Cruise Ship Medicine

Gary Podolsky MD

Learning Objectives:

1. Introduce clinicians to the on board environment aboard a Cruise ship

2. Learn the common and important illnesses and injuries to passengers and crew at sea

3. Discuss Medical Officers role in Sanitation, Outbreaks and Occupational needs of the cruise

4. Discuss Human Rights Issues aboard for Crew members and Passengers Safety concerns

5. Advice for Family Medicine and Travel Medicine Professionals to prepare their patients for cruise travel: pre-trip physicals, immunization, chemoprophylaxis and education about inherent risks of cruise travel and limits of resources

Introduction

When I first decided to talk about my experiences as a cruise ship physician I simply told my experiences as they unfolded to me. There are many idyllic views of working aboard a cruise ship and I had to reconcile these with my experiences and the stories I had heard from my fellow crewmembers. There are many authorities on the state of health aboard cruise ships .1-13 Many of the testimonials from physicians I had heard were solely praising the merits of working afloat and did not mention any of the problems I found myself confronted with. I find it hard to believe we worked in the same media .The travel industry barely mentions any form of risk in their pamphlets. In preparation for this talk I read several recent guidebooks on cruising. Other than a description of the facilities they offered nothing on safety issues.

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 14-17 It is generally difficult to sue a cruise ship company because often passengers live outside the port of jurisdiction and there is also a time limitation effect. The number of completed lawsuits may represent the tip of the iceberg against the industry.

I have included statements and from American College of Emergency Physicians (ACEP) and the Centre for Disease Control (CDC) on their guidelines towards Cruise Medicine 19-20 .

It should be noted though that they are only guidelines and not always watched. Hopefully by forcible confronted with these problems the Cruise industry will reform by progressive actions. This is unlikely to evolve by itself and existing and proposed guidelines 16, 17,27-29 will need to be enforced from without by watchdog organizations. I have also included some information regarding legal liability and the rights of passengers and crews 15-17,29 . This is a difficult subject to summarize The medico legal environment aboard is an important part of this talk and must be included although I can only comment on how it affected the past treatment and disposition of the cases on my ships and do not wish to generalize to the whole industry. I have included many good resources that will help readers find answers to the current status of some issues I raise. All of the case histories recorded did happen but the names of individuals and companies have been left out or changed.

Life aboard a Cruise Ship

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 groups of people are congregated together as well as the types of problems specific to a remote marine environment. Cruise ships are a 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 the cruise environment.

Captain 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.

Staff Captain The Staff Captain and his staff assist the Captain. It is the Staff Captain who is in charge of disciplining all cruise ship employees. The deck crews are also under the staff captain and perform a variety of maintenance and repair work necessary for the ships function

The Hotel Manager runs the 'Hotel' part of the ship, with the Chief Purser and the rest of the pursers running the accommodations.

The Food and Beverage Manager also is responsible for the catering and dining services aboard. Hygiene is a very crucial issue and will be discussed later. There is an important coresponsibility shared with the Chief Medical Officer for ensuring that the Ships Sanitation record is clean.

The Chief Steward is responsible for the stewards, who run guest services such as room service delivery and the cleaning of rooms.

The Cruise Director is an important liaison with the passengers and is in charge of the cruise staff. This includes the dancers and shore excursions. This image is best exemplified as "Julie" from the "LoveBoat" and of all the perceived stereotypes this is the one that most holds true to the TV show.

The Casino Manager also has an important role as he oversees the management of gambling a significant revenue for the ship.

Chief Engineer is responsible for the running of the engines and other systems

Other Separate Department heads include: the Chief Radio Officer who was responsible for communications, Child Care Director who manages all the day care staff, Beauty Salon Manager , and the regular Shop Manager . The departments work together to service the passengers. Every week the captain holds a meeting, which all the major departments attend.

Security Chief is responsible for ensuring the safety of the passengers and crew from each other and from external threats. If there is an altercation aboard ship people were told not become involved unless absolutely necessary and instead wait for 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 incident there were multiple victims and blood was 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.

During our weekly Captain's Meeting we were briefed on how to look out for drug smugglers we were informed that it was highly likely that they would try to come aboard. We were to look closely for anyone who resisted having their photo with our Parrot, Giant Lizard or Pirate since this would be one sign that would give them away!

