Maritime medicine refers to providing medical care for seafarers¹ including the people working in the merchant marine, the commercial fishing fleets, offshore oil platforms, and the cruise ship industry, the segment best known to most of us. It also includes provision of care through shore based pre-employment and seafarer consultation clinics. These various maritime medical practices present very different alternatives to the clinics, emergency rooms, and hospital environments where most of us practice. They may provide a working vacation (often emphasis on “work”), a few months sabbatical, or a career.

Practicing medicine at sea incorporates many aspects of “wilderness medicine.” Dr Warren Bowman’s editorial in Wilderness Medicine,² “Perspectives on being a wilderness physician” describes wilderness medicine as medical care delivery in situations where “definitive medical care may be hours or days away because of distance, adverse environmental conditions, lack of transportation, or difficulties in communication.” This definition applies to work in parks, forests, and other designated wilderness areas, but is equally applicable in other environments including Antarctic research stations, remote clinics in developed countries, healthcare facilities in many “third world” countries, rural or urban locales after natural disasters, and in most of the cruise industry.

Cruise medicine provides the challenges and rewards of practicing medicine in a resource limited environment while providing the opportunity to travel to interesting, sometimes very remote, places and to meet people also intrigued by international travel and ecotourism. Numerous opportunities are available. Large ships cruise the more typical “tourist routes” of Europe, the Caribbean, and Alaska and have clinics that may be similar to a medical office at home. Smaller expedition vessels are more likely to travel to geographically remote areas, usually with specific educational themes, but you may find your cabin is also your minimally equipped office.

“Over enough time, anything and everything will happen.”

This is a work environment very different from home, where wilderness medicine training, skills, and experience are invaluable. The optimal doctor for work on a cruise vessel is a family doctor or general internist who initially spent a couple of years in a surgical residency and ended up in accident and emergency. Unfortunately for the industry, that describes very few of us. The work includes that of a typical family practice and emergency room for a community of 100–5000 people, depending on the size of the vessel. Over enough time, anything and everything will happen. Patients are seen regularly for acute illnesses and exacerbations of chronic disease, acute trauma care (passenger sports/recreation injuries and crew occupational injuries), behavioural health for both passengers and crew, and ongoing management of chronic diseases for the crew, who may be on board for 10 months and are often not fluent in English. In addition, the doctor will have to deal with any medical emergencies and may be simultaneously supervising control of an influenza or Norovirus epidemic. Unlike at home, the doctor will be expected to provide the “999/911” emergency services, see patients in the outpatient clinic, accident and emergency, and infirmary (all of which are usually the same place), while often also serving as the laboratory and radiology technician, pharmacist, mental health consultant, physiotherapist, epidemiologist, visiting nurse service, clerk, and billing agent. Most companies hire primary care or accident and emergency trained doctors and nurses trained in accident and emergency or intensive care, but there are positions available for other specialists with extensive generalist experience outside of their specialty. As many of these vessels have only one doctor, there are a very limited number of positions available for physician assistants and nurse practitioners, both usually filling nursing positions.

Although you read about the newest vessels in the industry, many active vessels were built over the last 30+ years, so shipboard medical facilities are quite variable. They may be fairly extensive on large, newer vessels, where your main limitations are manpower, remoteness, and the inability to do sophisticated testing. On smaller expedition vessels, the doctor may be the entire medical staff, with limited basic testing and treatment options available. The expedition vessels are also less likely to have available shore side resources than vessels travelling on the tourist routes.

Making a diagnosis and treatment plan for a patient’s problem in an environment of sometimes very limited resources is the most unique challenge for the shipboard doctor. Those limitations can be magnified when patients neither recognise nor accept that they are in a wilderness environment. Passengers may be unprepared for the rigors of travel and poorly acclimatised to the voyage environment. They usually eat more high calorie/high salt food and may not have their medicines because they have forgotten them or their luggage was lost. Advertising and the media have glamorised the cruise industry, leading many passengers to expect the same level of care on board a cruise ship that they might find in a large urban hospital. Although a large cruise ship may in fact be better equipped than the local hospital in some ports of call, diagnostic equipment and therapeutic options remain limited. On an expedition ship in many parts of the world, such as the Antarctic peninsula, there are no shore side services, and the doctor may be the only resource available for days. Evacuating a patient from a ship is difficult at best; in many places in the world, it is impossible.

The challenges may be great but so are the rewards. Should you find this a field of medicine that might appeal to you, some resources are listed that will help you learn more about medical practice in the cruise industry.

RESOURCES

• American College of Emergency Physicians Section of Cruise Ship & Maritime Medicine; PO Box 619911, Dallas, TX 75261, USA. The section publishes an approximately quarterly newsletter that includes a list of many of the cruise companies and the contact person for their medical department. This can also be accessed from the ACEP website. www.acep.org.

• American College of Emergency Physicians Health Care Guidelines on Cruise Ship Medical Facilities, Approved by the ACEP Section of Maritime and Cruise Ship Medicine. Oct 2000. Available from ACEP or from its website in the section of Cruise Ship and Maritime Medicine.

• Harrison T, ed. Cruise medicine. 2nd ed. Annapolis, MD: Maritime Health Systems, Ltd, 1999. Available from the ACEP bookstore.

• International Council of Cruise Lines, 2111 Wilson Boulevard, 8th Floor, Arlington, VA 22201. An independent council that promotes all aspects of the cruise industry, with membership by the larger companies in the cruise industry.

• Web sites of the individual cruise companies, including large companies and small ecotourism companies that may not be listed by either of the above groups. ICCL only represents its members, and the ACEP Cruise Medicine section only involves those companies whose medical advisors choose to participate.