in the area and while they may not specifically endorse any they can tell you about recent complaints. This also is true for recent problems at local businesses like hotels and restaurants.

Security

Security forces aboard ship exist more to police employees rather than protect passengers. If there is an altercation aboard ship do not become involved unless absolutely necessary. Notify security. Before strict guidelines were issued, there were frequent brawls among crew members, usually over unattended women. (After our cruise line revised its chaperones policy "allowing persons under 21 years of age as passengers only if accompanied by an escort over 25 years" there has been a significant reduction in fights.) During one incidence there were multiple victims and blood smeared over the entire Lido deck. The injured parties were escorted off the ship and told to pursue civil lawsuits against each other in the U.S., as the incidents had occurred in international waters. Generally, the ships' security unit adopts a passive approach to surveillance since there is "no place to run." If caught, they will be processed, and if necessary, confined to an empty pantry, which also doubles as the morgue.

I had missed reporting a woman being beaten by her husband because no one had pointed out her bruises to me while I was in another room treating her husband with a broken hand. Spousal abuse especially among newlyweds is not unknown on cruise ships. As with mainland laws, unless someone brings forth a complaint, there is nothing that can be done.

Interacting with the Crew

The crew consists of many nationalities with different backgrounds. Theft is rare but if suspected should be reported to security. Most of the crew despite coming from poor backgrounds are hardworking and honest. The deck hands may work more than 12 hours a day at less than minimum wage and are often treated poorly by other staff and passengers. They often depend on tips from customers yet may do very well from the tips they make relative to their native countries. Speaking with the crew is a good opportunity to learn about other countries outside the cruise.

The popular impression of the cruise industry is very idyllic and inaccurate in many respects but whether as a working vacation or as a planned trip cruising is still a great opportunity to see coastal areas because of the unique mode of travel. Travelers should be prepared and not expect full resources we have at home in managing problems.