The crew is truly international being from all over the world. We had members from China, Philippines, Indonesia, Caribbean, South America, Europe, and Australia. It may surprise people to know how little English was spoken or understood. The Captain, Staff Captain and the remaining Staff were all from Italy and few spoke English good to well. I was told that our company only hires members of the Staff department from Italy because of a prior agreement the company had made with the Italian government. There was a big problem in communication with the rest of the departments. 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. When examining patients I would always insist on an interpreter since communication became too difficult. With enough effort I was always able to find an interpreter which greatly facilitated understanding.

The Medical Department

Depending on the size of the ship, there are 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 composition and training of medical staff as not all are board certified. Although the American College of Emergency Physicians (ACEP) has made guidelines (See Appendix 1) the cruise ship industry is not under obligation to follow these and ships are not monitored nor inspected by ACEP.

The infirmary is open during regular office hours for both passengers and crew, and is open 24 hours for emergencies. Each ship's infirmary has different capabilities, but generally includes IV fluids, splints, ACLS medications and a defibrillator. ( Appendix 1)

Medical staff can perform minor procedures, treat accidents, dispense medications and begin treatment for cardiac problems. Most ships have the capabilities to communicate with backup experts on shore. Our ship had a satellite phone to communicate with a Miami Emergency Physician to provide Medical backup advice. This is useful for both medical and legal considerations. In general the consulting physician would generally agree with me that an evacuation was advisable in situations that I deemed to be emergent.. 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. Infirmary beds are available for quarantine or for observation of ill patients. 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 meds and anti-nauseates were for purchase in the gift store by passengers. Anyone requiring an assessment or refill was required to see a physician.

Treating Passengers       Vaccinations for Cruise Ships

Immunizations are recommended for both the port destinations as well as for the ship itself. For short cruises a booster tetanus, diphtheria, and polio, hepatitis A, typhoid, influenza and possible hepatitis B (for those exposed to high risk situations) is recommended. Outbreaks of influenza, rubella and other diseases occur on cruises 31-33 . Ports of call may be in developing countries, and people often eat on shore so vaccinations must also cover the itinerary. Also, the ship's food handlers come from many developing countries and sanitation is not always optimal.

One crew member was a little upset when he found a gnawed toothpick in his 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.

We had 2 crewmembers with chickenpox during our voyages while I was working. Passengers and crew should be confirmed to be immune before joining the ship. Adults who come from equatorial countries are apt to be susceptible since not all adults may be assumed to have had varicella infections previously. Our crew members had to be carefully quarantined, which is not simple aboard ship. The hotel manager had to carefully search the ship for empty beds and crew were quarantined with room service for the duration of their contagiousness. Pregnant women should be confirmed to be immune to rubella and varicella before they travel since many outbreaks have occurred.

Yellow Fever Immunization

Yellow fever immunization for cruise ship travelers is controversial. Yellow fever vaccination is firstly recommended for anyone at risk for significant exposure to yellow fever. This may occur through daytime exposure to infected Aedes egytii mosquitoes. The vaccine had previously been thought to be very safe but recent concerns about viscerotropic side effects causing symptoms similar to actual yellow fever have been observed in patients immunized for yellow fever. These patients have been older so those who are over 65 or immunocompromised are thought to be more susceptible to these side effects. It is recommended that yellow fever vaccination be used with caution in high-risk individuals although even apparently healthy young people can also become very sick..

Yellow fever vaccination is also required by certain countries for entry from travelers who are entering from countries where yellow fever is present or the possibility of yellow fever exists (yellow fever endemic areas). This is to protect that country from any imported yellow fever virus being introduced into their mosquitoes so that an urban cycle of yellow fever does not start. For reference of each country's yellow fever requirements the CDC provides updated information 1 . Some cruise itineraries take place through yellow fever endemic countries and ports of call may include cities where travelers may do a shore leave. Yellow fever may not exist in the port but in the surrounding countryside, which, although travel to is unlikely, is still accessible by day-trippers. Balancing out the needs of the passengers to fulfill their entry requirements may be difficult. Yellow fever waivers are given for true medical contraindications and will allow people with egg allergies and immunocompromised statuses to travel but waivers should not be abused since these very individuals who have their yellow card waived can also become the perfect vehicle to spread yellow fever.

