EILIF DAHL

A.10.0.1 Background

Like medicine in general, as well as the cruise industry itself, cruise ship medicine has developed tremendously during the last 30 years.

Progress has not happened because of international regulations, but mostly because of increasing passenger expectations, and the actions of the cruise companies. The American College of Emergency Physicians (ACEP) has also shown interest in this area of medicine and established a ‘Section for Cruise Ship and Maritime Medicine’ in 1990. Its most important achievement is the development of the ‘Health Care Guidelines for Cruise Ship Medical Facilities’ created in 1995 as the result of consensus among active ship´s doctors [1].

ACEP has collaborated with members of the Cruise Lines International Association (CLIA) to further develop and implement the Guidelines since then. Representing more than 95 % of the global cruise capacity, CLIA is the world’s largest cruise industry trade association and focuses on passenger satisfaction, particularly regarding service, safety, security and health [2]. The ACEP Guidelines are now mandatory for all of the CLIA member’s oceangoing ships and can be considered as a minimum global standard. This is particularly relevant for all ships carrying US citizens, not least for medico-legal reasons.

A.10.0.2 The ACEP Health Care Guidelines [1]

The ACEP/CLIA Health Care Guidelines give detailed recommendations on 11 topics:

• Medical Facility
• Medical Staff Qualifications and Experience
• Clinical Practice
• Documentation
• Equipment
• Pharmacy
• Infection Control
• Imaging
• Medico-Legal Practice
• Patient Feedback
• Contingency Medical Plans

They also warn that due to the remote itineraries and complex logistics challenges specific to cruise ship medicine, emergencies can periodically and temporarily disrupt the full provision of staffing, equipment and supplies as described.

A.10.0.3 Medical staff on board

Responsibilities to Passengers and Crew

All medical services available for seafarers on cruise ships will also be available for passengers, and vice versa. However, there are some important differences. Whilst it is the shipping company´s duty to provide medical treatment for the crew free of charge, the cruise ships offer their medical amenities on board as an optional service to the passengers, usually for a fee. The passengers can choose to visit a medical facility ashore in the next port instead of seeing a ship´s doctor, whilst the seafarers, in most cases, have to accept the administrative and medical decisions of the medical staff, or ultimately the Master, on board. The ship´s doctors are primarily on board to take care of medical emergencies for both crew and passengers. In addition, for the passengers, he is a stand-in for their private physician for the duration of the cruise, in most cases less than two weeks. Moreover, for most of the crew, the ship´s doctor is their de facto primary physician as they spend more months of the year at sea than at home.

In other words, for the passengers, the ship’s doctor is an offered service during the passenger’s cruise, but for the crew he is their free primary physician for their whole contract.

Accordingly, the aim of medical care for these two general patient groups will differ in many ways. The doctor’s primary aim is to provide state-of–the art care for all conditions for both groups. The secondary aim for a speedy recovery on board is common to both but for very different reasons in the two groups. Both want to recover as uneventfully, quickly and completely as possible, the passengers to be able to enjoy as much of their expensive and highly anticipated adventure as possible, the seafarers to be able to return to work and provide for their families.

Some crew may have a restriction on their medical certificate stating that they can only sail if a doctor is on board. This places an additional burden on the medical staff and should be discussed with shore side staff before such a seafarer joins a ship. Further information on the medical selection of seafarers is available in Chapter 4.8.

On-Call and Emergency Duty

The ACEP Guidelines [1] ensure that on all cruise ships at least one qualified medical professional will be available 24/7 to see patients, be they passengers or crew. At sea, usually at least one doctor and one nurse are on call, while all medical staff members must be prepared to be called in case of emergencies. An emergency number is available to call at any time, posted in all cabins and in all public areas. Emergency calls are arranged through the Bridge over the Public Announcement System. When called, the duty nurse will attend the scene with emergency remedies in a first responder bag. Once the nurse has assessed the situation, they can call for additional personnel as needed. All medical staff on board will usually be required to respond to a publicly announced emergency call. Calls for  non-emergencies are usually coordinated through the reception desk on a dedicated number that is widely available.

In-Port Manning

On ships with more than one doctor, usually both one doctor and one nurse will be part of the in-port manning system’, and remain on board at all times. This ensures that there is sufficient manpower on board in port to manage any immediate care that is required. On a ship with only one doctor on board the requirement is for an ‘available medical professional’ to remain on board. This may be the doctor and/or the duty nurse. If the nurse is alone on board, he evaluates the situation and provides initial care within his capabilities. If further, immediate assistance is required, the bridge is asked to request emergency medical assistance from ashore.

Qualifications 

According to the ACEP Guidelines [1], ship´s doctors will have at least 3 years of postgraduate clinical practice in general and emergency medicine, and at least one on each ship must be certified in Advanced Cardiovascular Life Support (ACLS), Advanced Trauma Life Support (ATLS), and, if children are allowed on board, Advanced Paediatric Life Support (APLS). The medical personnel should be able to start appropriate resuscitation, stabilization, diagnostic and therapeutic maneuvers for critically ill or injured or medically unstable patients and assist in medical evacuation if appropriate. Patients requiring more advanced care should be referred to a shore-side medical facility at the earliest, appropriate opportunity.

A.10.0.4 Medical Facilities 

Most patients are seen as an outpatient in the doctor’s office and the Medical Facility has regular office hours for passengers and crew, usually every day, both in the morning and in the afternoon. Outside office hours the duty nurse screens calls and will call in the doctor as and when required medically, or at the specific request of a passenger.

Limited care for patients who require admission to the Medical Facility is available and the facility will have a treatment room, some ward beds, an intensive care room and equipment for processing limited laboratory investigations, taking and reading plain X-rays, monitoring vital signs and administering medications.

A.10.0.5 Limitations of care available on board 

The ACEP guidelines [1] clearly emphasize emergency care and passengers should not expect to find medical facilities on board comparable to hospitals ashore. Even simple nursing may only be possible until the next port due to limited ward capacity and the number of medical professionals aboard.  The aim of medical care on board is to stabilize the patient and manage appropriately until the next available, appropriate port. Some cases can be successfully managed on board, for example, patients who require a simple procedure or treatment of a condition that is expected to heal without complications and patients who can recuperate in their own cabin without constant medical supervision.

However, any patient who will require  in-patient nursing care for a few days or more, or whose condition may deteriorate and exceed the capability on board should be disembarked in the next appropriate port.

Most ships' medical facilities are not equipped or intended for invasive surgery. Even if the ship's doctor is a surgeon, the patient should be referred ashore for surgical procedures, for example an appendectomy, unless it is essential to perform emergency surgery in order to preserve life. An ectopic pregnancy may be one such situation. When the ship is far from the nearest port and outside of helicopter range, conservative approaches not usually followed ashore may have to be used.

A.10.0.6 Passenger Referral Ashore

The primary purpose of the ship's medical facilities is to make medical services available to passengers for common medical problems and, in emergency cases, to stabilize the patient until they can be referred to a health care facility ashore. In most cases, a shore-side specialist has far greater resources and facilities available for diagnosis and treatment than can possibly be made available on a ship. Whenever possible, the doctor should not let the ship leave port with a passenger on board who may need emergency or general hospitalization ashore.

