The operational environment of commercial travel can be as challenging as any other for the EMS physician to provide quality emergency medical care. As an aging population remains mobile and continues to travel, the importance of planning and preparation for emergency medical care has become more important than ever. Planning for and providing emergency medical care in commercial travel environments such as a cruise ship or passenger airline require a thorough understanding of the limitations those environments produce.

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  Describe the cruise ship medical operations and the EMS physician role onboard.

  
  
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  Discuss unique challenges in patient management at sea.

  
  
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  Describe airline medical operations and the EMS physician role as medical director for airline operations.

  
  
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  Discuss unique challenges in patient management in the air.

  
  
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  Discuss basic jurisdictional and FAA regulations pertaining to in-flight medical emergencies.

  
  
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  Describe the process of flight diversion for a medical emergency.

  
  
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  Describe typical resort medical operations and the concept of “concierge medicine” for resort guests.

  
  
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  Discuss licensure and liability issues for EMS physicians practicing travel medicine.

Consider the example of delivering clinical care during an in-flight medical emergency requires the EMS physician to not only understand the pathophysiology of a given medical condition, but also appreciate operational considerations such as altitude and flight physiology, providing medical care within the equipment and resource-limited environment, and consider the overall impact of deciding whether or not to divert a flight.

Provision of medical care onboard a cruise ship is no less challenging. It is typically the medical officer’s responsibility to plan for medical care and potential onboard disasters, respond to emergencies, monitor and respond to potential epidemiologic events, oversee ancillary medical staff, and be the overall “medical conscience” for the command staff of a vessel. The challenge in making the decision to divert to a nearby port or have a patient medically evacuated from sea requires proper forethought and planning on the part of the medical officer. Resort medicine can be challenging since many of the typical services provided may not be emergent in nature depending on the type of resort; however, at any moment a medical emergency can be encountered and the EMS physician must be ready to respond especially since many resorts may be located somewhere advanced medical care is not available.

Consider other aspects of EMS medicine which have similar planning and operational considerations to airline cruise ship and resort medicine. Operational preplanning for anticipated illnesses and preventive health services in the urban search and rescue, fireground support, or tactical medical environment is performed to minimize injury or illness to team members as well as maximize the overall success of the mission. This approach has great relevance to medical care planning for cruise ship or airline medicine. Delivering medical care in the unique physical environment such as a passenger airline draws on practices and principles of helicopter and air medical transport which may be all too familiar to the EMS physician. Regardless of the operational environment, the EMS physician must appreciate the balance he or she must maintain between providing state-of-the-art emergency medical care and seeing that the nonmedical objectives are successfully met. The objectives of this chapter are to provide the EMS physician a basic understanding of the cruise ship, airline, and resort medicine as it pertains to his or her role as a provider or medical director.

Passenger travel onboard luxury cruise lines continue to be a popular vacation choice. The US Department of Transportation (DOT) Maritime Administration estimates that approximately 10.6 million passengers were carried on North American–based cruise ships during 2010. This number is up from 9.9 million passengers who traveled in 2009.¹ These numbers were over the estimated capacity for both 2009 and 2010, representing over 100% occupancy rates and a considerable degree of cruise ship travel by the general public. Cruise ships have grown in size with current luxury vessels capable of carrying up to 5400 passengers. Over the past 5 years, the average size of ships has increased by approximately 14.2% to 2272 passengers. Some of the largest passenger capacity vessels can carry up to 5400 passengers.¹ Providing health care at sea can be considered part wilderness medicine, travel medicine, and preventive health medicine. The EMS physician must consider the limitations in medical resources, diagnostic equipment, and available consultation when evaluating patients as well as the operational challenges that occur when a medical evacuation is needed. Preventive health becomes extremely important in the closed population of a cruise ship and the risk of rapidly spreading infectious diseases. In this manner, the best medical care is sometimes preventative.² Considering the diverse passenger population and worldwide locations most cruise ships travel, cruise line medical operations have had to adapt and meet the challenge of providing medical while being miles out to sea. There is no particular personal demographic to describe patients encountered at sea. Cruise ship passengers can be viewed as a cohort of the general population at large with similar chronic illnesses and comorbidities. Travel for days at a time at sea can pose a challenge for passengers with complex medical conditions. Although most cruise line passengers are advised to medically prepare for a trip by securing adequate personal medications, medical clearance by a personal physician when necessary, updating specific immunizations, etc, it is still up to the medical department onboard to prepare to encounter any type of medical or surgical emergency.

