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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.
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.”
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.”
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?”
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”!
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.”
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.
Qualifications for expedition cruise ship doctors vary for each ship.
Generally, requirements include:
• Active state medical license
• Current passport
• ACLS, ATLS, or equivalent
• Good general health and flexible attitude
• Availability for a 3 to 6-week tour of duty. Experience in Emergency Medicine, Family Practice, General Surgery, or Internal Medicine is a plus. “You’ll be suturing small wounds.”
Additional preparation for a ship doctor position might include:
• Membership and attending conferences of organizations such as the Wilderness Medical Society (WMS) or International Society of Travel Medicine (ISTM)
• Keeping physically and mentally fit with regular activities, i.e. hiking, swimming, etc.
• Networking with other cruise ship physicians with experience aboard the same ship
• Planning pre- or post-excursions to derive the utmost from your remote travel
• Staying optimistic!
Clipper Cruise Line specializes in small cruise ship expedition-type experiences in remote areas of Alaska, Russia, Japan, Asia and South Pacific, aboard the Clipper Odyssey. The ship doctor must be able to handle a multitude of general medical problems and consider a number of solutions, with limited alternatives/supplies available.
Flexibility, availability and affability, with a teamwork attitude, are important factors for this position. Daily sick-call hours and emergency availability to paxs and crew members.
Ship doctor applicants should have the following: 1) Current US State Licensure & CV; 2) Copy photo page passport; 3) ACLS or equiv.; 4) Good general health/positive attitude; 5) Available for 3-6 weeks tour of duty. Preference given to past ship physician experience and/or military service. Computer skills essential.
EM, FM, IM or Surg preferred. No labs, xray or nurse available. Contracts provide Med. Liab. Insur., air/land travel to and from ship, and cruise itinerary for doctor and comp cruise for companion.
c. Wilderness Medicine Magazine, 2007. Used with permission
Barefoot children splashing in ocean waves, folks out for an afternoon drive. A typical small town summer day. But in this community, the kids are splashing in waves only a couple degrees above freezing and the family drives around in an ATV.
Welcome to Savoonga, on Alaska’s St. Lawrence Island in the Bering Strait, the self-styled “Walrus Capital of the World.” Here, approximately 700 Yup’ik Eskimo live as their ancestors did—harvesting marine animals such as walrus, seal, and whale, an activity referred to as “subsistence living.” Unlike Native peoples in the Lower 48 (an Alaskan term for the contiguous 48 states), Native Alaskans do not live on reservations.
On July 3 as locals prepared for a big Fourth of July celebration, business at the local health clinic was keeping five Community Health Aides (CHA) busy. “Our PA (Physician Assistant) that we share with Gambell (another Yup’ik community on the island) is out today.”
Nevertheless, when WMS member Pierre Guibor, MD, arrived with the expedition cruise ship Clipper Odyssey, they graciously showed him their facility, which is affiliated with the Norton Sound Health Corporation.
Two exam rooms and a pharmacy take care of general health problems such as common colds, ear infections, and bronchitis. “We see a wide variety of problems, but not much TB (tuberculosis),” said one CHA, “but we see a lot of pneumonia and ATV accidents.” With no cars or trucks in Savoonga, ATVs and bicycles in the summer and snow machines in the winter provide the only transportation. Visitors observed only one ATV rider (and no one on a bicycle) wearing a helmet.
The Clinic does minor surgery. However, major surgeries as well as emergencies are flown to Nome, a process which can take as long as five hours. In addition, all OBs are sent out—low-risk to Nome 167 miles away and high-risk to Anchorage—by plane.
Clinic staff has noted a trend in their village. “Younger and younger people are starting to smoke.” And although St. Lawrence Island is legally dry, “some people bring it in illegally, so we have alcohol-related problems, too.”
Each aide sees approximately 7-8 patients per day during the 5-day week. At the time of this visit, the X-ray machine wasn’t working and there was no lab. “We have plans for a new clinic to be built next summer. Our community is growing!”
“Our community is over 2,000 years old,” proclaimed one proud resident of the Inupiaq village of Little Diomede, Alaska. “And tomorrow is across the Strait.”
Like the Yup’ik residents of Savoonga, the Inupiaq also continue their native culture by harvesting marine mammals from the Bering Sea.
Unlike flat Savoonga, however, Little Diomede, population 140, rises nearly straight up a rocky hillside. Villagers clamber up and down steep rocky paths, not sidewalks or streets, that connect the village’s 30 or so buildings—general store, post office, church, school, residences and clinic. Visitors marvel how a community has survived and thrived on the edge of the Bering Strait, a few hours sailing from the Arctic Circle—and only two and a half miles from Big Diomede, Russia, where it’s already tomorrow.
“The International Date Line runs right out there,” explains resident Andrew Kunayak, Jr., gesturing to the sea. He escorted Dr. Guibor through the village, past racks of drying oogruk (bearded seal) to the Village of Diomede Health Center for a quick visit.
Summer sun shone July 5 “for the first time this summer!” proclaimed an enthusiastic Suzy Iyapano of the Village of Diomede Health Center as she welcomed Dr. Guibor. “Our two health aides provide general health care to our community of about 140. We do basic lab work, but some labs are air delivered to Nome for analysis. No X-rays, though. Serious cases are medevaced to Nome.” She gestured to the adjacent heli-pad where residents eagerly awaited the mail ’copter.
“In the winter, we use snow machines to shuttle to an airstrip on the ice after it freezes,” added Andrew. Winter temperatures average minus 30 degrees F, he noted.
As Dr. Guibor’s cruise ship departed Little Diomede’s anchorage, he reflected on the quality of health care available to Savoonga, Little Diomede, and other isolated Last Frontier communities. “All of the medical stations provide basic medical care to the local communities. Some have basic X-rays and ultrasound studies available; anything requiring specialized care can be handled by teleconferencing with Nome. Special chemistries and patient transfers may be obtained within 24 hours by helicopter, depending on the weather. Clouds, rain, sleet, and snow and ice are major logistical factors in air and sea transportation in this part of the world. Sometimes hours turn into days or days turn into weeks in delay. OB cases are sent out to Nome by air at 32 weeks, however, there is an occasional unplanned premature delivery in the clinic or homes. And dental care is difficult to obtain. Many of the adults are missing most of their teeth.”
Remembering the warm welcomes he received, he emphasized, “The medical health care personnel—mostly local villagers—are responsible, attentive, and friendly. They have my respect.”
For further information contact:
The Village of Diomede Health Center at 907-686-2201;
The Savoonga Health Center at 907-984-6984;
or The Adak Health Center at 907-592-8382.
For employment information,
contact the Norton Sound Health Corporation
at jobs@nshcorp.org, 907-443-4525;
or jobs1@nshcorp.org, 907-443-3305.
c. Wilderness Medicine 2007
