Roll the Dice

Roll the Dice, Pick a Doc and Hope for the Best

 

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What ship, what cabin and doctor who?

Not enough attention is given to medical services when people decide to travel, especially on cruise ships. I got first-hand knowledge when I became a cruise ship physician (1990 to 1994).

I had just left my 18-year position as Medical Director for the Nevada Atomic Test Site and was leafing through a family practice medical journal in the library of the teaching hospital. An ad for a ship’s physician caught my attention. An emergency group out of Baltimore, Maryland had contracted for the medial services of the Regent Lines, under the contract name of Maritime Medical Services.

Dr. Kreisler and wife with Ernest Borgnine

Dr. Kreisler and wife with Ernest Borgnine

A Greek entrepreneur purchased the Regent Lines, (five ships named The Regent Sun, The Regent Sea, The Regent Rainbow, The Regent Spirit and The Regent Star) refitted them and contracted out many of the ship’s services, like medical and food. The cabins were spacious; the food and entertainment were good; itineraries were interesting; and prices were very competitive.

I applied for the job after getting an enthusiastic okay from my wife. Our children had left the nest and she relished the idea of joining me for romantic adventures in domestic and foreign ports. After waiting for several weeks for a reply, I decided to call and see if I was still being considered for a job.
A gravelly-voiced female with a distinctive asthmatic wheeze answered the phone. After saying “Maritime Medical,” she went into a series of wet coughs, and paused to catch her breath.

Oh, yes, “she said. “I remember your application. I’m glad you called. We happen to be looking for someone just like you. Can you be ready to travel by next week?” she asked.

I welcomed the assignment and we became good telephone buddies. I accepted the reality of dealing with a loosely run business model. I also encouraged my newly found Maritime Medical friend to stop smoking. I subsequently became an aficionado of cruising as a ship’s physician, as a passenger and as a guest lecturer.
My wife and I boarded the Regent Sun in Ft. Lauderdale, Florida and settled in for a 10-day Caribbean cruise. The first port was San Juan, Puerto Rico. The seas became a little rough as we started our two-day run to San Juan. I got a request for a cabin visit. A woman suspected that her husband was reacting poorly to the rolling and pitching of the ship. The nurse asked if she would consider bringing the husband down to the medical clinic to avoid the extra charge of visiting their cabin. No, she wanted us to come up, and as soon as possible.

The poor man was sitting in bed, whiter than his sheets. He appeared confused about time and place, and was having trouble focusing as I introduced my nurse and myself. It didn’t take long to determine he was experiencing double vision, difficulty in coordinating his arm movements, and was not able to carry on a logical conversation. I took the wife aside and asked about his medical history since this was not motion sickness.

He had been diagnosed with lung cancer a few months prior to this cruise. His doctor had made him ‘more comfortable’ prior to their sailing by removing a few quarts of liquid from his chest. I would have liked having his doctor on board so that he could take care of this man who, in my opinion, should have never been allowed to go on this cruise.

I informed his wife what she should have known (maybe she was told and chose to ignore it?); her husband had lung cancer in various parts of his body (including metastases to brain) which caused his current problems, not motion sickness. I outlined a plan for trying to make her husband more comfortable during the next two days at sea. She would then have two options when we got to San Juan.

I told her we could move him to one of our two beds in the medical department, or we could start treatment in the cabin and see how he did with periodic visits. The nurse outlined the fees she could expect, and we got signed agreements for everything. She opted for the cabin trial.

We started intravenous fluids, patched one eye for visual comfort, and gave him medication for nausea. I then took an educated guess: I figured his mental status was probably due in some degree to brain inflammation and swelling caused by the metastatic lung cancer. I added a sizable amount of cortisone to his intravenous fluids with the hope of decreasing reactive brain inflammation. The nurse and I drew up a schedule for periodic cabin visits, and on-call availability for possible emergencies. I informed the Hotel Manager and the ship’s Captain of the situation. It was fine with them, as long as it didn’t require diverting or disrupting the ship’s planned itinerary.

By the next morning, I was ready to light a candle (not normal for a minimally observant Jewish boy) and make a donation. The man was remarkably better. I humbly accepted the praises and thanks of the wife, while I crossed my fingers and toes, with the hope he would remain improved long enough to get on a plane in San Juan and head home. Her two options, once we got to San Juan, were to board a commercial flight and head home (if we could get seats), or check into a local hospital and make arrangements from there.

God smiled. She was a travel agent and arranged for two first-class seats. A private charter flight would have cost over $20,000. We assisted with the transfer to the airport and arranged for medical care upon their New York arrival. I asked if she could drop me a note about their trip back. I never heard from her, but fellow passengers for the remainder of the cruise told me they got word they had made it back okay and appreciated the care given aboard the ship.

On another trip, the ship’s Captain asked me to come down to his office for a meeting with the ship’s Security Officer. An unmarried couple, traveling together, had been drinking quite heavily. The man was 10 to 15 years older than his traveling companion. The couple had been noisy and disruptive from the beginning of the cruise, and it was getting progressively worse. Neighbors complained of noise and suspected violence. Apparently, alcohol had unleashed his mean streak. The Security Officer took the battered, inebriated woman to a vacant lounge area and was concerned about serious harm to the woman. I suggested they keep the man in his cabin and bring the women down to medical. I offered to sedate the man if he balked at confinement to his cabin.

The lady was in her late 50’s and very drunk. Her clothes looked like she’d been sleeping in them for several days. Her nylon stockings were full of tears, hair disheveled and she smelled like leftover saloon yuck.

