by C. Arkangel MD, FAAEM, FACEP
Being a physician on a cruise ship necessitates more than just responding to a long blast on the ship’s whistle that is followed by CODE BRAVE BRAVO STARBOARD (“Man Overboard, right side of ship”). It involves more than simply being decked out formally, in uniform, meeting and drinking with beautiful people from all over the world who ask, “Are you the Captain?” and “Can I take a picture with you?”
Cruise Ship Medicine provides cruise line guests, and crew members, with timely access to quality medical services that range from minor, but urgent, situations to severe illness, injury and emergencies. This responsibility, for the health and welfare of passengers and crew members, is a unique and usually enjoyable experience. It may also be a lonesome responsibility. The ships’ physicians need no longer feel as isolated as in the past, trying to reach shoreside facilities and consultants. The advances in technology, like enhanced telecommunications and Internet access, have exponentially improved care in recent years.
Both the general public and the medical community often have a misconception of what Cruise Ship Medicine really entails. This misconception involves medical maladies limited to sunburn, motion sickness, gastroenteritis and minor injuries secondary to falls while intoxicated or seasick. Included with this misconception is the view that physicians and nurses are merely on holiday, they have only four (4) hours of clinic daily, and they Party! Party! Now, for the real story of Cruise Ship Medicine!
Cardiopulmonary arrest, acute coronary syndromes, acute brain attack, DKA, asthma/COPD, GI bleed, acute abdomen, ectopic pregnancy/threatened abortion, epidemics, status epilepticus, venous thromboembolic disease, psychiatric disorders, alcohol and other drug abuse – are disease entities that I have personally seen and cared for in the brief two years that I been employed by cruise lines.
We have an infirmary on ship, not a hospital, with limited staff to care for acute care patients, and the medical staff is on 24-hour call, 7 days a week. The logistics of and decision to effect an emergency disembarkation can be significant: How long can we keep this patient onboard safely? Is this patient stable enough to be extracted by helicopter via a hook and basket? Will this patient tolerate a transfer and transport by a Coast Guard cutter? Does the closest shore medical facility provide the necessary care and facilities? If we divert to an alternate port, how does this affect the 2000-plus passengers who had hoped to visit the dream-of-their lifetime port? Once the patient and their family disembark, how will they get back to the USA? Do they have travel insurance? No, it is seldom a simple, “Captain, we need to medically disembark this passenger as an “emergency” situation.
North American clients make up approximately 75 percent of the world’s cruise line guests with 60 percent of the world’s fleet based in North America to service this major market. The Caribbean Sea is the primary destination in half of all cruises. Other top destinations include the Mediterranean, Alaska, Europe, and the west coast of Mexico, and ever-expanding cruise itineraries.
Industry-wide, the average cruise line guest is 45 50 years of age with certain cruise lines attracting a senior clientele while others cater to the younger crowd. More chronic medical problems, such as Acute Coronary Syndrome or COPD are seen in the mature guests and a younger age group may have more injuries due to alcohol debauchery and sports activities.
Today’s large cruise ships can serve as a gathering place for the global community. Passengers and crew, from around the world, bring together a diversity of cultures as well as diversities of medical and immunization backgrounds, and health risk behaviors. On my last cruise, the 1200-member crew represented 52 nations! Thank goodness that English is the official language of this cruise line.
Cruise voyages can last from several hours, (e.g., gambling cruises) to several months, (e.g., around-the-world and semester-at-sea cruises). However, the average duration of cruise travel is seven (7) days. This is certainly sufficient time for ample opportunity for passengers and crew to come into repeated and prolonged contact through shared activities. Participating in games, dining ingesting food and water discloses many opportunities for exposure and transmission of communicable diseases.
Embarking passengers and crew can import and spread communicable diseases onboard. Then, add the multiple port stops where differences may exist in sanitation standards and disease exposure risks. Detecting and preventing infectious diseases, acquired during cruises, are important not only to protect the health of cruise travelers, but to avoid global dissemination of disease in home communities as passengers and crew disembark.
During a one-week cruise to the Caribbean, on average, a ship’s medical staff will see 3-5 percent of the guests and 7-10 percent of the crew members – or about 1 percent of the total shipboard population each day for some kind of illness or injury. Eighty to 90 percent of the visits to the infirmary will be for non-urgent medical problems, 10-15 percent for urgent problems and 5-10 percent for serious illness or injury that may require shipboard hospitalization and/or emergency evacuation to a full-service shore side medical facility.
Here is my experience:
I entered the realm of cruise ship medicine only after I retired from UTHSCSA and after 30 years of EM, usually in very busy Emergency Departments and Level I Trauma Center facilities. I work as an independent contractor for the largest cruise line with tours from one to six weeks. I have been fortunate to only work on super cruisers which have a staff of two physicians and four nurses. Super cruisers can handle 3000-3500 guests and usually have a crew of 1100-1200. My physician colleagues have been from UK, India, and South Africa. The nurses, usually ICU or ED RNs that I have had the privilege to work with have been from NY, TN, UK, New Zealand, Philippines, Australia, and South Africa. The nurses see the greater majority of the patients since they work on medically sound protocols (e.g., AGE, sea sickness, sunburn, minor bruises and lacerations). Most of what we do in the infirmary does not fall into the category of life threatening emergencies or even anything close. I find it is a refreshing, enjoyable opportunity to spend time with patients that they cannot get from their physician at home. Again, it is only possible because the nurses are able to see and treat, with great passenger confidence and appreciation, many of the ailments that passengers or crew have or fear that they may have.
