Last July, Charles Pexa, M.D., left Vancouver, British Columbia, for a 14-day round trip to Alaska aboard the 58,000-ton cruise ship, Veendam, along with some 1,350 other vacationers and 580 crew members. Pexa wasn’t your typical cruise passenger, however. An emergency physician who practices part time at North Memorial Medical Center in Minneapolis, he was beginning his third tour of duty as a cruise ship physician for the Holland America Line.
Aboard the ship, Pexa sees patients daily during the two hours when the clinic is officially open but is on call 24/7 throughout the cruise. He primarily tends to minor ailments. “Mostly, I see passengers who have respiratory infections, urinary infections, or minor trauma such as sprains and strains from falls,” he says. Not surprisingly, quite a few passengers make their way to “sick bay” suffering from seasickness; these patients are usually attended to by the nursing staff. “They give them meclizine or Dramamine. But I do see some passengers who get very seasick and can become dehydrated.” His most unusual cases have involved patients with serious conditions such as acute MI, stroke, or GI bleeding.
Medicine Aboard Ship
The American College of Emergency Physicians (ACEP) maintains a listing of doctors who have registered with the ACEP’s Cruise Ship and Maritime Medicine division. Most have ER experience, although the qualifications for cruise ship physicians vary according to the different lines. For instance, Holland America requires that its physicians be North American-licensed and board-certified in their specialty; preference is given to emergency medicine practitioners with three years of experience. Carnival Cruise Lines hires emergency physicians and primary care physicians with at least three years of emergency medicine experience, and P&O Princess Cruises International requires its physicians to have at least three years of postgraduate experience in family practice, emergency medicine, or critical care medicine. With 32 years of ER experience, Pexa easily meets the requirements.
In addition to maintaining a registry of physicians, the ACEP provides guidelines for maritime medical care for passengers and crew. These guidelines recommend that each cruise ship infirmary have at least one examination room, one stabilization room, and one ICU room, as well as an isolation room or the capability to isolate patients. Ships also must have at least one inpatient bed per 1,000 passengers and crew.
Aboard the Veendam, Pexa works out of a spacious clinic on a lower deck (the area of the ship that tends to be more stable in rough weather) that is staffed by one physician for the passengers and another for the crew, and two nurses. (The size of the medical staff varies depending on the ship’s size and the number of passengers.) In addition to an X-ray machine, the ship’s clinic has airway equipment, cardiac monitors, defibrillators, an electrocardiograph, an infusion pump, a pulse oximeter, a nebulizer, automatic or manual respiratory support equipment, and cervical spine immobilization capabilities.
Although well-equipped for many emergencies, the floating medical center does have its limitations. “We don’t have an operating room,” Pexa says. “I can treat lacerations, splint fractures, start IVs, insert tubes for breathing and provide many other treatments, but we can’t do surgery.” If a patient does need surgery or suffers a stroke or heart attack, he says the goal is to stabilize them, then get them to an onshore hospital as soon as possible. On one of his tours, he says the ship had to turn around to get to an island that had more sophisticated care for a very ill patient.
Call of the Sea
Pexa became interested in cruise ship medicine eight years ago while on a vacation cruise. The onboard physician turned out to be a former colleague. When Pexa semi-retired in 2008, he decided working on a ship would be “interesting and fun.” He hopes to do two or three cruises a year.
Last November, he completed a fourth trip, this time to the Caribbean. “All my cruises to date have been to the Caribbean, Alaska, or Mexico.” His interest in cruise ship medicine has attracted the attention of his colleagues in Minneapolis. “One was just accepted but hasn’t gone on a cruise yet,” he says. “The other one started before me; but I think he got the idea from me, as I had been talking about it for 10 years.”
Sally van Boheemen, a nurse and director of fleet medical operations for Holland America, says physicians interested in applying for a cruise ship medicine position should check the ACEP website (www.acep.org). “The ACEP lists each cruise line, what the requirements are, and who to contact,” says van Boheemen, who works from an office in Seattle. She says the crew doctors generally sign on for a longer stint (six to nine months) than the passenger doctors. “Guests come and go each week, but most of our crew seek medical care for ongoing issues, so continuity of care is important. Having the same doctor see them and do rechecks is much like having a family doctor at home,” she says.
Van Boheemen says the quality of cruise ship medicine has improved significantly in recent years. “I started in the industry 20 years ago. Point-of-care testing equipment did not really exist, so even determining basic lab values was impossible,” she says. “Now, we can test everything from cardiac enzymes to electrolytes to liver enzymes. That makes diagnosing conditions much more specific on board and decreases the need to disembark every sick guest.”
She explains that passengers are charged for onboard medical treatment, with an office visit starting at around $90. Most travel insurance policies pay for medicine, medical visits, and hospitalizations. However, most health insurers and Medicare do not pay, as they consider the care delivered out of the country.
Life on the Water
The cruises Pexa has worked have lasted two to four weeks. He hopes to sign up for longer ones in the future. “There’s a hierarchy of cruise ship physicians,” he says. “You have to work your way up the seniority list to get the special trips to Europe and the South Pacific.”
Cruise doctors are paid between $4,000 and $6,000 per month, and all food and accommodations are provided. “I don’t get the fancy cabins,” he says with a grin, “just a crew’s room, maybe with a window.” But his wife, Carol, does accompany him on each trip as medical staff spouses sail free.
Because he is continuously on call, trips off the ship as a tourist are rare. So during his down time, he works out in the gym and reads on deck. “We have a place to live for a while, we get fed, I work, and there’s a sense of adventure on each trip,” he says. “I meet a lot of interesting and nice people. Most are pleasant and easy to deal with, so I really enjoy the job.”—Nick Thomas