EXPEDITION CRUISE SHIP DOCTOR — WILDERNESS MEDICINE AT SEA

* Second Place Winner of Features category in the New Mexico Press Women's Communication Contest 2008.
Published in Wilderness Medicine Magazine, Spring 2007

I was snorkeling with twelve expedition cruise ship passengers on Belize’s White Reef. Suddenly the divemaster yelled, waved his arms and pointed down. A 42-year-old female passenger lay flat on the sandy bottom. I took a deep breath and free-dove 30 feet. . . .

If the phrase “cruise ship doctor” conjures images of partying Love Boatstyle mega-liners, a stint on an expedition cruise vessel will blow that cliché higher than a whale’s spout.

“It’s wilderness medicine at sea,” says WMS member Pierre Guibor MD. In his eighth year as expedition cruise ship physician, he has sailed both small and large cruise lines from the Arctic Circle to South America. Currently, he serves as Cruise Medicine and Surgery Consultant for Clipper Cruise Lines.

Expedition cruise vessels typically carry 120 passengers and 80 crew. The ship’s doctor functions alone—without nurse, labs, X-ray or specialty consults—in remote locales such as Russia’s Kamchatka Peninsula, Galápagos, the South Pacific, or Belizean reefs.

“WHERE AM I?”

She was seizing. I grasped her under her chin, pushed off the bottom and kicked hard to the surface, emerging next to the panga [small skiff]. The captain and mate pulled her 90-pound limp, cyanotic body aboard. I jerked off my fins and mask and leaped up the panga’s ladder. She was not breathing, had no pulse and her stomach was distended. I performed one abdominal thrust. Water gushed over the bottom of the panga. Laying her on her back, I cleared her airway with my fingers. She was still unconscious, not breathing and pulseless. I gave her two mouth-to-mouth breaths and started cardiac compressions. After 30 seconds—which seemed like 30 minutes—she coughed and started breathing on her own. Her pulse returned. Her color went from dark blue to pink in one minute. She opened her eyes and said, “Where am I?”

Dr. Guibor’s efforts had just begun. Onboard the cruise ship, he plunged into emergency evacuation efforts that he had initiated by radio from the panga, mobilizing the ship captain, first officer, hotel manager, cruise director, Belize agent, the ship’s U.S. office, and the patient’s insurance company. In the patient’s cabin, Dr. Guibor re-warmed her, performed a complete physical exam—during which she denied a prior history of seizures—and started two large bore IVs in each arm with Ringers Lactate.

Thirty minutes later, evacuation began. Dr. Guibor, the patient, and her mother bounced across the waves in the little open outboard panga to the small city of Dendriga, Belize. “I kept her warm with blankets and jackets.” Night fell. When the panga stuck on a sandbar, the crew and captain jumped out and pushed it over. Onshore, they transferred to the ship agent’s Suburban. It was 10 PM. “We drove from Dendriga over an unpaved road to Belize City.” During the entire trip, “I kept my index and middle finger on her radial pulse, the IVs open and ran O2 with a nasal cannula—until the O2 ran out. I attached AED pads for cardiac monitoring—and in case a shockable cardiac event occurred. We were fortunate; she didn’t seize during transport.”

At 6 AM, they arrived at the Belize City Medical Clinic. “Before boarding the ship I had already checked out this facility, anticipating an emergency.” The patient remained there on IV Dilantin for two more days before flying back to the U.S. by commercial carrier.

Dr. Guibor, who returned to the ship once she had been admitted, followed-up after her return to the U.S. “She’s had no recurrence of seizures. It’s been over four years and I’m still in contact with her, Christmas cards and emails.”

THAT’S WHY THEY (DON’T) PAY ME THE BIG BUCKS

Small expedition cruise ship doctors are usually not salaried. So why trade 3 to 6 weeks of your valued office time for a stint of wilderness medicine at sea?

I stood on top of the highest temple in the Mayan ruins of Tikal. The steamy Guatemalan jungle spread below me. Howler monkeys boomed. Something red—a scarlet macaw maybe?—flashed in the distance. I had just climbed five stories of steep stone stairs and listened to expert naturalists and historians. A few hours earlier I’d been bouncing over the jungle canopy in a little plane. Spanning over 400 years in less than a day—priceless.

Cruise lines usually provide complimentary air transportation, cruise experience, and shore excursions to the ship doctor. The doctor’s companion or spouse may also receive the cruise but is responsible for his/her air transportation to and from the ship plus shore excursions. Since most small expedition ship’s cruises range from $6,500 to $15,000 per person, this translates into a sizable compensation package.