Common medical problems aboard ship for Passengers

With a large passenger count and a crew almost as large basically anything can happen aboard. Clinicians may expect to see anything, as passengers will often minimize their illnesses despite what their tickets warn against.

Peake 34 reports a breakdown of common complaints aboard which reflects a distribution similar to an urgent care facility.

Table 1.Breakdown of Infirmary visits by Main Diagnosis 34

Traveller'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 passengers and crew. If the ship has an incidence of 3%, it is considered significant and must be submitted to the CDC 35-46 . They generally investigate large outbreaks. Part of the assessment of cruise ship hygiene depends on the regular submission of the weekly diarrhea log and failing to comply will cost points off the ships rating, so this is done scrupulously and is one of the major duties of the ships doctor.

Sea Sickness.

It usually takes a few days to get your "sea legs". Avoiding excessive alcohol and sunburn, helps prevent dehydration. Medications such as Gravol, Meclizine, and Phenergan, all help in controlling symptoms (during the first few days). Injections of Phenergan are available and are usually effective. Pregnant women may have prescriptions from their own doctors (for Gravol or Diclectin) or may try ginger. To avoid seasickness it is recommended to stay in the middle of the ship, near the center of gravity where there is less sway). Avoid reading. If above deck, focus on far away objects. Sea bands to provide acupressure to prevent and alleviate seasickness were very popular although there was very little evidence that they helped anyone.

Sexually Transmitted Diseases (STDs)

Many of the crew, especially officers are openly promiscuous with passengers 47-48 . 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. Many crew members had multiple partners and some had literally a 'girlfriend in every port'. The crew is not regularly tested for STD's. Both male and female crew members will be fired if they are found in any passengers' cabin, unless they are working there. Occasionally there are charges 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's jurisdiction..

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 the stewards responsible for this cabin did not have the proper training to do so. Many special themed cruises are available. Among these are dialysis cruises with specialized medical care 49 .

Accidents

Incidents whether on or off the ship, should be reported and documented by the ship's security staff as well as medical personnel. Most injuries are simple and similar those in an urgent care clinics 34 . As mentioned above, simple fights break out. X-rays were unavailable on board but available at all ports if required for non-urgent problems.   Some accidents were from stumbles and falls. After a fall in a previously safe part of the ship the Captain's staff would post another ubiquitous "Watch your step" sign near the offending area so as to limit future liability.   There were a small minority of accidents brought to our attention by " career passengers " which were people who had sustained previous falls on prior cruises and would again attempt to get future free trips. These passengers were always examined for free and a detailed report was forwarded to security. The hotel manager would then decide if any compensation was appropriate.

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 50-52 .

Assaults

There are many recorded assaults on both guests and crewmembers by both passengers and crew.   The cruise ship is looked on as a finite area and security is ever present. Crewmembers are instructed not to get involved in altercations and simply observe until security officers arrive.  

A DJ was assaulted by a teenager causing a severe tendon injury In his dominant hand. He was injured while attempting to stop the boy from stealing music. Surprisingly many of the security officers were diminutive and not at all physically imposing and would not help the DJ against the boy. He was surprised he was criticized for defending company property. It was generally believed among crew that the main purpose of security was to observe and keep them from violating the company's rules and not to protect them or passengers.  

When I first worked for the cruise line altercations between young men were common over women. Our cruise line made a very clever change to their rules, which made theses types of fights less common. It was observed that fights often occurred as groups of men came aboard to meet college spring break coeds. The company changed its admission rules that limited anyone under the age of 21 from coming aboard unless they had a chaperone over the age of 25 years. This prevented groups coming aboard with one member over 21 acting as the chaperone. 16  

One big fight turned into a riot after two groups fought over one girl on the lido deck three o'clock in the morning. One man had extensive lacerations that were caused when another broke a beer bottle over his head and another individual had a broken nose. Blood had been smeared across the entire lido deck as drunken bystanders had spread the blood in a panic. Clearly from eyewitnesses and the amount of damage done, security was unable to deal with the situation. I treated several of the major participants but those with minor injuries typically did not present to the infirmerary. A security officer gave the men their reports and both men were told to take their grievances to a civil court in Florida if they wanted to litigate against each other.  