Studies have been published in the literature attempting to describe the epidemiology of illness and injury encountered while at sea. A quick review of the available literature demonstrates that medical complaints remain the most common types of reason for accessing medical services on a cruise ship over traumatic injuries.^3–6 In two studies specifically looking at cruise ship infirmary visits, respiratory diseases were the most common reason for visit. Other common visit diagnoses included nervous system/sensory organ systems including motion sickness, gastrointestinal, dermatologic, and cardiovascular diseases.^3,4 Traumatic injuries remained less common than medical illnesses and in both of the aforementioned studies represented less than 20% of all ship infirmary visits. Of the traumatic injuries, the most common include sprains, soft tissue contusions, and wounds and fractures.^3,4 One study examining the frequency of accidents and injuries occurring at sea found similar results over 3 years with wounds, contusions, joint sprains, and bony fractures as the most common types of injuries. The most common mechanism was due to a slip or fall typically within a passenger cabin compartment or bathroom.⁵ Considering maritime health care for nonpassenger cruise ships, similar injury patterns are reported in the literature among sea goers such as merchant mariners and typically encompass more medical and urgent care complaints than serious traumatic or work-related injuries.⁷

Preventive health considerations and rapidly spreading infectious diseases deserve special mention when considering the overall delivery of health care onboard a cruise ship.^8–11 Numerous case reports and media attention on diseases such as viral gastroenteritis spreading through ships and ruining vacationers have made preventive health an important aspect of the ship medical officer’s duties. Common sources of viral infectious outbreaks include food handling and water sources onboard the ship. A review of recent foodborne and waterborne outbreaks reveal commonly encountered bacterial pathogens such as E Coli, Salmonella, and Shigella, whereas common viral pathogens are mainly attributed to noroviruses.^12,13 Most, if not all of these, outbreaks can be traced back to some type of storage or mishandling issue which results in inappropriate pathogen growth. The cruise ship environment is especially susceptible to these outbreaks due to the relative proximity passengers and crewmembers have to each other onboard the closed physical space of a ship. This makes hand-washing and other sanitary strategies important. Limited space at sea also means limited supplies of noncontaminated food or water to sustain passengers and crewmembers until a ship can return to shore. Finally, treatment for large victim numbers becomes challenging given the limited resources of most ship infirmaries. As one could imagine, a significant epidemiological event could easily overwhelm the staff and resources of a ship’s medical department.

In efforts to better plan and prepare for epidemiological catastrophes onboard a cruise ship, the CDC has available resources to help ship clinicians with preventing and managing these incidents. In 1975, the CDC developed the Vessel Sanitation Program (VSP) to help the cruise line industry minimize the risk of acute diarrheal diseases among passenger and crewmembers sailing into the United States. Overall, the incidence of acute diarrheal diseases onboard cruise ships has declined from 1999 to 2000 as part of these efforts.¹⁴ The CDC also publishes the Vessel Sanitation Program Operations Manual which is regularly updated and acts as a general resource for ship medical officers in preventing such outbreaks.¹⁵ The CDC also provides informational bulletins for clinicians on specific pathogens that ship medical officers may encounter such as Noroviruses.¹⁶ It is important that the EMS physician understand his or her role not only as a clinician but also as a preventive health officer whose duties may also include supervising food and water handling and storage, monitoring of sanitary conditions in other ship areas such as food storage and preparation areas or bathrooms.