The infirmary is open 12 hours daily, with physician present for 3 hours in the morning and 3 hours in the afternoon. However, the medical team is on call 24 hours a day and can be reached by pager, mobile phone, or radio. A nurse carries the 9-1-1 phone when the infirmary is closed. With two physicians, I was on call every other day, except for emergencies. I was able to ride a horse bareback in the Caribbean, go tubing in an underwater cave in Belize, canopy tour in Grand Cayman, power snorkel, and kayak in both Montego Bay and Jamaica and cycle in Jamaica and Saint John. Sleep during the night is usually uninterrupted, especially when I was off.
The medical team has individual, private cabins usually on Deck 0 where the infirmary is located, but the senior physician, which I usually was, had a larger cabin on the 5th floor forward, along with the other senior officers of the ship. This cabin had a tub, instead of a shower, in the bathroom, a bedroom with TV/VCR, multiple closets and a sitting room with TV/ DVD, plus a computer with Internet capability and two large windows. The other physician has a smaller cabin on Deck 0 with portholes, but still a luxury when compared to a poncho liner and poncho in the field. A steward was assigned to look after the cabin, take my laundry to the cleaners, and provide amenities, like bottled water. Meals are available at the staff or officers dining room, or up with guests under certain conditions. The crew and guest gymnasiums are available during off times. The uniforms, and alterations, are provided. There are two formal nights per 7-day cruise and the physicians are presented along with the other senior officers to the guests on the first formal night. Duty-free shopping is available at the ship’s gift shops along with a crew discount. Other than tips and shopping, all provided services are free. However, life on board the ship is quite different from that on land. I encountered no adjustment period or even a touch of seasickness.
Let’s look at those we serve, especially the passengers. When do passengers bear a responsibility for their own health and medical care? Passengers have access to a host of information about their disease processes, but are they smarter? Would they think to bring a copy of their ECG or know their allergies or bring a list of their medications and dosages with them? Would they carry their prescription medications, or would they pack them in their shipped luggage – which has been lost or is traveling round and round on an endless conveyor system? Renting mopeds in Third World countries without helmets is a Darwinian test of intelligence.
How about the infectious disease fellow who brought his two young children with diarrhea and was perturbed when we did not permit them into the child day camp and quarantined his cabin and family?
“Come on, Doc. I know I have angina and have had a CABG and two angioplasties, but hurry up and make me better so I can make the midnight buffet.”
“Well, I did not bring any of my medicines because I was going on a cruise and on vacation.”
“What do you mean, Doctor, that you cannot do my planned C-section if I go into premature labor?”
“Hey, Bubba, doesn’t that sausage from the street vendor look better than the food on the ship? I think I’m
going to get me one.”
“Why did you think that a cruise ship would be such an attractive place 24 hours after chemotherapy and a
blood transfusion?”
“Studs and studettes please do not drink so much that what is consensual at midnight becomes assault at 10 am.”
“9-1-1, this is Dr. Arkangel. No, Ma’am, this number is for medical emergencies and I cannot give you room service.”
“You want to know how to operate the microwave in your closet? Ma’am, there are no microwave ovens in any cabin – that is your room safe!”
“Doctor, I know that your patient always dreamed of going on a cruise, but she was just discharged from the
ICU for a massive pulmonary embolism. I will tell you what. If she survives the hypoxia on the four-hour plane flight, we will let her on board.”
Physicians, please stop facilitating the follies of your patients.
“Thank you,” “muchas gracias,” and “mahalo nui loa” for the many wonderful passengers who do inform us of their medical conditions before boarding, see their physicians prior to coming on a cruise, and to those who bring their medical records, medication lists, and old ECGs with them, and finally, to those who remember all their medications and take them while on board and dispose of their syringes properly and purchase travel insurance, “THANK YOU FOR BEING RESPONSIBLE ADULTS!”
I can personally tell you that it is possible to have an enjoyable and unique experience as a cruise ship physician while still following all of the rules established for the benefit of the passengers, the crew and the cruise line. See you on a cruise! Aloha!
A first generation American, C. Arkangel, MD was born and raised in Hawaii. He graduated from the U.S. Military Academy, West Point, NY, in 1965. He was commissioned as an Infantry Officer and served two tours in Vietnam as advisor to a Vietnamese Infantry unit and commander of a rifle company in the 101st Airborne Division. He received his medical training at Rutgers Medical School, interned at Madigan Army Medical Center, Tacoma, WA, and was part of the pilot class of Emergency Medicine in the military at Brooke Army Medical Center. He is a diplomat and fellow, ABEM, ACEP, AAEM. Dr. Arkangel retired as Joint Special Operations Command Surgeon in 1985 at Fort Bragg, then was recalled for Desert Storm in 1991. He joined the Trauma Service, Department of Surgery, and UTHSCSA in 1992 as the first residency-trained Emergency Physician, retiring in 2006. He now resides at Fair Oaks Ranch with his bride of 43 years, Judith Ann. They have three children and three grandchildren.