Sexual attacks and rapes have frequently been reported aboard cruise ships and are generally under reported and settled out of court 14-17,53 . Several successful lawsuits and prosecutions have been completed for rape and child molestation accusations against cruise ship employees.  For our company, o fficially no crewmember was allowed to be in a passenger's room unless allowed to attend on official business and they were found they would be fired. However, if they brought a passenger back to their own quarters any relation that occurred was implied to be consensual and was overlooked since the company would not be liable for rape.  

Aboard the ship there was clear demarcation along class ranks. For simple laborers (galley workers, stewards) a zero tolerance attitude was taken. For other "middle class" worker (shop staff, cruise hospitality workers and junior officers) a more indulgent attitude was allowed. For senior staff (department chiefs) more rules did not apply. Senior officers would have their wives and children aboard with them during a one-week stretch only to have a mistress come on the following week. Musicians freely admitted to having contests to see who would sleep with certain passengers first and would claim up to five different women in one week. Clearly much of the time their relations are consensual and equally sought by both passengers and crew but many passengers have reported excessive harassment by senior officers.  

Lydia One evening a 19-year-old woman mentioned to me how one of the senior engineers (50 years old) had attempted to drag her by her wrists towards his cabin. She had resisted and told me she had reported the episode to security. I spoke with the Security Chief and he denied that he had heard anything.. I talked to her again and she admitted that she had decided to not pursue a complaint, as she did not want to get the poor man in trouble.   Later that cruise during the Captains weekly staff meeting a complaint letter from another passenger was being reviewed. One complaint stated as the Captain summarized that the "Italian Officers were getting too aggressive in the disco'. The Captain wanted to find out who had written it and when he found out it was from a 50 year old married women he chuckled and dismissed it out of hand.  

"Deena" During one of the nights, one of the beauty salon girls was attacked by her boyfriend in a public corridor (in full view of other passengers and crew) and dragged into her cabin. Her boyfriend worked on another cruise line and was visiting. While I was examining her in my office for superficial bruises and abrasions the staff Captain appeared and demanded that she decide within ten minutes to press charges. If she would, her attacker would be deported back to his home country and if not he would resume his job on the other Cruise company. While waiting to disembark at the next port of call she was forced to confront her assailant as he also waited to disembark. Security had made no effort to separate the two. The cruise industry has a long history of sending its problems away quickly to side step liability and lawsuits.

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 one practitioner to whom we had been referring crew to and found him and his facility acceptable but some patients returned with expensive prescriptions for multivitamins or very poor 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. The international society of travel medicine also has a listing of travel clinics worldwide but not every country is represented 54 .

We used a local Dentist in Mazatlan to replace fillings for crew. I was curious to visit so I inspected it once. The Dentist was very apprehensive about his attention to sterility. Although it was not my intention to grade him I found his office very professional and clean with a working autoclave.

Safety Drills -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!" 16

All crewmen are trained as sea men and are required to practice mustard drills several times to be proficient.

During one drill I was required to take my place in Lifeboat number one, which in the case of an emergency would contain the Captain, Chief Radio Officer and me, Chief Medical Officer. In this drill ropes on tethered pulleys physically lowered us into the water and back again. The Chief Radio Officer explained to me that the Captain never went into the Lifeboat because he didn't trust them 16 especially since a boat had flipped from bad ropes and caused a crewmember to crush his legs. This was settled out of court. The Radio Officer also pointed out that in the event of an emergency that would tilt the boat significantly starboard or port due to the ships height and placement of the lifeboats, not all lifeboats would be serviceable!

The Mustard Drill for the Medical team was the infirmary, which for our ship was deck 3. We were to gather there and wait for casualties. As this was close to the bottom levels we were also told to quickly evacuate on our own initiative if we saw water coming up the stairwell! Our drill team did not perform well during our fire drill with 2 members of the stretcher drill not showing up. The crew was able to put out a real fire aboard in the laundry, which was self limited and only lasted 30 seconds, or less.

Inspection Day

It is well known that cruise ships are inspected by the Coast Guard and Center for Disease Control (CDC). The CDC publishes a green sheet based on random inspections of cruise ships see Table 2.