The role of the insurance company

If the passenger is referred ashore for ongoing treatment, it is good practice, with the passenger’s permission, to inform their insurance company of the arrangements and ensure that the case is handed over to them for ongoing monitoring and support of the passenger and their family who may disembark with them. Cruise companies may also have Passenger Care Teams who provide support in this situation. Insurance companies, or their contracted assistance company may also be able to assist in finding the most appropriate medical facility or have their own preferred providers.

Additional information on the role of the assistance company in coordinating care overseas can be found in Ch 5.13.

Standard of care

Given that there are medical personnel on board and limited care can be offered, it is vital that any referral ashore for ongoing management is an improvement in the standard and level of care to what can be received on the ship. Communication with shore side staff, insurance companies, port agents and local medical facilities may be needed to ensure that the facility can offer what is required and of an appropriate standard. This includes investigations such as a CT scan or angiogram to complex tertiary care, ICU and/or surgery, for example neurosurgery. If this is not the case, the passenger should be kept on board or arrangements made to evacuate them to the nearest appropriate place, for example, by Air Ambulance.

Passenger refusal

If the passenger refuses to leave the ship or refuses to stay at the hospital ashore and returns to the ship, the doctor should discuss the situation as soon as possible with the Master. The patient must sign an illness ‘Letter of Indemnity’ indicating that they are continuing the cruise against the advice of the ship's doctor. Such a signature does not mean that the patient is no longer the doctor’s concern. On the contrary, the medical staff will still be expected to do their very best, the patient has merely been warned in advance that their best may not be good enough. A refusal to sign the necessary forms must be documented in the patient medical record. It may also be helpful to note the names of others who were present at the consultation shore side and at the discussion regarding signing the letter of indemnity.

A.10.0.7 Emergency medical evacuation [3]

Options

If the patient requires immediate care that cannot be provided on board and cannot wait until the next port is reached, an emergency medical evacuation may be required. Options include:

• Speeding up and reaching the next planned port early
• Deviate the ship to a port that is closer
• Evacuate by boat (ship’s rescue boat) or other vessel e.g. coast guard boat
• Evacuate by helicopter

Risk assessment

All medical evacuations are disruptive, work-intensive, time consuming, expensive, and, most importantly, potentially dangerous not only for everyone on board but for all involved in the rescue operation. A full risk assessment must be completed and this is very different to a similar assessment on board a merchant vessel with no medical staff on board.

Factors to consider include but are not limited to:

• Distance to nearest port – will the patient arrive at an appropriate facility in time for it to improve the care or outcome?
• Standard of care ashore – as above, if the care required by the patient is not available due consideration must be given to keeping the patient on board until another port can be reached.
• Weather conditions – rain, wind and fog can all cause potential issues for helicopter evacuations and transfer to a boat can be impossible in bad sea conditions.
• The clinical suitability of the patient for evacuation – it is potentially catastrophic to take an unstable patient into a boat or helicopter where the care that can be provided is limited by equipment and access to the patient. However if the patient cannot be further stabilised on board it may be the only option.
• Availability of an appropriate helicopter or boat if within range. The standard of medical care that can be provided on either will vary hugely around the world.
• Risk of evacuation procedure – to the patient, the ship and others on board. Risks include an uncomfortable sail for passengers if the ship increases speed in poor weather conditions, the helicopter crashing with possible loss of life and potentially damaging the ship, issues in transfer of the patient from the ship to another boat etc.
• Need for air ambulance evacuation to a higher level of care elsewhere – if the only available port cannot offer an improved level of nursing or medical care, it may offer the possibility of an air ambulance evacuation to an appropriate level of care. This needs careful cooperation and communication between all parties involved.
• Financial impact of deviation e.g. extra fuel to increase speed or divert, berthing fees for added time in port, compensation to passengers for lost excursions, disruption to the schedule and any discomfort, cost of the helicopter or boat evacuation, etc.

Such a risk assessment must involve the doctor treating the patient, shore side medical staff, the Master, the patient’s next of kin, any insurance or assistance company, the helicopter or boat provider and staff from the receiving medical facility or TMAS where appropriate.

This is discussed further in Ch 5.7.

A.10.0.8 Factors influencing passenger health

The practice of cruise ship medicine varies with

• passenger and crew demographics such as age distribution and nationalities,
• cruise line,
• type of cruise, for example on-board activities and land excursions offered,
• ship size,
• itinerary including cruise length and destinations,
• number and experience of medical staff, etc.

Age

Whilst all crew are of working age, with a global average around 30 years, the passengers will be of all ages. There is no upper age limit if the passenger is otherwise healthy. While all crew must pass a medical examination every two years, no such requirement exists for passengers. Formerly an activity primarily for the older generations, ‘blue-haired ladies’, the global average age of cruise passengers is now below 50 years. Some cruises appeal to the younger age range, some to families with small children, some to seniors, whilst most ships will not carry newborns and infants under 3 or 6 months and a few do not accept passengers less than 18 years of age. Cruises appealing to the very young, very old or severely disabled passengers are medically more demanding. Often those in the poorest health will choose the remotest itineraries without considering the risk and discomfort engendered by falling ill and possible disembarkation.

Ship size

Whilst smaller ships may offer more personalized service, large ships have bigger medical facilities and more medical staff.

• Small cruise ships can have only 1 doctor and no nursing staff
• Medium-sized, most, ships have 1 doctor and 2 or 3 nurses
• Larger cruise ships have 1-3 doctors, 2-6 nurses and possibly a medical secretary

Itineraries

Long voyages to remote areas are more complicated than short cruses concerning medical care. However, they are mostly done with smaller ships and often attract older passengers. World Cruises are particularly challenging with a duration of up to 90-110 days, many days spent out of helicopter range and poor medical facilities in many of the ports. Cruise ship medicine on a world cruise involves a busy and varied general practice where 50% of the consults will concern skin and respiration conditions [4]. However, the medical staff must be prepared to handle all types of emergencies, without outside help, for many days.

A.10.0.9 Specific challenges

Blood Transfusion at Sea

Uncontrolled bleeding is, rightly, feared at sea. Blood banks ashore will not release blood unless there is a designated recipient. To obtain blood for transfusion is a major challenge, especially during long voyages outside of helicopter range. Beyond the ACEP Guidelines for Health Care, some ships have equipment for blood collection, blood type confirmation and for HIV and hepatitis testing, for use as a last lifesaving effort, on vital indication only. There are no controlled studies that have been performed on cruise ships. However, in 2009, Royal Caribbean Cruise Line (RCCL) introduced a blood transfusion program that included training of all of their ship´s doctors and nurses. The results were presented in a 2015 article and showed that of 57 patients who had undergone shipboard transfusion of catastrophic, non-compressible haemorrhage, 51 survived to hospital discharge home [5]. RCCL assessed that more than 40 of the survivors would have died without transfusion.  A detailed transfusion protocol and a mandatory training program for the doctors and nurses are essential. When confronted with a patient needing a blood product, the shipboard medical team should make an announcement requesting that passengers who are blood donors come to the on-board medical centre for review to see whether they are potentially compatible blood donors. Their blood group must be determined by testing, and if they are blood group O negative or positive and potential donors, they are then screened for HIV and Hepatitis B and C using rapid tests. Appropriate consent for these investigations is required. The passenger´s own family members are preferred donors. It is important to make certain that potential donors remain easily available until it is clear that their services will not be needed.

