Cruise Ship Medicine

Staff

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. 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 but everyone adjusted.

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. 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 (advanced cardiac life support) medications and a defibrillator. The 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. This is useful for both medical and legal considerations. Infirmary beds are available for observation. Passengers are generally 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.

There is a good proportion of occupational medicine among the crew, especially overuse problems. If a crew member 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.

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 passengers and crew. If the ship has an incidence of 0.5%, it is considered significant and, if the ship calls at a U.S. port, the outbreak must be reported to the U.S. Centers for Disease Control. They generally investigate large outbreaks.

Sea Sickness. It usually takes a few days to get your "sea legs". Avoiding excessive alcohol and sunburn, helps prevent dehydration. Medications such as dimenhydrinate, meclizine, and phenothiozine, 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, diclectin (also known as Bendectin ) or may try ginger. To avoid seasickness, stay in the middle of the ship, near the center of gravity and where there is less sway. Avoid reading. 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 STDs. Both male and female crewmembers will be fired if they are found in a women’s 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 at sea actions occur, there may be no “law" and the ship is under the captain’s jurisdiction.

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

Pregnancy. Some cruise lines have policies that if their female employees get pregnant, they are sent home. Further, 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. Birth control pills were not recommended by the infirmary because the pills were not officially endorsed by our cruise line. 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 serious severe medical problems, we encountered several people who “pushed the envelope” of what was acceptable safe travel.

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 maintaining this cabin did not have the proper training to do so.

Evacuations

Evacuation is indicated for patients that are very ill, badly injured or in need of immediate testing. But evacuation is not always practical, and is 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 logistically difficult. Also, many sick or injured passengers are reluctant to leave the ship. And changing course angers lots of other 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

Passengers planning to go on a cruise should review their immunizations with a health care professional familiar with travel medicine. On one cruise, we had 2 crewmembers with chickenpox (varicella), for example. Those crew members had to be carefully quarantined which is not simple aboard ship. Passengers and crew should be immune. Adults who come from equatorial countries are apt to be susceptible to chicken pox. Pregnant women should be immune to rubella since outbreaks have occurred aboard ship. Depending on the ports of call, cruise passengers may need immunizations against one or more of the following: tetanus, diphtheria, polio, hepatitis A, typhoid, influenza and, possibly, hepatitis B - for those who expose themselves to high risk situations.

Other Medical Problems

Observe food and water precautions, especially at ports of call in developing countries. Also, the ship’s food handlers come from 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 embark on day trips to shore and are usually back before nightfall. They usually will not require antimalarial medications. They may be exposed to insect-borne diseases like yellow fever and dengue fever, for example. This is something we did not directly address with passengers, as they should receive this type of advice during 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.

Man Overboard

“One of the passengers had been standing on the upper rails, urinating while intoxicated, and fell into the sea. Many cruise ships and other rescue crafts 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!”

People do go overboard and it is important to know the proper way 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.

Working with Shore Doctors in Foreign Countries

Ships try to maintain list of doctors at ports of call who seem to provide reasonable treatment. But sometimes patients chose their own doctors, with variable results. For example, we visited a doctor to whom we had been referring crew and found him and his facility acceptable, but some patients returned with prescriptions for multivitamins or very lame advice. When interacting with shore doctors, it’s best to work with people you know. 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 chaperone 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 incident 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 missed reporting a woman who had been beaten by her husband. I was in another room treating her husband with a broken hand. No one had pointed out her bruises to me. As with mainland laws, unless someone brings forth a complaint, there is nothing that can be done. Spousal abuse, especially among newlyweds, is not unknown on cruise ships.

Interacting with the Crew

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

The popular impression of the cruise industry is very idyllic and inaccurate in many respects. But cruising is still a great way to enjoy oneself and see many ports in a short period of time. Travelers should be prepared and not expect the full level of medical resources we have to manage problems at home.

Gary practices travel and sports medicine in Winnipeg, Canada. Besides having been chief medical officer for a major cruise line, he has worked as an emergency physician and a general practitioner. He also has an interest in altitude and dive medicine. He is an active member of ISTM. His Email address is gary_podolsky@yahoo.com