I should point out that inspections are not completely random because there is enough time for companies to touch up. The inspection for our fleet only occurred in American ports. So while at least four of our boats were inspected the rest of the fleet had a few days warning when they would be inspected as they arrived into US waters from foreign ports.

Our traveler's diarrhea log was completed each week and was required for the green sheet so that was one aspect of the green sheet that was easy to control. We never exceeded the 3% incidence necessary to take action. The night we were scheduled to arrive in port we had a near collision with a fishing boat. The crew and I were told that it was in our lane but air on board radar was on the wrong setting. At the last instant our ship veered to miss it. The next morning I awoke to find a mess in my room as all bundles had fallen out of cabinets, chairs and tables. In the infirmary, things were worse with all the medical supplies on the ground and a few glass items broken. I called all staff in off duty or otherwise and in the next two hours we cleaned up everything, fixing any damages or duty items. The inspector came in and passed us with only a few points off (none of it was medical).The passengers had been told we had hit a few large waves in the night but the Los Angeles Times reported the event 16 . The Company had been worried because two of our sister ships had failed. One had failed because of a dead cockroach that had been found in a public ice cream machine. On the ship I had worked on cockroaches were acknowledged permanent guests. To combat them poison was spread by the staff crew around the drains in the sinks and restrooms.

Our other ship had failed when one of the onboard swimming pools was over chlorinated while another was under chlorinated conditions, which have been linked with Legionella outbreaks 55-58 .

When a similar review by the Coast Guard was due the Captain knew it was coming so it was no surprise.

Occupational and Family Medicine Aboard for Crew Members

There is a good proportion of occupational medicine among the crew, especially musculoskeletal overuse problems 59 . 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 in the past. The general crew was multinational and made up of members of all 6 continents and many had variable states of health care, some of them claimed to never having seen a doctor in their life. Members from developed countries had claimed to have a pre-crew physical as well as an HIV test. I myself had no physical or confirmation of prior vaccinations done.

All crewmembers were compelled to complete a Panamanian physical on the ship that I worked on which 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 than anything else.

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 working in their native countries.

"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. Because we were under a flag of convenience regular rules and regulations that one would expect in North America were absent. There is no minimum wage for workers or labour protection laws. Some crew worked in excess of 12 hrs per day at less than 1 dollar per hour. While it is true that they may indeed do better aboard a cruise ship than they would in their own home developing country this is still exploitation.

Most crewmembers are passive and accept what is meted out to them but I observed a sudden change or

" Last Day Syndrome " where previously quiet crew would speak out if challenged by the usual authorities. They knew that they were going home regardless and didn't care anymore.

One casino worker violently let out that she was glad that she would no longer be treated like an animal and allowed to walk down a hallway without constantly under suspicion of breaking company rules. Supervisors knew well enough to stay away from crew near their last day.

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 weeks 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.

Case Study Lorelei, The Non-Ideal Worker

I had been seeing a manager from the casino with recurrent right shoulder pain for several weeks after a lighting fixture in her room had fallen on her at night. She had received anti-inflammatory medication and physiotherapy during our ports of call. Finally we referred her to a shore side orthopedic doctor who ordered an MRI and gave one cortisone injection. She failed to improve and was mostly miserable in her job. Company policy was for her o return home to Columbia and get definitive care there. The cruise we were on traveled in a circuit starting from Tampa to Grand Cayman to Cozumel and then New Orleans before Tampa again. She had been told that she would disembark in Tampa. The company secretly arranged for her to be disembarked 3 days earlier in New Orleans. From there she would be returned to Columbia so as to have no chance of meeting with any US based lawyers to either apply for landed immigrant status or initiate an injury lawsuit.

Family and General Practice

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 they're for them to see twice a day between or during their shifts but previous physicians did not encourage this. This population could have any conceivable condition and some were aboard for over 12 months.

Our cruise line had a strict policy that if their female employees get pregnant, they are 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. He also had added " that the company officially did not promote birth control pills for employees because of the unknown long term side effects but they were welcome to see a shore doctor and get these privately ".

Case Study, D was a young woman who had recently discovered she was pregnant. She knew that she would be sent home but told her supervisor anyway. Both she and her boss came to the infirmary and asked for a therapeutic abortion. As is the custom in Canada I immediately started to fill out a shore side referral for a gynecologist referral. My nurse at the time took my referral and ripped it into small pieces, and took out some torn pages from the New Orleans Yellow pages directory. She gave the girls the name and contact number for an abortion clinic at our next port stop and added, "don't you ever tell anyone who gave this to you". She later explained that this is how this was done onboard.