Informed consent for blood transfusion should be obtained from the patient as soon as it becomes clear that this may be necessary. It is preferable to allow the patient to consider the options, risks and benefits, while they are relatively alert, rather than wait for them to lapse into hemodynamic instability, and then try to discuss the issues.

Passenger Accidents and Injuries

Every cruise company has its own detailed instructions on how to deal with passenger accidents aboard and ashore, and the medical staff members must study them closely and follow them to the letter. This is an area of high litigation for most companies and compliance with procedures along with good record keeping is key.

Imaging of Passenger Injuries

All cruise ships have X-ray equipment, and it should be used appropriately to exclude fractures or dislocations. The quality of the images has become far better with digital equipment, and many companies have contracted shore-side radiology departments that will read images transmitted from their ships. X-ray contrast remedies are usually not carried on board and passengers should be referred ashore at the next appropriate port if further radiological investigation is necessary. Ultrasound equipment is not specified in the ACEP Health Care Guidelines, but is used on selected ships, and The Germany Maritime Medical Association has issued guidelines that make ultrasound mandatory on cruise vessels registered in Germany [6][7].

The Passenger Accident Report

Before leaving the Medical Facility, the injured passenger should fill out a standard accident report form, preferably in their own handwriting, and sign it. As a rule, only a copy of this report can be given to the passenger when requests for accident reports are made.

On board protocols

A full and detailed medical record should be kept including all relevant information, regardless of how minor the accident or resulting injuries may seem at the time. The doctor and nurse will render all necessary treatment and will refer the injured passenger ashore for further evaluation and treatment if necessary, or if requested by the passenger or next-of-kin. All medical treatment must be properly documented together with all follow-up care. If accident care is given free of charge, this is to be considered a goodwill gesture from the company and is not to be taken as an admission of legal responsibility. Medical staff should make no indication or suggestion of liability.

The ship’s investigating officer, usually the safety or security officer, must be notified verbally by medical staff when a passenger, or crewmember, is injured either on board or ashore. If possible, the investigator should inspect the scene as it was at the time of the accident before any cleaning or other tampering of potential evidence occurs. Thorough investigation of all accidents is necessary not only to prevent or prepare for litigation, but also to record the facts and to prevent similar accidents from happening to passengers or crew in the future.

Crime Victims / Sexual Assaults

All cruise lines have strict policies against any kind of harassment. CLIA members have established a ‘Zero Tolerance Policy on Crime’ with guidelines for reporting allegations of serious crimes to appropriate law enforcement authorities [2]. Management of such cases may involve flag State police and authorities in the next port as well as laboratory services in a third country. The Staff Captain is usually in charge of such investigations and if the victim is female, interviews should be conducted by or in the presence of a female staff member.

All medical staff must familiarize themselves with the detailed company-specific guidelines and the ACEP Health Care Guidelines regarding their role [1]. According to the Guidelines, each ship will carry a minimum of two sexual assault evidence collection kits and have at least one clinical staff member on board who has completed recognized training relating to the treatment and care of sexual assault victims. Each ship will also carry emergency post-coital contraception and post exposure prophylaxis (anti-retroviral and antibacterial medications).

Further information on crime at sea is available in Ch 9.7.

Dental care

Passengers or crew members with acute toothache may be disappointed not to get expert help on board a cruise ship, but simple dental care is possible. The mainstay of treatment is with antibiotics and painkillers, but some ship’s doctors can repair dentures, insert temporary fillings, and re-cement crowns. Referral ashore in the next appropriate port may be possible but most dental conditions can wait until a 1-2 week cruise ends and passengers can see their own dentist at home. Crew members should be assessed on a case by case basis. This ‘wait-and-see’ attitude might be encouraged because port referrals often cause frustration and anger because

• prices for emergency dentistry in ports are uncontrolled and often (too) high
• the time in port is often too short for proper repair and follow up is impossible to arrange
• communication is often poor, both written and verbally to the patient. This may create issues if further care is needed elsewhere

Ships that call regularly to the same destinations may develop good relations with reputable port dentists, with whom passengers and crew can get emergency appointments on short notice. A few cruise lines had programs of full service dentistry aboard, provided by shore-side companies as independent contractors. However, after initial enthusiasm, the programs seem to have folded. One problem was lack of guaranteed cabin space for the dentist during fully booked cruises. Another was lack of space for a dentist office on most ships.

Pregnancy

Complications at any time during pregnancy, in particular miscarriages and ectopic pregnancies, are always more dramatic at sea and therefore dreaded by medical staff. This is especially the case on cruises to remote areas where shore-side medical facilities and blood transfusions are not available.

In 2006, an expert panel of medical cruise representatives supported by CLIA suggested that passengers should be prohibited from sailing if they will enter the 24th week of pregnancy by the beginning of their cruise. Most major cruise lines now adhere to the 24^th gestation week rule for pregnancy.  The same limit is also included in the fitness criteria of the ILO/IMO Guidelines on the medical examinations of seafarers [8] and used by many flag States in their medical regulations.

Disembarkation of pregnant passengers and crew

If a woman is hospitalized ashore for complications arising from pregnancy, she may not be able to travel in time to give birth in her home country. Many airlines have restrictions on travel for people in the last weeks of pregnancy and may require a certificate stating that it is safe to travel by air. Unfortunately, this may not be the case until after delivery. It is usually considered safe to travel by air 1-2 weeks after an uneventful vaginal delivery, but in the case of complications air travel to get home may have to be indefinitely delayed.

There may also be diplomatic complications that can prolong repatriation if a baby is born in international waters on a vessel registered in a country different from the one where mother and child are urgently disembarked after delivery. The lack of a passport and visa for the child may make it very difficult to transit some countries, such as the USA, in order to get home.

Newborns and Infants

Medical facilities on cruise ships are not suitable for, neither are ship’s doctors expected to be trained in, neonatal care. Moreover, care of a sick infant requires paediatric equipment not carried on most regular cruise ships. Therefore, most representatives at the CLIA panel also felt that children should not be permitted to sail prior to 12 weeks of age on the first day of cruise. However, they found it reasonable that certain lines may extend this minimum age based on other risk factors, for example, longer or more remote cruise itineraries where appropriate facilities ashore are inaccessible. The Passenger Cruise Ticket Contract of the various companies states that no infants under a specific age, at least 6 months for most cruises but 12 months for other cruises be brought on board their vessels and refer to their website for the most current minimum age requirements.

Disabilities and Pre-existing Medical Conditions

Although passengers only require a medical certificate in some specific cases, their general fitness to travel should always be considered, as well as the risks of exacerbation of any pre-existing condition. Those who are fit to travel but not to fly often cruise from a homeport, but should they be disembarked en route, travel home can be difficult. In addition, a passenger capable of walking short distances at home may be challenged by walking from their cabin to the restaurant on ships over 300 meters long.  The additional movement of the ship increases the challenge. The frail and elderly often find they need a wheelchair, but then also need to take a companion who is able to push it. Passengers with pre-existing conditions should remember to bring the following in their hand luggage:

• Enough current medication for the cruise + pre- and post-cruise travel
• A summary of their medical file in English, including:
  • list of current, and previously used, medicines with doses
  • previous illnesses and surgeries,
  • known allergies,
  • adverse effects from prior medication,
  • own blood type and rhesus factor
• A copy of their most recent electrocardiogram (ECG)
• A valid blood donor card if available
• Proof of travel insurance to cover all known medical ailments, hospitalization ashore and repatriation

Passengers with mobility, communication or other impairments, or other special or medical needs that may require medical care or special accommodations during the cruise should consult the cruise company well in advance.