The nurse cleaned her up and put her into an infirmary bed. I started an intravenous (she certainly needed fluids) and periodically added enough Valium to keep her sleepy for the rest of the voyage. I planned to let her wake up 4-5 hours before docking in New York. I suggested telling her male companion, if he asked, that she was resting in a private cabin under doctor’s orders. Both ships’ officers were concerned about their liability. I documented in the medical record the action taken to protect these two patients from harming each other, as well as ensuring the health and safety of other passengers. The nurse and I took turns covering the night hours.

We docked in New York at midnight, 12 hours late. No one was allowed to leave the ship until clearance early the next morning. At that hour, the air was damp. The dock, two levels below the terminal disembarkation ramp, looked wet, grimy, and deserted. It was dead quiet, like a subway tunnel scene for a Hitchcock movie.

I stopped the intravenous and Valium on my sleeping beauty patient and sent her back to her beau around 2:00 AM. She looked ten years younger and radiant as she left the ship around 10:00 AM that morning; hand in hand with her sobered sugar daddy. They could have passed as poster people for a senior honeymoon cruise; lovers without a care in the world. He paid the $1200 medical bill in cash. The nurse and I each got 10 percent of $1200.

I called my wife to let her know I’d be late getting back home. I thanked the nurse for her help and she thanked me for helping her make the most money she’d ever made on any 10-day cruise. We earned it.

The most colorful Love Boat character was an unmarried Greek captain who rivaled Bill Clinton’s womanizing persona. He literally had women in every port as well as inland cities. I’ll never forget the time he appeared on the bridge with nothing but a towel around his waist. We were maneuvering away from the dock in Tampa, Florida. A heavy wind threatened a collision with the pilings. I never knew why the Captain wasn’t on the bridge with the Staff Captain when we prepared to get underway as had always been the case. Maybe the Captain decided to shower off his most recent romantic encounter. In any event he appeared in his towel-sarong to shout orders and keep the ship from bumping the dock. The towel came off with the heated activity. He paid no attention to the exposure. A picture of that event would have made a great ad for a “bare-ass cruise with a bare-ass captain in the Caribbean.”
This same Captain asked me to call one of his girlfriends in Las Vegas where I lived. He asked me to give her his regards. “Ask her why she never writes or calls me? Ask her if she is mad at me?”

I called her and passed on the message that he would like to hear from her. She responded, “Ask that S.O.B. why he never answered my letters,” followed by a very explicit string of adjectives. After a deep breath, she and asked, “Are you married?”

I replied, “Yes,” thank God.

The truth about cruises is that most are very enjoyable, as evidenced by their popularity. It’s up to you to pick itineraries that minimize exposure to weather problems by choosing the right place at the right time of the year. Avoid ships with histories of substandard passenger services; use Google and travel magazines as guides. Be prepared with your own medicines and basic first-aid supplies and knowledge if you plan to visit out-of-the-way places. If you’re going to roll the dice on a cruise, stack the odds in your favor.

My observation is that, in general, medical recruiters for cruise lines prefer foreign nationals. They work cheaper and are less problematic in the litigious arena. Who would you sue if a problem arose and the medical supplier was an independent contractor? An event could most likely occur in international waters or in a foreign port, with a foreign-trained, foreign national physician. If you read your cruise contract papers, you might be surprised to see a ship’s disclaimer for medical care responsibility.

Next time you take a cruise, look at the nationalities of the ship’s crew: musicians, deck hands, officers and hotel staff. There are usually between 35 and 50 different nationalities represented on a medium-sized cruise ship (1500 passengers). THERE ARE NO MANDATORY STANDARDS for physicians or nurses. Ships going in and out of ports in the United States  have to comply with safety and health regulations, but there are no required educational or competency standards for medical personnel. Many lines would stay out of American ports if they could; thus avoiding U.S. Coast Guard inspections. Some smaller lines, like those in the Mediterranean, never do venture past the Strait of Gibraltar. I’d encourage you to check health and safety details before planning a dream vacation confined to distant parts of the world.

Most ships are registered in places other than the United States, for economic and political/legal reasons. So, you can roll the dice, pick a cruise and hope for the best or you can seek answers to pertinent questions and then hope for the best.

Cruise insurance comes in all sizes and shapes. Travel magazines recommend third-party coverage. If you insure with the cruise line, the coverage could be as worthless as the line, should they declare bankruptcy and leave you stranded. This happened with the Regent Line (where I had worked), and later with the Renaissance Line. Always read the fine print before buying medical coverage and/or cruise cancellation/delay. For example, will your insurance cover expensive air evacuation, should the need arise? Condé Nast and Travel Leisure magazines have good recommendations for insurance coverage.

The owner of the Regent Line was apparently well trained in deficit financing; he kept the subcontractors and investors dangling while he siphoned off a good part of the cash flow. Sadly, the operation went bankrupt in 1995.

 

Leonard Kreisler, MD 

Excerpt from book by Leonard Kreisler, MD. Roll the Dice, Pick a Doc and Hope for the Best. Booksurge Publishing; 2009

Published on February 19, 2013

Biosketch

Dr. Leonard Kreisler, MD received his Board Certification in Occupational and Environmental Medicine as well as Family Practice. He has fifty years in health care delivery (forty in Las Vegas). Dr. Kreisler’s medical practice started in 1960 with 13 years as an old-fashioned Marcus Welby-type family doctor in Peekskill, NY. He currently enjoys writing and lecturing on healthcare issues.