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. Although tickets told passengers they could not come aboard with certain advanced illnesses we frequently would see patients cart their own oxygen aboard.

Rarely some patients preregistered with us by giving us a copy of their old medical records and an introductory letter from their physician in case they had a problem.

Confidentiality - "Friends of the Clinic"

This next section is a topic that I don't believe has been addressed anywhere. I am referring to the number of non-medical people who used the infirmary space for personal use, which compromised patient confidentiality. The infirmary clinic hours were run during two specific times although we always would accommodate emergencies.

The nurses aboard are given considerable autonomy in the running of the clinic. This is expected since many of the physicians filled temporary positions on our line and were generally temporary whereas the nurses had larger six month plus contracts. This led to many nurses acquiring friends that would stop over during working hours making it difficult to keep them from learning that other crew were there. As the ship is a small environment, rumors would easily get around. In one case one married nurse's onboard lover would stay overnight, as her cabin was located in a separate confined section of the infirmary, and would leave as I arrived for work. This same nurse was later removed from the ship and transferred to another on the grounds that another nurse who was the Chief Engineer's mistress wanted her position!

Medical staff would also make gifts of medical supplies or favors to crew staff. This seemingly innocent practice rapidly polarized the crew's staff against the other nursing staff responsible for inventory.

Irregularities in Dispensing Medication

One nurse had been giving young women surgical dressing so that they would not have to pay for sanitary napkins. This was a minor offence but created great resentment among other staff who were responsible for overhead. Later this same individual was found dispensing morphine to a young male crewmember for mild back pain without my prescription or knowledge. In this case we had a long talk with her and she professed to reform but resumed her ways very quickly. As Chief Medical Officer I was faced with a dilemma. If I fired her, and I didn't believe I had authority enough to do this, I would be condemning the rest of the nursing staff to do more work until we reached the next port or were able to find a replacement. This was also during a portion of the cruise where our satellite phone did not work and I could not consult the Fleet Chief Medical Officer for direction.

Because of the infirmary's close quarters special sensitivity should be used in guarding crew's medical information.

The crew was very apprehensive at first from receiving medical care aboard. They seemed to generally feel that there was little attention to their prior problems by either nurses or physicians. As many Doctors viewed their job as a vacation they often let many nurses do their job for them.

Case Study Emily

One woman had told me she had approached a previous doctor with complaints of fixed suicide ideation including active plans of throwing herself overboard but was told by him there was nothing he could do for her depression. He also specifically told her he was too busy to arrange any time to speak or console her and didn't believe that any pharmacotherapy would benefit her so he declined any therapy. I found that some days I had four to five hours of free time and such a response to a person is inexcusable. This same doctor had been prescribing continuous doxycycline indefinitely for a man for 6 weeks for no other reason than that he might have a STD. In another instance the nurses had covered for him because he was too intoxicated to attend to a patient suffering myocardial infarction resuscitation.

There were enough similar accounts backed with records to affirm that crewmembers often received substandard medical care. In another situation neither of the nurses aboard was capable of putting a very easy intravenous line on a stable patient. Physicians and nurses who had experience in Family Practice and Emergency were much more skilled and professional in dealing with emergencies in general while those who had cruise careers were noticeably less skilled in attending emergencies. It would suggest that many incapable individuals may possibly gravitate towards a cruise career as they would be freer to do what they may with less professional supervision.

Several crewmembers related that they obtained their own medications- birth control, antibiotics, and analgesics from Mexican pharmacies without prescriptions so they would not get hassled in the clinics. They preferred to pay for their own medications even though the company would dispense many for free. Another crew stated there was a thriving trade in street drugs aboard although I myself never saw any evidence of this.

Significant Injuries Requiring Evacuations

Medical evacuations are indicated for patients who are very ill, badly injured or in need of immediate treatment. 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.

Transport time for sick patients will vary according to where in the cruise the event takes place. One study showed a main time from the physician calling for an evacuation to arrival at hospital was 16.6 hours 60,61 .

from a port of call and with no significant air evacuation available, this will obviously cause a delay in patient transfer.