Reduced mobility

Unpacking a suitcase only once, seeing multiple destinations, great entertainment and the wheelchair accessibility of the ship, are factors that appeal to cruise passengers with reduced mobility. However, before booking, passengers must research and evaluate many other aspects of the cruise in order to ensure a healthy vacation experience. Ships are different, even within the same company. Newer ships built according to recommendations from the Americans with Disabilities Act (ADA) [9], are usually better equipped for passengers with restricted mobility. However, destinations and shore excursions may be less accessible. Some ships use a tender to bring travelers into some ports and passengers who have trouble walking or depend on mobility devices may not be allowed on the tender and might need to remain on the ship.

Passengers are advised to carefully review the company policies regarding equipment that is available and allowed on board.  Ships carry a small number of wheelchairs that are reserved for emergencies and cannot be loaned to passengers with preexisting mobility issues. There are rental companies that are able to supply equipment that is not available, but permitted, on board. Mobility equipment such as wheelchairs and scooters must be of a size and type that can be accommodated on the vessel and be stored in the passenger´s cabin, never in hallways or public areas due to safety regulations. Most ships require that disabled passengers travel with a caregiver who is familiar with all the necessary equipment.

Once a passenger decides on a particular cruise, they are advised to book early and specify any special needs. Many of the available services must be arranged 30 or 60 days prior to a cruise. Given that the number of cabins that can accommodate the turning radius of a wheelchair and offer a roll-in shower is limited, it may be necessary to book as much as a year in advance.

Service Animals

According to the Americans with Disabilities Act (ADA), a service animal is an animal that is ‘individually trained to work or perform tasks for the benefit of a person with a disability’ [9].

Most service animals are dogs and they may

• guide people who are blind,
• alert people who are deaf,
• pull a wheelchair,
• alert and protect a person who is having a seizure,
• alert diabetics about critical blood sugar levels,
• remind a person with mental illness to take prescribed medications, and
• calm a person with Post Traumatic Stress Disorder (PTSD) during an anxiety attack.

In order to accompany a passenger on a cruise ship, the work or task a dog has been trained to provide must be directly related to the person’s disability. Dogs whose sole function is to provide comfort or emotional support do not qualify under the ADA.

Most major cruise lines welcome service animals if for no other reason than to comply with ADA and similar anti-discrimination and civil rights laws of other countries. They outline their specific rules regarding service animals on their websites. Owners are required to ensure that all necessary vaccinations and documentation are up to date, for all of the destinations included in the cruise.

The service dog accompanies the passenger throughout the cruise and is permitted in all public areas, including dining venues. While in public areas, service dogs must be on a leash, harness or other restraining device. Due to health regulations, they are not permitted in pools, whirlpools or spas. The ships will offer special relief areas. The service dog cannot be left in the cabin unattended, and its supervision and care, including food, is the sole responsibility of the owner.

Oxygen requirement

Oxygen concentrators may be used on most ships if the passenger brings their own or makes a direct arrangement with an independent medical contractor who agrees to undertake all required arrangements without involving the medical facilities and its staff. Such a contractor must assume complete medical responsibility. The use of an oxygen concentrator on board must be declared to the company before boarding.                   

The concentrator-dependent passenger and the traveling companion must be completely familiar with the operation of the concentrator. They must agree in advance to leave the ship immediately if they cannot operate the concentrator, if the equipment malfunctions or if the passenger develops any medical issue that may require additional medical assistance to that which can be provided on board.

All passengers with underlying disease, particularly requiring continuous oxygen must be aware that the ships are often in areas where evacuation to modern medical facilities ashore may not be possible for days, and that the medical facility on board can only offer limited care for a relatively short period of time. The supply of oxygen on board is limited and is there for all emergencies amongst the passengers and the crew. Supplies must be prioritized if there are many passengers or crew who require supplemental oxygen.

For safety reasons liquid or gas oxygen tanks are usually not permitted in any staterooms or public area, nor is the ship able to store portable oxygen tanks for passengers who may need oxygen during shore excursions.

Hence, if a passenger requires oxygen continuously and wishes to leave their cabin they are probably not fit to travel on a cruise.

Renal Dialysis

Many ships will accept passengers with kidney failure that require continuous ambulatory peritoneal dialysis as long as they bring all of the necessary equipment onboard and are capable of doing all procedures themselves, self-administration. They should also carry extra dialysis fluid, suitable antibiotics for peritonitis, and a full medical report including contact details for their nephrologist.

If physician-assisted hemodialysis is required, some companies will assist commercial providers to perform hemodialysis programs at sea if the latter take all medical and legal responsibilities and do not involve the ship’s regular medical staff in the procedures.

Organ Transplants

Organ transplant recipients must bring all of their own medication. It is highly unlikely that this medication will be available on board and it may be difficult to obtain in a different country. On board medical staff may assist in the intravenous or intramuscular administration of such medication, as a paid service.

Mental Health Issues

Any passenger with a psychiatric condition must be assessed very carefully prior to travel. The disruption to their usual routine, seasickness, the access to alcohol, contact with many unfamiliar people in a confined space and the lack of regular contact with an individual’s support network are just some of the factors that can lead to a worsening of the passenger’s mental state. Even those with mild dementia must travel with an able companion and those with more serious mental health issues may well be advised not to travel. The opportunity for suicide is ever present, and once overboard, survival is unlikely.  If suicidal intent is suspected, 24-hour watch is instigated until the passenger can be disembarked for psychiatric assessment in the next port. Again passengers must be aware that psychiatric care in a foreign port may not be of the same standard as they are used to and there may be many cultural differences as well.

Motion Sickness

Motion sickness is often a laughing matter for those not affected, but can be an emergency matter on cruise ships. Seasick seafarers mean impaired safety and service for the passengers, and severely seasick passengers, unless promptly treated, will hardly ever take another cruise.

On smaller ships cruising in locations with expected rough weather, motion sickness may be the most frequent cause of medical consultations. On larger cruise ships, staying in the centre of the ship, relatively close to sea level where there is less movement, can prevent or reduce seasickness without pharmacological intervention.

Prevention is the mainstay of management.  Any passenger completely dependent on oral medications, for example transplant recipients, should be carefully advised with respect to motion sickness and its prevention. 

Passengers prone to motion sickness should take medication prior to sailing, since absorption is reduced in those already affected.  Very susceptible persons should continue medication throughout the trip.  Antihistamines by mouth are commonly used, while Scopolamine patches are not prescribed on most cruise vessels because of side effects such as confusion in the elderly.  Still doctors on all passenger ships need to be familiar with all adverse effects of Scopolamine, because passengers bring patches aboard and often over- or misuse them, with unexpected results. Passengers already unwell may consult the ship’s doctor for intramuscular medication, usually Promethazine. The added sedative effect is often appreciated.  

The provision of oral medication will vary between cruise lines, so passengers are well advised to bring their own supplies.

