It is estimated that nearly 10 million people will travel this year on more than 230 cruise ships worldwide.  North American clients make up approximately 75% of the world’s cruise line guests.  Sixty percent of the world fleet is based in North America to service this major market, with the Caribbean Sea as the primary destination in half of all cruises. 

The availability of qualified medical personnel and a properly equipped infirmary aboard ship are key elements in providing for the appropriate medical care and safety of a cruise line’s guests and crew members.  Cruise Ship Medicine is the practice of medicine aboard cruise ships designed to provide cruise line guests and crew members with timely access to quality medical services for minor to severe illness and injury. 

Several factors influence the specific requirements for medical staff and equipment onboard a cruise ship.  These include:  1) The size of the ship.  2) The total number of guests and crew members.  3) The average age of the guests, their baseline health status, and their planned activities.  Industry-wide, the average cruise line guest is 45-50 years of age.  Certain cruise lines attract a senior clientele while others cater to the younger crowd.  An older age group will tend to have more chronic medical problems, such as heart and lung disease, that may act up while they are traveling.  A younger age group may have more injuries due to alcohol use and sports activities.  4) The destination and length of the cruise.  Longer periods away from the home port, especially days at sea, necessitate stocking up on more frequently used supplies.  Knowledge of the types and quality of medical facilities along the itinerary is important to determine if guests or crew members can be sent shoreside for additional care or if they have to be air evacuated back to the home port.  It's important to view a ship's medical facility as an infirmary and not a hospital.  Although most of the medical conditions that arise aboard ship can be treated as they would at an ambulatory care center at home, more severe problems may require a fully staffed and equipped shoreside hospital after the patient is stabilized in the infirmary. 

On average, during a 1 week cruise to the Caribbean, a ship’s medical staff will see 3-5% of the guests and 7-10 % of the crew members (or about 1% of the total shipboard population each day) for some type of illness or injury.  80-90% of the visits to the infirmary will be for non-urgent medical problems, 10-15% for urgent problems, and 5-10% for serious illness or injury that may require shipboard hospitalization and/or emergency medical evacuation to a full service shoreside medical facility. 

There is often a misconception, both by the general public and the medical community, of what Cruise Ship Medicine really entails.  Many think that the maladies encountered aboard a cruise ship are limited to seasickness, sunburn and gastroenteritis and that the doctors and nurses are merely on holiday.  The reality of Cruise Ship Medicine is much different, as noted below. 

On a weekly basis, the ship’s medical staff will evaluate guests and crew members with myriad complaints, similar to what one would expect to see in a low volume (though not necessarily low acuity) emergency department or ambulatory care center. 

Important elements of Cruise Ship Medicine, as in other divisions of travel medicine, are anticipation of the guest’s and crew member’s medical needs and being prepared to deliver the proper care for these needs.  At times it may be necessary to improvise medical services due to limitations in the shipboard medical facility’s equipment, formulary and staff.  A victim of serious illness or injury may need to be observed in the shipboard facility until safe transportation to an appropriate shoreside medical facility becomes available. 

Several factors are required for a well designed ship's medical department.  Adequate space must be assigned in the architectural plans of the ship to allow for the delivery of necessary medical services for guests and crew members.  There should be a secondary medical area designated in the event of a disaster when the primary medical facility becomes unusable.  The medical facility must be equipped with essential diagnostic and therapeutic supplies and equipment.  An efficient medical care delivery system is needed in order to meet the needs of quests and crew members despite limitations in equipment and staff when compared to a shoreside hospital.  Most important, the medical department must be staffed by qualified doctors and nurses who are capable of working in an isolated environment.  The final plan of any particular medical department will be influenced by the ship’s size and design, total number of guests & crew members, guest demographics, expected number of medical facility patient visits, and the ship’s itinerary.  All of these issues are addressed in the ACEP Section of Cruise Ship and Maritime Medicine below.