Some urgent emergency situations that had occurred for me are:

Deep vein thrombosis in the deep blue sea    A young woman with a prior pulmonary embolism from a deep vein thrombosis presented to our infirmary in the middle of the Gulf of Mexico with symptoms of her previous deep vein thrombosis. After consulting with a physician in Miami and the patient, we agreed to initiate a heparin infusion empirically and take blood to establish a baseline PT, PTT. The woman had an uneventful transfer to Tampa.

Open fracture    On a cruise out of Grand Cayman a deckhand had crushed his index finger with an open wound. Although not life threatening, an open dirty wound could not wait for air next port of call and I advised evacuation. In this instance the ship had to be turned around back to the Grand Cayman. The staff was very unhappy with my decision and I was shown a bill for all the "wasted fuel" that my diversion has caused by one of the junior engineers.

Second open Fracture from doing the Jitterbug While leaving Tampa an elderly couple had been dancing the jitter bug and the lady had sustained an open fracture of her right wrist. A small cube of wrist bone was actually located on the dance floor. I had wanted to attempt to identify it but it was thrown out like waste before I could secure it. Since the cruise was still in American water I had assumed that it would be an easy evacuation. Initially the cruise was only two hours out of port heading for the Caribbean at 900 pm. The coast guard was contacted and despite our Captain's protests that I just put a cast on it until we get to Grand Cayman I understood that we would get an evacuation. After three hours of waiting I found the Captain had changed the plan to meet a coast guard ship in 15 hours. I spoke with the coast guard again this time impressing that this woman had at least a limb threatening injury and given her diabetes and past medical health a risk for sepsis. The coast guard agreed to send a helicopter. The husband who had previously been told he could not go with his wife now would be allowed to go. At three a.m. I received a phone call from one of the Italian officers informing me that the 'helicopter is broken'. He followed with a pregnant pause, which I believe he expected me to yell at him. (I didn't) I asked and found that the next one would be available at 0500. The copter arrived with a wire litter basket and hoisted the patient up. In this case the patient was seen in Fort Lauderdale and had a 3.5-hour debridement surgery. Her husband hearing of her state was forced to have his cruise by himself until we reached Grand Cayman one and a half days later.

Indeterminate Chest Pain and denial During a trip out of our San Fernando Port, one of our elderly patients had syncope without chest pain. He had a strong history of vascular disease and stroke. After his collapse his physical exam was unremarkable and EKG only showed non-specific ST changes. I contacted Miami and discussed the situation. Of coarse there was no way of ruling out an event since we had no way of assessing enzymes available. After a talk with the patient I advised him to treat this as a myocardial event and he should he on oxygen and transferred. He disagreed and wished to remain a passenger. He had that right and we could not transfer him while at sea against his will. This ship would also charge him for oxygen and observation in the infirmary so he declined all treatment. This was all happening as we were leaving US water and we would shortly be in a position where air evacuation would be impossible. To make things worse one of the nurses I had previously disciplined for giving narcotics without my knowledge (see other anecdote) was now advising the patient not to listen to me. After we passed out of US waters the patient remained stable. At the Captain's discretion we created a port we would not normally go to at Cabot San Lucas. By now being "at port" we had the discretion to force the patient to receive medical attention. He was transferred via a launch since our ship remained at sea. Now unhappy with being in a Mexico hospital he arranged a separate jet evacuation himself to return to Los Angeles. During the time I spent assessing him I had originally attempted to obtain his prior EKG from his family physician in Santa Monica, but the sat phone which wasn't always working broke down and although I was able to speak with his doctors office I was unable to receive the fax of his prior records and EKG. I strongly advocate all cardiovascular patients to bring with them a recent EKG and legible list of their medications and relevant medical history. This makes working in the dark easier.

Stroke in Port On arrival in Tampa one man presented with numbness and hemiparesis just as I was departing the ship. I put him on ASA and oxygen but I found that I was on my own. The porters seemed disinterested in calling for an ambulance because they has so much to do and my nurse who like myself was ending her current contract left the ship in the middle of the resuscitation! After much convincing I persuaded the remaining staff to help me and we transferred him off.