Further information on the pathophysiology and management of seasickness is available in Ch 6.7

Some passengers may also suffer ‘land sickness’, that is, a sensation of continuing motion noted for 1-2 hours after disembarkation that settles spontaneously. Mal de Débarquement Syndrome, however, is a rare disorder of perceived motion that may persist for months to years after a voyage. More common in women than men, the persistent and treatment-resistant symptoms include a sensation of motion usually associated with fatigue, imbalance, and impaired cognition. The cause is unknown.

Risks Ashore

Passengers may develop a false sense of security from the carefully regulated environment on board. This can be dangerous if and when they venture ashore in port, especially if they do so alone and not as part of an arranged tour.  All passengers are advised against indiscriminate eating and drinking ashore, and should be vaccinated according to the recommendations for every port. Passengers should also receive advice on general and specific risks relevant to the location. The risks for a traveler visiting a port for just a few hours in the daytime is very different for that of a traveler spending a significant time inland, particularly for malaria.  Protection from mosquitos remains important in both malarial and dengue risk areas although antimalarial medication may not be required.

Other risks ashore include

• Uneven and poor pavements, paths and roads including cobbled streets
• Travel in vehicles such as tuk-tuks, or taxis with no seatbelts and poor safety features.
• Mugging and pickpockets.
• Marine envenomation from jelly fish, sea snakes and fish
• Animal bites in areas with rabies
• Participation in extreme sports that may range from scuba diving to bungy jumping. Passengers should ensure that any travel insurance includes cover for participation in such activities.
• Poor medical care. If an incident occurs ashore it may not be possible or reasonable for the passenger to return to the ship for medical assessment and treatment and care must be received ashore.

A.10.0.10 Public Health considerations

Cruise ships are isolated communi­ties with a high population density, crowded public rooms and living accommodation, shared sanitary facilities, and common water and food supplies. Hence, infectious diseases are easily transmitted on board, through contaminated food, water, surfaces and infected persons.

Vessel Sanitation Programmes

Acute Gastroenteritis (AGE) has always been a major nuisance at sea. Outbreaks on cruise vessels in the early 1970s were predominantly the result of food poisoning, mostly caused by bacteria. In 1975, the US Centers for Disease Prevention and Control (CDC) established an extensive Vessel Sanitation Program (VSP) for all passenger ships visiting US ports in order to prevent and handle outbreaks [10]. It included unannounced audits twice a year. The VSP led to improved ship hygiene and fewer AGE outbreaks up to the year 2000. However, despite high VSP compliance, the number of AGE outbreaks on ships increased from 2001 to 2004. The symptoms were the same as for food poisoning but the main cause was not bacterial, but a virus. Norovirus can transmit through food, water, contaminated surfaces and direct person-to-person contact.

Over the years, CDC has increasingly focused on infections transmitted on ships from person to person and on the importance of patient isolation. In cooperation with the cruise industry, the VSP Operations Manual has developed into a comprehensive guidebook. It contains detailed procedures for the management of infectious disease on board, including food and water safety, the reporting and management of both respiratory and gastrointestinal infectious diseases, and mandatory patient isolation for infection diseases that can be transmitted from person-to-person [10]. In Europe, although the practices of hygiene inspections on board ships varied between countries, within the same country or even within the same port, the relevant authorities were slow to follow the American public health initiatives for cruise ships and the European Centre for Disease Prevention and Control (ECDC) was not established until 2005 [11]. Through SHIPSAN TRAINET (2008-2011), the European Commission developed and implemented a training programme with 33 partners from 24 European countries. The resulting ”European Manual for hygiene standards and communicable diseases surveillance on passenger ships” was based on CDC´s VSP, but also received input from many other sources [12]. Most coastal states around the globe have now developed similar vessel sanitation programs, such as the Brazilian ANVISA [13].

Pre-boarding screening

Preventing contagious persons, passengers and crew alike, from boarding is important. Most ships conduct pre-boarding screening with a health questionnaire for both respiratory and gastro-intestinal illness. If passengers or crew indicate that they have had any recent symptoms, they are assessed by medical staff, and may have to agree to temporary isolation if allowed to board. Passengers who report symptoms of illness that may have been transmitted from person-to-person are subjected to strict isolation protocols to prevent or contain outbreaks.

On-board measures

Public health on board is protected by a robust system of oversight and enforcement. Cruise ships employ strict cleaning and sanitation practices according to the vessel sanitation programs [10,12] and Public Health authorities worldwide inspect cruise ships and enforce international and local health requirements. Before or on arrival at a port of a new country during international voyages, the captain of all ships must supply information regarding health conditions aboard by delivering WHO´s Maritime Declaration of Health to the port authority [14]. More information on the MDH is available in Ch 8.

Acute Gastroenteritis (AGE) caused by Norovirus

Norovirus flourishes in close communities such as cruise ships, hospitals, childcare centres and other institutions. It is very contagious and can be transmitted from an infected person, through contaminated food or water, or by touching contaminated surfaces. The incubation period is 12-48 hours and infections are self-limiting and seldom serious for the individual patient. Norovirus leads to abdominal pain, nausea, vomiting and diarrhea and is the most common cause of acute gastroenteritis both ashore and on ships worldwide. As the incidence of norovirus increases ashore, so it increases on board, often brought on board by passengers travelling from areas with a local outbreak. Stringent procedures are in place to contain infection, emphasizing hand hygiene and isolation of all cases. The best way to prevent norovirus is thorough, frequent hand washing. Alcohol-based hand sanitizers are not as effective against this virus as washing your hands with soap and water [10, 12]. Passengers experiencing even vague symptoms should not try to self-medicate, but report immediately to the medical centre on board and follow advice from the medical staff closely.

Isolation

According to the vessel sanitation manuals, anyone who presents with even slight gastrointestinal symptoms must be considered as having a norovirus infection and be isolated. The mandatory isolation of sufferers is very inconvenient and thus unpopular among passengers and crew, but is essential to prevent or contain outbreaks. Therefore, isolation should start upon presentation of a single symptom such as vomiting or one loose bowel movement, and be enforced for at least 24 hours to see if the symptom was a single occurrence or the first sign of an infection. With ongoing symptoms isolation should continue for passengers for at least 24 hours after resolution of their symptoms and for food handling and medical crew for a minimum of 48 hours [10,12].

Passengers and crew must be advised to follow such isolation measures closely as failure to do so can lead to disembarkation at the next port. The speed and effectiveness of the medical staff in identifying a potential index case is the main factor in determining whether the outcome will be just a few isolated persons or a full-blown outbreak that may eventually stop the ship from cruising. During outbreaks passengers are advised not to use public toilets, not to touch commonly used surfaces, like elevator buttons and door handles, and to abstain from hand shaking.

Since it is not practically possible to clinically separate Norovirus AGE from AGE of other causes, relevant data from all cases with reportable AGE symptoms are entered in the ship´s standardised surveillance log for AGE, or ‘Gastro-log’, as de facto Norovirus infections.

Respiratory infections

Common cold

Acute respiratory tract infections (ARIs) are very common on all cruise vessels. Most are mild and easily handled by the ship´s medical staff. 

The COVID-19 pandemic will thoroughly change maritime public health programs in the future. Further information on pandemic management is available in Ch 8. But note, from now on, any respiratory symptom presented in a cruise setting, even the slightest sniffles, must be taken seriously and be treated, and isolated, as a COVID-19 case until that diagnosis is disproven.