Maritime health care pose some unique challenges and operational considerations for the EMS physician to manage. Operationally, almost all ships follow a similar chain of command. The EMS physician would likely see themselves serving the role as a medical officer within the medical department of a ship. The medical officer typically oversees the medical department unless there is a chief medical officer. A cruise ship is typically divided into its different functional departments. Two common departments are the deck department and the engineering department. The deck department typically commands and navigates the ship. The captain of the ship is considered the overall commander of the vessel with subordinate officers such as the first officer, second officer, third officer, etc, as the next chain of command. The medical officer typically functions as a special staff member to the captain providing guidance and insight with respect to medical and health issues. At sea, one of the most challenging decisions to make for the medical officer is whether or not a ship must initiate a medical evacuation at sea or divert the ship to a nearby port due to passenger or crewmember illness or injury. Such decisions are not taken lightly and must be weighed against the overall well-being of this ship if a diversion is to be made. Although this decision can be costly, it should always be a consideration if risk to life is significant. The EMS physician should also consider the fact that aeromedical evacuation from sea is not usually his or her final decision; rather it is left to the flight surgeon or medical officer and pilot of the responding agency such as the US Coast Guard.¹⁷ Effective transfer to definitive care may not always involve emergent evacuation at sea by helicopter. In fact, sometimes, knowing what available resources at particular ports of call is essential in planning medical care during a given voyage. Communications capability while at sea is another crucial aspect of medical care the EMS physician should be familiar with. This may include satellite or radio communications. Ultimately, any of the above decisions is made in conjunction with the captain of the ship as he or she has ultimate operational control of the vessel.

The role of the EMS physician as ship medical officer will often include multiple job roles from preventive health officer and sanitation officer to both primary care and acute care clinician as mentioned previously. Provision of good medical care onboard begins with proper medical preplanning by the medical department. Medical preplanning for a cruise includes taking into consideration travel location and ports of call, knowing the endemic diseases and illnesses, planning for appropriate vaccinations and adequate treatment supplies for endemic diseases, and gathering as much medical information about passengers and crewmembers as possible. Major cruise lines maintain medical departments that include ground or shore operations to perform these preplanning activities as well as monitoring and quality improvement functions. The EMS physician may find themselves functioning as the medical director for a cruise line and function in this administrative capacity. This may include oversight of training and clinical care by physician extenders, nurses, paramedics, and EMTs. It is also important that training for medical scenarios onboard the ship while at port and at sea occurs regularly to maintain the response readiness of the medical department. Along with knowing endemic diseases, it is also important to research regional weather patterns and its impact on ship operations. High winds and rough seas will greatly affect passenger comfort as well as increase the likelihood of fall injuries on deck. Weather can also affect food storage considerations and vector-borne illnesses as well. Knowing local medical facilities and capabilities will also help guide the medical officer in making the most informed decision on diversion and medical referral/evaluation at port.

Preventive health services such as food handling and storage inspections, water treatment and wastewater management, and other sanitary functions are just as valuable as clinical duties. These supervisory activities begin at port prior to departure and throughout the cruise to minimize the chance of any epidemiological outbreaks. As mentioned previously, the uncontrolled outbreak of a highly contagious disease such as Norovirus gastroenteritis can significantly affect cruise operations. Preventive health includes routine surveillance for such diseases while at sea so appropriate measures can be taken before a critical mass of individuals are affected. Responding to emergent medical and surgical conditions is also an important aspect of cruise medicine. As with any planning for emergency medical care, the EMS physician should consider the most common illnesses and injuries as well as the most severe ones to prepare for. According to previously published studies, common life-threatening conditions mirror those seen in most emergency departments and include asthma exacerbation, angina, myocardial infarction, syncope, congestive heart failure, and stroke.⁴ Data suggest that the overwhelming majority of patients remain onboard the ship and can be managed accordingly. It is relatively rare that a diversion must be made for medical disembarkation or an immediate aeromedical evacuation be initiated. Most complex complaints can be managed with follow-up arranged at a port-of-call with subsequent evacuation.^3,5