Each of these situations exemplifies the variability of available resources at different times on the same type of cruise. Communication with a multilingual crew is difficult and advanced planning is necessary and the same approach will not work each time. Conclusion

Cruise ship vacations are currently a very popular form of travel and offer several advantages for travelers with handicaps, special needs (including dialysis) and the elderly all of who may vacation in a controlled environment. Concerns due to remoteness of specialized care and questionable onboard practices may spoil this idyllic solution.

Travelers should first be sure that they are fit enough for remote travel 62-64, and have with them their current medical records and enough medication. If questionable they should review their health with their family physician and ensure that they have all the recommended immunizations including if appropriate, yellow fever.

Cruise ships must have competent medical staff. At present whether adequate care exists is questionable ,65,66 . Published guidelines exist but are not mandatory and it is unclear how closely they are followed among all ships and companies. It is also difficult to declare standards since an infirmary will never be equal to an emergency department yet many of the successful lawsuits suggest that much more improvements need to be made. Infectious outbreaks occur regularly on ships. Not all passengers or crew are fully immunized or screened so this is likely to continue and cruise guests must accept some risk. Seniors are encouraged to have their influenza and pneumococcal immunizations and all women susceptible to varicella or rubella should be vaccinated before their pregnancies.

The shipboard environment has previously been thought to be a blank slate but crewmembers from all over the world may also carry polio, tuberculosis, typhoid, hepatitis A and B, and HIV so passengers should consider the ship as another country unto itself in their pre-trip planning.

Finally Cruise ship physicians must be prepared to deal with occupational and family practice health issues. Issues of Human Rights and Sanitation are intimately related with Health although not "part of the job description". Raising the problems with "Flags of Convenience" will lead to the discontinuation of many health issues and ultimately aid passenger, crew and cruise line in the long term.

Appendix 1 Recommendations for Onboard Medical Staffing aboard Cruise ships

The specific medical needs of a cruise ship are dependent on variables such as: ship size, itinerary, anticipated patient mix, anticipated number of patients' visits, etc. These factors will modify the applicability of these guidelines especially with regards to staffing, medical equipment and the ships' formulary.

Medical care on cruise ships would be enhanced by ensuring that cruise ships have:

•  A ship medical centre with medical staff (physicians and registered nurses) on call 24 hours per day, examination and treatment areas and an inpatient medical holding unit adequate for the size of the ship. A medical centre with adequate space for diagnosis and treatment of passengers and crew with 360° patient accessibility around all beds / stretchers and adequate space for storage.

•  One examination / stabilization room per ship

•  One ICU room per ship

•  Minimum number inpatient beds of one bed per1000 passengers and crew

•  Isolation room or the capability to provide isolation of patients

•  Access by wheelchairs / stretchers

•  Wheelchair accessible toilet on all new builds delivered after January 1, 1997

•  A contingency medical plan defining:

•  One or more locations on the ship that should:

•  be in a different fire zone (from the primary medical centre)

•  be easily accessible

•  have lighting and power supply on the emergency system.

•  Portable medical equipment and supplies including:

•  Documentation and planning material

•  Medical waste and personal protective equipment

•  Airway equipment, oxygen and supplies

•  IV Fluids and supplies

•  Immobilization equipment and supplies

•  Diagnostic and laboratory supplies

•  Dressings

•  Treatment - medications and supplies

•  Defibrillator and supplies

•  Communication equipment for each member of the medical staff

•  A clear procedure in case the primary medical space cannot be used

•  Crew assigned to assist the medial staff

•  Medical staff who have undergone a credentialing process to verify the following qualifications:

•  Current physician or registered nurse licensure

•  Three years of post-graduate / post-registration clinical practice in general and emergency medicine

OR

•  Board certification in:

•  Emergency Medicine or

•  Family Practice or

•  Internal Medicine

•  Competent skill level in advanced life support and cardiac care.

•  Physicians with minor surgical skills (i.e. suturing, I&D abscesses, etc)

•  Fluent in the official language of the cruise line, the ship and that of most passengers

•  A medical record and communication system that provides:

•  Well organized, legible and consistent documentation of all medical care

•  Patient confidentiality

•  Emergency medical equipment, medications and procedures:

•  Equipment:

•  Airway equipment - bag valve mask, ET tubes,