Influenza and Influenza-like Illness (ILI)

For practical purposes, the vessel sanitation programs distinguish between ARIs and influenza and influenza-like illnesses (ILIs). An ILI is defined as a patient presenting with sudden onset of fever of ≥38°C (100°F) and cough or sore throat in the absence of other diagnoses [12]. There are standard tests for influenza A and B aboard most cruise vessels [1].

Relevant data from all ILI cases and proven influenza cases must be entered into a standardized surveillance log for respiratory illnesses, ‘ILI-log’, and both types must be isolated in their cabins for at least 24 hours after they are free of fever without the use of fever-reducing medications [12].  

Vaccination of crew and passengers is an effective way of preventing influenza outbreaks. On most ships seasonal influenza vaccination is offered to all crewmembers every year, with the stated aim of > 75 % crew coverage. This is primarily to protect passengers, which is of particular importance for the very young, the old and the immuno-compromised ones. Also, passengers at risk should be advised by their family doctors to be vaccinated at least two weeks before the voyage, in order to develop immunity before boarding the ship. 

Legionnaires´ Disease (Legionella)

Occasionally cases of Legionella can be traced back to jacuzzis and dead ends in the potable water system.  Clear procedures for cleaning, disinfection, inspection and flushing of these are therefore in place. The condition is serious, but can be treated with antibiotics. Prompt and accurate diagnosis is therefore essential. Passengers with suspected pneumonia should therefore have a chest X-ray taken and be tested for legionella on board [1].

Childhood Illnesses

Major cruise lines now require pre-employment proof of immunity of measles, mumps and rubella, antibody levels or MMR vaccination, from all crew. This is mainly for the protection of susceptible passengers.

Sexually Transmitted and Blood Borne Diseases

Both passengers and crew are at risk of sexually transmitted disease from contacts on board and ashore.  Needle stick injuries are a risk, from either legitimate use or drug abuse.  Passengers injecting medications should ask for a sharps bin for safe needle disposal.

More information on Public Health in the maritime setting is available in Ch 8.

A.10.0.11 Medico-legal aspects

Travel Insurance

All passengers are strongly advised to purchase travel insurance covering cancellation pre travel, medical care on board and ashore, hospitalization and repatriation. Preexisting conditions must be declared and passengers should ensure that their cover extends to all ports visited on the cruise and any additional sporting activities they may wish to try.

Regular medical insurance is usually not valid abroad or on board ship, even on a vessel docked in a port where the insurance is valid. Secondary insurance or additional travel insurance for the duration of the voyage is usually necessary.

Litigation

The Passenger Cruise Ticket Contract

The main condition for buying a cruise and going aboard a cruise ship is to accept the Passenger Cruise/CruiseTour Ticket Contract, which adheres to CLIA´s  ‘Passenger Bill of Rights’ and describes the terms and conditions that will apply to the relationship between the passenger and the vessel. Many sections deal with passenger health and prospective cruisers are strongly advised to read it carefully.

In case of passenger dissatisfaction with any cruise-related issue, most companies will do their utmost to solve the issue to mutual agreement.  However, if the case cannot easily be resolved, the Cruise Ticket Contract states where and when any claims against the vessel or company shall be litigated. For most ships carrying American passengers, medical malpractice claims will be litigated in a specified US court even though hardly any ocean-going cruise vessels are registered in the USA and few ship´s doctors hold US medical licenses.

Ship´s Doctors – Independent Contractors or Employees?

Until recently, most cruise ship doctors were independent contractors, and the companies argued that they were not in a position to control or even supervise the doctor’s medical practice on board. In 1988 a US court ruled that a ship owner cannot be held vicariously liable for the negligence of a contracted ship´s doctor directed at the ship´s passengers, Barbetta versus S/S Bermuda Star. But in 2014 a US Appellate Court overturned that rule, based on another case, Franza versus RCL so now the ship´s doctor is regarded as a cruise company employee rather than an  independent contractor [15]

Following this judgment, it is the company and not the individual ship´s doctor who will be sued in malpractice cases, and the ship´s doctors are now, to their uniform relief, predominantly hired employees and not independent contractors

Passenger Lawsuit against the Vessel

Any accident, in fact any medical staff/patient encounter, may result in litigation claiming missed injuries, wrong diagnosis or treatment, incompetence, negligence, abandonment etc. The primary litigation target is usually the company, and for the company it is important to ensure the full cooperation of the doctor and the nurses and vice versa. However a victim often ‘throws a wide net’ initially and includes the ship’s management and members of the medical staff in the law suit. It is then important for the company to distance itself from the medical staff members by pointing out that the doctor’s and the nurses’ credentials were screened by independent experts, and that the ship did nothing to prevent the doctor from doing his job properly.

The doctor should always take threats of a lawsuit very seriously, but not personally. In any case of litigation he or she should cooperate fully with the company’s risk management and defense counsel and at all times keep them well informed. Detailed written documentation of information obtained, findings, considerations/deliberations, treatments during the consultations as well as documentation of all follow-up will be key elements of a successful litigation defense.

Additional information on liability is available in Ch 2.10.

References

1. American College of Emergency Physicians. Cruise Ship Medicine Section. Health Care Guidelines for Cruise Ship Medical Facilities. https://www.acep.org/patient-care/policy-statements/health-care-guidelines-for-cruise-ship-medical-facilities/#sm.00001oz1nz0cjff0owcs23qt8vjno (Accessed May 2021)

2. Cruise Lines International Association.  https://cruising.org/-/media/research-updates/research/clia-2019-state-of-the-industry-presentation-(1).ashx (Accessed 26 June 2021)

3. Steve Williams, Eilif Dahl. Briefing notes on emergency medical disembarks by helicopter at sea in North America. Int Marit Health 2014; 65, 1:7-12

4. Eilif Dahl. Medical practice during a World Cruise: A descriptive epidemiological study of injury and illness among passengers and crew.  Int Marit Health 2005; 56 (1-4): 115-128

5.  Strandenes G, Hervig TA, Bjerkvig CK, Williams S, Eliassen HS, Fosse TK, Torvanger H, Cap AP. The Lost Art of Whole Blood Transfusion in Austere Environments. Current Sports Medicine Reports 2015; 14 (2): 129-134. https://journals.lww.com/acsm-csmr/Fulltext/2015/03000/The_Lost_Art_of_Whole_Blood_Transfusion_in_Austere.16.aspx (Accessed 26 June 2021)

6. Dahl E. Medical ultrasound on cruise ship. Int Marit Health 2020; 71 (1): 10-11 

7. Seidenstuecker KH, Neidhardt S. Qualification of ship doctors: a German approach. Int Marit Health. 2014; 65(4): 181–186, doi: 10.5603/IMH.2014.0035. 

