Shipboard medicine is no carnival

Without all the benefits of a land-based clinic, a virus outbreak on a cruise ship can overwhelm the ship's doctor and medical staff.

By Victoria Stagg Elliott, amednews staff. March 3, 2003.

In the past months, several cruise ship voyages have been disrupted by outbreaks of norovirus, making passengers and crew miserable. Dr. Jabez Steenkamp is the ship's doctor on board the MS Carnival Conquest, which had three outbreaks in December 2002. His job was to contain the outbreak and keep the rest of the ship healthy.

Dr. Steenkamp has worked on cruise ships for 3 1/2 years. Dr. Steenkamp discussed with AMNews the challenges of practicing shipboard medicine.

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Question: When did you realize you were in an outbreak situation?

Answer: We keep a very strict log of every guest and crew member that presents with gastrointestinal symptoms. Sailing from New Orleans in December, we had two guests with symptoms in the first 24 hours. That is normal. Twenty-four hours later, the count was 12. We knew that this was out of the ordinary, and we immediately started outbreak measures.

Q: Were you able to trace the cause of the outbreak?

A: We identified a guest whose symptoms started 36 hours before he boarded the ship. He was in the recovery phase when he came on board. It is possible that he "brought" the virus to the ship.

The "Conquest forearm tap" replaced handshakes in order to thwart the spread of norovirus.

Q: What was it like when the rest of the ship realized there was an outbreak?

A: The majority of the guests and crew never got sick.

Our highest recorded number of sick people was 229 guests and 39 crew -- or 7.2% of guests and 3.3% of crew. Most of the guests were still having a great time cruising, and I am sure most were unaware that we were having an outbreak.

Q: Was there anything medically you would have liked to have access to but didn't because you were on a cruise ship?

A: As far as treatment goes, we have everything we need to treat someone with a gastrointestinal illness. The only problem is that the small infirmary and the small medical team easily gets overwhelmed if there is a sudden increase in the number of patients. We simply do not have the space and the manpower to handle 300 sick people at a time.

The only thing we did not have access to was a lab, and there was no way to make a definitive diagnosis of which virus was causing all the trouble. Samples were sent to a lab in the United States, and norovirus was confirmed in February as the cause of the outbreaks.

Cruise ship doctors don't have access to blood products for transfusion.

Q: What public health measures did you take when you realized it was an outbreak?

A: Cases were quarantined in their cabins for 48 hours, and their contacts were quarantined for 24 hours with strict observation to see if they developed any symptoms.

It was possible to ensure that crew complied with these measures. But, of course, we do not have a police force on board to make sure that guests followed these guidelines.

Cabins also received special cleaning treatments from the housekeeping staff. If anybody vomited in a public area, the area was immediately secured and housekeeping did special cleaning in that area.

An environmental team came on board and they cleaned all public areas and all cabins.

Guests and crew were discouraged from greeting each other by shaking hands. The cruise director had the bright idea to introduce the "Conquest forearm tap." Named for the ship, this way of greeting each other by knocking elbows together quickly became very popular and created a high level of awareness among crew and guests of the importance of exercising personal hygiene measures.

Q: Have you ever experienced a situation like this before?

A: Christmas 1999 was a bad season for the flu, and the ship where I worked had an outbreak. The worst was 80 people sick in their cabins. We ran out of cough medicine. But this was the first time I had to deal with an outbreak of gastrointestinal illness on a cruise ship.

Q: What's the worst medical issue you've ever had to deal with?

A: We do not carry blood products on our ships, and the worst medical problem is when you see someone bleeding to death. You don't have the one thing that will save their life: blood!

On one cruise, a fairly young lady presented with an upper GI bleed. I watched her life draining out of her body and realized that I was completely unable to do anything.

The ship arrived at port in the early hours of the morning, and we delivered her to the ambulance on the pier with a heartbeat but barely a blood pressure. She was taken to the emergency department where she was given an immediate blood transfusion. She survived.

A case like that is worse than having a death on board. In my career as ship's doctor I have seen only four deaths on board. All were sudden, and from natural causes.

Q: Is your life anything like that of the doctor on the "Love Boat"?

A: Are you kidding?