 The Section of Cruise Ship and Maritime Medicine was organized in 1990 by members of the American College of Emergency Physicians experienced in the practice of cruise ship medicine.  The objectives of the Section are:   1) Serve as a resource to the cruise industry, their medical departments, and physicians interested in cruise ship medicine.  2) Develop guidelines for quality and consistent medical care aboard cruise ships.  3) Encourage research on cruise ship medicine.  4) Provide educational opportunities for cruise ship medical and administrative staff members.  5) Promote the importance and enhancement of onboard medical care.  6)  Educate the medical establishment about the content and complexity of cruise ship medicine.  The Section currently has over 300 members. 

The Section's "Health Care Guidelines for Cruise Ship Medical Facilities" were first released in 1995 and then revised in 1997 and 2000.  The Guidelines are the recommendations of several cruise line medical directors and experienced ship's physicians from within the industry.  These practitioners are credentialed in United States, British, Canadian and Norwegian land based facilities and are active members of ACEP.

The American College of Emergency Physicians believes that appropriate emergency care and health care maintenance for passengers and crew members aboard ships sailing in international waters are desirable. The cruise ship industry and its medical departments should retain medical personnel who can:

Provide quality maritime medical care for passengers and crew members aboard cruise ships;

Initiate appropriate stabilization, diagnostic, and therapeutic maneuvers for critically ill or medically unstable patients;

Support, comfort, and care for patients on board ship; and

Assist, in conjunction with the cruise line, in the medical evacuation of patients in a timely fashion when appropriate.

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:

1.  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 per 1000 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

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

Current physician or registered nurse licensure

Board certification in:

Emergency Medicine or

Family Practice or

Internal Medicine

        OR

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

3.  A medical record and communication system that provides:

Well organized, legible and consistent documentation of all medical care

Patient confidentiality

4.  Emergency medical equipment, medications and procedures:

Equipment:

Airway equipment - bag valve mask, ET tubes, stylet, lubricant vasoconstrictor, suction equipment (portable)

Cardiac monitor and back-up monitor (2)

Defibrillators, two (2) portable, one of which may be semi automatic

External cardiac pacing capability

Electrocardiograph

Infusion pump

Pulse oximeter

Nebulizer

Automatic or manual respiratory support equipment

Oxygen (including portable oxygen)

Wheelchair

Stair chair and stretcher

Refrigerator / Freezer

Long and short back boards cervical spine immobilization capabilities

Trauma cart supplies

Medications

Emergency medications and supplies for management of common medical emergencies, to include:

Thrombolytics and sufficient quantities of advanced life support medications, in accordance with international ALS guidelines, for the management of two complex cardiac arrests

Gastrointestinal system medications

Cardiovascular system medications

Respiratory system medications

Central nervous system

Infectious disease medications

Endocrine system medication

Obstetrics, gynecology and urinary tract disorder medications

Musculoskeletal and joint disease medications

Eye medications

Ear, nose and oropharynx medications

Skin disease medications

Immunological products and vaccines

Anesthesia medications

Procedures

Medical operations manual as required by International Safety Management code

Medical staff orientation to the medical center

Maintenance for all medical equipment as recommended by manufacturer

Code team trained and updated regularly

Mock code and contingency medical plan drills on a recurrent basis and as recommended by ships' physician

Emergency preparedness plan as required by the International Safety Management code

Internal and external audits

5.  Basic laboratory and X-ray capabilities

Hemoglobin / hematocrit estimations, urinalysis, pregnancy tests, blood glucose (all with quality control program as recommended by the manufacturer)

X-ray machine for new builds delivered after January 1, 1997

6.  A process whereby passengers (prior to embarkation) are requested to provide information regarding any medical needs that may require medical care on board.

7.  A health, hygiene and safety program for medical personnel

A regular health, hygiene and safety program for medical personnel

An annual TB screening program for all medical personnel

 References 

American College of Emergency Physicians
Section of Cruise Ship and Maritime Medicine
PO Box 619911, Dallas, TX 75261-9911  (800) 798-1822
Web Site www.acep.org 

Harrison TE,; Cruise Medicine, Second Edition, Maritime Health Systems, Ltd., Millersville, MD, 1999 

Mcintosh I; "Health and Safety on Cruise Ships," Travel Medicine International, 1997, 15 (6) 

Peake DE; "Descriptive Epidemiology of Injury and Illness Among Cruise Ship Passengers," Annals of Emergency Medicine, 1999 January; 33 (1)

22/04/02