8. International Labour Office; International Maritime Organization.  Guidelines on the medical examinations of seafarers; 2013.  https://www.ilo.org/wcmsp5/groups/public/---ed_dialogue/---sector/documents/normativeinstrument/wcms_174794.pdf (Accessed 26 June 2021)

9. The U.S. Department of Justice. Americans with Disabilities

Act (ADA).  https://www.ada.gov (Accessed 26 June 2021)

10. U.S. Centers for Disease Control and Prevention. Vessel Sanitation Program. https://www.cdc.gov/nceh/vsp/docs/vsp_operations_manual_2018-508.pdf (Accessed 27 June 2021)

11. The European Centre for Disease Prevention and Control (ECDC)  https://www.ecdc.europa.eu/en (Accessed 27 June 2021)

12. EU SHIPSAN ACT joint action. European Manual for Hygiene Standards and Communicable Disease Surveillance on Passenger Ships,  2nd edition, 2016. https://www.shipsan.eu/Portals/0/docs/EU_Manual_Second_Edition.pdf

13. ANVISA Sanitary Guide for Cruise Ships //www.gard.no/Content/22311206/PROINDE%20Shipboard%20Sanitary%20Inspection%20in%20Brazil%20-_July%202016.pdf

14. World Health Organization (WHO). International Health Regulations (2005) 3rd ed. Geneva: WHO; 2005. http://www.who.int/ihr/publications/9789241596664/en/ (Accessed 28 June 2021)

15. Dahl E. Cruise ship´s doctors – company employees or independent contractors? Int Marit Health 2016; 67, 3: 153-158

A.10.1 2.14  ACEP Health Care Guidelines for Cruise Ship Medical Facilities, January 2019

Guideline 1: Medical Facility, 

1. 1  Contains adequate space for diagnosis and treatment of patients with 360° patient accessibility around at least one bed.
2. 2  Has hand wash sinks with hot/cold mixing tap, liquid antibacterial soap, paper towels and waste bin in or adjacent to all clinical exam rooms. For exam rooms without sinks, alcohol hand sanitizers should be available.
3. 3  Has adequate space for storage of medical supplies, equipment and drugs.
4. 4  Has an examination, treatment and inpatient area adequate for the size of the ship.
5. 5  Has at least one examination / stabilization room.
6. 6  Has at least one (1) intensive care unit (ICU) room.
7. 7  Has at least one (1) inpatient bed per 1000 passengers and crew.
8. 8  Has at least one (1) isolation room or the capability to provide isolation of patients.
9. 9  Is accessible by wheelchairs and stretchers.
10. 10  Has at least one (1) wheelchair accessible toilet on all new builds delivered after January 1, 1997.

Guideline 2: Staff

1. 1  Qualifications and Experience: Maintains qualified and experienced clinical staff that have undergone a credentialing process to verify that:
   1. 1.1  All clinical staff hold current full registration and a license to practice.
   2. 1.2  All clinical staff have at least three years of post-graduate /post-registration experience.
   3. 1.3  Physicians have at least three years of post-graduate / post-registration experience in general and emergency medicine OR are board certified in Emergency Medicine or Family Medicine or Internal Medicine.
2. 2  Certifications
   1. 2.1  All clinical staff certified in advanced life support such as ACLS (Advanced Cardiac Life Support), ALS (Advanced Life Support) or an equivalent certification or physician specialist training (e.g. emergency medicine, anesthesiology or critical care.)
   2. 2.2  Ships carrying children ≤ 12 years old should have at least one physician certified in PALS (Pediatric Advanced Life Support), APLS (Advanced Pediatric Life Support) or an equivalent certification or specialist training (e.g. emergency medicine or pediatric medicine. (Effective January 1, 2015))
   3. 2.3  At least one physician certified in advanced trauma life support such as ATLS (Advanced Trauma Life Support) or an equivalent certification or specialist training (e.g. emergency medicine or trauma. (Effective January 1, 2017))
3. 3  Skills:
4. 3.1  Physicians with a competent skill level in Emergency Cardiovascular Care.
5. 3.2  Physicians with minor surgical, orthopedic and procedural skills including suturing, and fracture/dislocation management.
6. 3.3  Physicians with procedural sedation skills.

2.4 Language: Clinical staff that have sufficient language skills in the official working language of the ship.

Guideline 3: Clinical Practice

1. 1  Medical facility shall have established medical policy and procedures which have been reviewed by a senior clinician.
2. 2  Structured clinical staff orientation to the medical facility.
3. 3  Designated rapid medical response team which is trained and exercised at least monthly.
4. 4  A dedicated emergency telephone number is advertised for both passengers and crew and is placed on telephones around the ship.
5. 5  When the ship is at sea, at least one physician and one additional clinical provider must be readily available to provide emergency medical care twenty-four hours a day.
6. 6  When the ship is in port, at least one clinical provider is available onboard.
7. 7  Ready access to both telephone and confidential email in order to communicate directly with shipboard and shore-side healthcare providers.
8. 8  An audit program of the medical facility that is conducted by healthcare professionals or persons experienced in healthcare audit.

Guideline 4: Documentation

4.1 A medical record system that provides:

1. 1.1  Well organized, legible and consistent documentation of all medical care.
2. 1.2  Patient confidentiality. All patient medical records should be regarded as strictly confidential medical information and should not be accessible to non- medical staff without the express written consent of the patient except as necessary to maintain safety on board or ashore, or to comply with applicable legal requirements to review, report or log the information. Maintenance of patient records should also be in compliance with applicable legal requirements imposed by data protection or medical privacy laws, for example, in jurisdictions such as the United States or Europe.

Guideline 5: Equipment

5.1 Vital signs equipment: Sphygmomanometers, stethoscopes, thermometers (including core/rectal temperature capabilities) and pulse oximeter (SaO2).

2. 2  Airway equipment - bag valve mask, laryngeal mask airway/supraglottic airway, laryngoscopes, endotracheal tubes, stylet/bougie, lubricant, portable suction equipment, surgical airway capability.
3. 3  At least two cardiac monitors.
4. 4  At least two defibrillators, one of which should be a portable automated external defibrillator (AED).
5. 5  External cardiac pacing capability.
6. 6  Electrocardiograph (EKG) capability.
7. 7  Electronic infusion capability.
8. 8  Nebulizer capability.
9. 9  Automatic medical ventilator.
10. 10  Oxygen tanks (including portable tanks ≤ 5 liters) and at least one oxygen concentrator and a sufficient number of flow regulators.
11. 11  Wheelchairs.
12. 12  Stair chair and stretcher.
13. 13  Refrigerator and Freezer for the safe storage of medicines and supplies.
14. 14  Long and short back boards with cervical spine immobilization capabilities.
15. 15  Trauma supplies.
16. 16  Laboratory testing capabilities:
    1. Complete Blood Count (CBC)
    2. Urinalysis: specific gravity, protein, red blood cells, white blood cells, nitrites, urobilogen, ketones, pH, glucose and albumin
    3. Pregnancy: qualitative qualitative human chorionic gonadotropin (HCG)
    4. Blood Glucose
    5. Electrolytes with a minimum of Sodium and Potassium
    6. Renal Function with a minimum of Creatinine and Urea
    7. Cardiac enzymes with a minimum of a CK-MB or Troponin assay
    8. Malaria
    9. Legionella
    10. Influenza A and B
    11. human immunodeficiency virus (HIV)
17. 17  All medical equipment is maintained in accordance with recognized biomedical quality control recommendations.

Guideline 6: Pharmacy

6.1 Maintain an evidence-based formulary on each ship with sufficient quantities of medications from the drug classes listed below. Optimal par levels will vary by the ship’s population size and itinerary.