In addition, the ship doctor—on his/her own—can research and arrange pre- or post-cruise travel. Dr. Guibor, a NAUI Dive Instructor and Divers Alert Network Referral Physician, often schedules scuba diving before and after his assignment. Being a professional diver jokingly earned him the ship doctor title when his vessel struck an uncharted rock and he “doctored the ship.” “On scuba, I evaluated and photographed puncture damage to the hull. Then I helped repair it!”

Intangibles also keep Dr. Guibor at sea. “There are rewards for making accurate decisions rapidly, much like combat,” says the former U.S. Marine. “Some of us with military service vicariously enjoy the sea experience that we had in the past.” As in the military, he enjoys working with ship officers who are consummate professionals, forming friendships that continue after the voyage ends.

But it isn’t all happy outcomes and Christmas cards.

“Downsides are isolation and uncertainty of your diagnosis and treatment plan for serious patients. If the condition worsens and you made an incorrect patient management decision, you are solely responsible. Ships stock limited medical supplies, including oxygen. If you run out, you can’t call Walgreen’s.”

AN ADVENTURE FOR THE INTREPID

Packing his duffle for the next assignment, he reflected, “Small expedition ship duty is much different from large cruise ship duty. You practice medicine under unusual circumstances, challenge yourself both physically and mentally, participate as a professional mariner providing the best care possible to passengers and crew for whom you’re their only resource—and experience some of the most remote parts of the world. The rewards are not so much financial but rather providing the service. Consider the currency, ‘Job well done, Doctor!’”

He closed the duffle. “Being a ‘team player’ on a small ship delivers great rewards. Would you like to find out?”

CHAIN OF COMMAND AND PEOPLE SKILLS

Unlike a hospital setting, the ship’s doctor frequently finds him/herself low in authority except when medical issues are in question. Balancing medical concerns with ocean-going operations requires tact—plus common sense and basic seamanship.

“Most Captains consider medical issues, unless life threatening, to be secondary. Learn the chain of command, such as the first officer who then communicates with the Captain if needed.”

The ship is an isolated, self-contained community at sea. Teamwork is essential. “A team consensus builder uses skills that enable the team members to arrive at the same conclusions for problem solving and corrective measures. Rather than forcing an issue in an authoritative manner, the effective ship doctor is low key, avoiding heavy-handed directives.” Dr. Guibor summons all his tact when advising passengers that treatment will involve “isolation in their cabin for several days of their expensive voyage”!

PERFORMING UNDER PRESSURE—CAN YOU DO IT?

Without labs, x-rays, EKG, nurse, or specialty consults, the expedition ship doctor reverts to the basics, “much like what we learned in medical school.” Most crucial: taking a thorough exam and history. “Document date and time of accident or onset of illness, signs and symptoms, allergies, medications, previous illnesses, and surgeries. Take blood pressure, pulse, respirations, and temperature on every patient, no matter the symptoms, diagnosis, or treatment.”

Fortunately, cases such as the seizing snorkeler are rare. “I see mostly GI episodes and sore throats with coughing. I clean minor wounds, give IM tetanus toxoid boosters, suture lacerations, and treat minor muscle aches and strains of passengers who didn’t work out prior to their expedition. And I stress the merits of hand washing!”

Severe trauma aboard ship is uncommon. However, “be ready to handle a tension pneumothorax or hemothorax with an emergency chest tube. Review cardio-pulmonary resuscitation (CPR) techniques. Take ACLS (Advanced Cardiac Life Support) or ATLS (Advanced Trauma Life Support) courses.”

Obtaining medications in exotic foreign locations presents challenges as well. Before leaving the U.S., Dr. Guibor emails the doctor currently onboard and determines which meds he should bring with him, in concurrence with the medical director of the cruise line. “But,” he cautions, “when doctors from different countries bring their favorite meds, unfamiliar brands cause confusion.” Passengers themselves cause confusion as well. “They stockpile all their meds in one bottle instead of in individually labeled ones. When asked, many can’t remember the name of the meds, dosage, frequency—even the MD who prescribed them!” Possible solution—a pre-cruise form listing meds, dosages, frequency, and prescribing doctor. “And it would be extremely helpful to have a copy of a recent EKG.”

MORE THAN SICK CALL

The ship doctor also forms part of the ship’s documents department. “The mandated Center for Disease Control (CDC) Gastrointestinal Upset Log is an important statement of wellbeing aboard the ships, whether in U.S. or International waters.” The ship doctor takes regular water samples and maintains the water sampling log testifying to the absence of E. coli. When a health issue affects a crew member or passenger, the doctor and hotel manager coordinate specific hygiene awareness or ship cleaning procedures. If an illness— usually diarrhea episodes—requires cabin isolation, the doctor coordinates with the hotel manager, captain, and first officer.