1. 1.1  Gastrointestinal system medications such as antacids, antispasmodics, H2- receptor antagonists, proton pump inhibitors, anti-motility drugs, stimulant laxatives, osmotic laxatives, hemorrhoidal preparations.
2. 1.2  Cardiovascular system medications such as cardiac glycosides, diuretics, anti-arrhythmic drugs, beta-adrenoceptor blocking drugs, hypertension and heart failure drugs, lipid regulating drugs, nitrates, calcium-channel blockers and other anti-anginal drugs, inotropic sympathomimetics, vasoconstrictor sympathomimetics, anticoagulants , antiplatelet drugs, anti-fibrinolytic drugs including thrombolytic medications sufficient for at least two patients. Sufficient quantities of advanced cardiac life support medications, in accordance with current international ACLS guidelines, for the management of two complex cardiopulmonary arrests.
3. 1.3  Respiratory system medications such as bronchodilators, corticosteroids, antihistamines, oxygen, cough preparations, systemic nasal decongestants.
4. 1.4  Central nervous system medications such as hypnotics and anxiolytics, drugs used in psychoses and related disorders, drugs used in nausea and vertigo, analgesics, antiepileptic drugs.
5. 1.5  Infectious disease medications such as penicillins including penicillinase- resistant penicillins, cephalosporins and other beta-lactams, tetracyclines, macrolides, trimethoprim/sulphonamides, metronidazole, quinolones, antifungal drugs, antiviral drugs, antimalarial drugs.
6. 1.6  Endocrine system medications such as diabetes drugs, thyroid drugs, corticosteroids.
7. 1.7  Obstetrics, gynecology and urinary tract disorder medications such as prostaglandins and oxytocics, drugs for vaginal and vulval conditions, contraceptives, drugs for genito-urinary disorders.
8. 1.8  Fluids and electrolytes such as oral and parenteral.
9. 1.9  Musculoskeletal and joint disease medications such as non-steroidal anti- inflammatory drugs, corticosteroids, drugs for soft-tissue inflammation and topical pain relief.
10. 1.10  Eye medications such as antibacterials, antivirals, corticosteroids, anti- inflammatory preparations, mydriatics and cycloplegics, treatments for glaucoma, local anesthetics, ocular lubricants, ocular diagnostic preparations.
11. 1.11  Ear, nose and oropharynx medications such as drugs for the treatment of otitis externa, removal of cerumen, oral ulceration, nasal allergy, topical nasal decongestant, oropharyngeal anti-infective drugs, lozenges and sprays.
12. 1.12  Skin disease medications such as emollient and barrier preparations, topical local anesthetics and antipruritics, topical corticosteroids, antiviral preparations, antibacterial preparations, antifungal preparations, skin cleansers and antiseptics.
13. 1.13  Vaccines such as hepatitis B vaccine, hepatitis B immunoglobulin, seasonal influenza vaccine, tetanus toxoid vaccine.
14. 1.14  Anesthesia medications such as intravenous anesthetics, anti-muscarinic drugs, anxiolytics, non-opioid and opioid analgesia, neuromuscular blocking drugs, antagonists for respiratory depression, local anesthesia.

Guideline 7: Infection Control

1. 1  A TB (tuberculosis) screening program at least every two (2) years for all clinical staff.
2. 2  Hepatitis B Immunity: All clinical staff who have a reasonable expectation of being exposed to blood must provide documented serological proof of Hepatitis B immunity (anti-HBs ≥ 10 mIU/mL or have documented proof of Hepatitis B vaccination) prior to any clinical work.
3. 3  Clinical staff participation in a seasonal influenza vaccination program.
4. 4  Clinical staff with immediate access to personal protective equipment (PPE) including gloves, gowns and N95 masks.

Guideline 8: Imaging

1. 1  X-ray imaging capabilities which includes one x-ray generator and one processing/developing system.
2. 2  Radiation protection equipment including shielding for both clinical staff and patients. Signage must be clearly displayed in the radiologically controlled area asking patients to inform clinical staff if they are, or might be, pregnant.
3. 3  Clinical staff working in radiologically controlled areas undergo basic radiography training in x-ray techniques and radiation safety prior to taking unsupervised x-rays.

Guideline 9: Medico-Legal Practice

1. 1  Each ship should carry a minimum of two sexual assault evidence collection kits.
2. 2  Each ship should have at least one clinical staff member on board who has completed training that meets the guidelines established by the American College of Emergency Physicians or an equivalency training, relating to the treatment and care of victims of sexual assault including the use of sexual assault evidence collection kits.
3. 3  Each ship should carry sufficient stock of emergency post-coital contraception and post exposure prophylaxis (PEP) anti-retroviral and antibacterial medications to minimize the risk of pregnancy and transmission of HIV and other sexually transmitted illnesses.
4. 4  The person affected should be provided with free and immediate access to a telephone, internet accessible computer and contact information for law enforcement, National Sexual Assault Hotline or support service, the nearest consulate or embassy, and if applicable the US Coast Guard. This information must be maintained within the Medical Facility or elsewhere on the ship.
5. 5  Prior to disembarkation, the person affected must be provided with a report for their own physician detailing the incident, the findings of the sexual assault examination, the treatment provided, psychological assessments and requests for further follow- up, treatment, testing or counseling.
6. 6  Pregnancy: Pregnant women who have entered the 24th week of estimated fetal gestational age at any time during the cruise should not be eligible to sail with the ship. The pregnancy policy should be made available to passengers during the booking process.
7. 7  Pediatric: Ships carrying children under the age of 12 years should carry necessary resuscitation equipment and supplies including pediatric medications, and at least one (1) Broselow / Hinkle Pediatric Emergency System or similar. The physicians on these ships should have the appropriate training, skills and equipment to treat pediatric patients, taking into consideration the itinerary such as remote and transoceanic voyages.

Guideline 10: Patient Feedback

1. 1  A process whereby passengers are able to provide pertinent information regarding special medical needs prior to embarkation.
2. 2  A policy and procedure for receiving, evaluating and responding (if necessary) to patient feedback, including complaints.

Guideline 11: Contingency Medical Plan

1. 1  Comprehensive written medical contingency plan which is subject to regular review, not to exceed three years. The plan incorporates mass casualty incidents (MCIs) and the procedure to be followed should the primary medical facility become non-operational.
2. 2  Mass casualty incident drills which are conducted on a regular basis.
3. 3  A contingency medical plan defining one (1) or more alternate care sites which should:
   1. 3.1  be in a different fire zone and deck from the primary medical facility
   2. 3.2  be easily accessible to crew and passengers.
   3. 3.3  have lighting and power supply on the emergency system.
4. 4  Portable medical equipment and supplies including:
   1. 4.1  Mass casualty triage documentation.
   2. 4.2  Airway equipment, oxygen and supplies.
   3. 4.3  IV Fluids and supplies.
   4. 4.4  Immobilization equipment and supplies.
   5. 4.5  Battery powered and easily portable diagnostic and laboratory supplies (e.g. glucometers, thermometers, stethoscopes, sphygmomanometers etc.).
   6. 4.6  Dressings.
   7. 4.7  Treatment – medications and supplies.
   8. 4.8  Defibrillator and supplies.
   9. 4.9 Medical waste and personal protective equipment.
5. 5  Portable two-way communication equipment available for each member of the clinical staff.
6. 6  Designated crew assigned to assist the clinical staff.)