Dr Jodie Sage / Emergency Medicine Registrar / South West
The seventh continent leaves many spellbound with its captivating beauty and unique wildlife. Expedition doctor Jodie Sage shares the challenges and rewards of medicine as the ship doctor from her experience operating at both Poles.
Working as a ship doctor in the Polar regions is both the same and completely different from working in the Emergency Department. Anything can change at any second, 24-hours a day. The big difference is that you are on your own. Completely. Yes, you may have a few first aid trained individuals. Yes, you may be able to coax a telemedicine link from the communications kit. But there is no slick trauma team to receive and package a patient ready for the all-seeing CT eye. There is no nurse around to flick that important ‘ON’ switch that you have forgotten as you struggle to suction that vomity airway and wonder why the sats bipper continues to plummet (if you’re lucky enough to have a sats probe). It is you, whatever kit is on the ship, and possibly a satellite phone – if there is signal, which for large parts of these trips, there is not.
I mulled these limitations over as I contemplated the patient in front of me, waggling their dislocated finger at me expectantly. Aboard a ship a considerable number of miles south of Argentina, it suddenly felt very different from my day job.
Despite it being an incredible opportunity, it is not a light undertaking.
The lure of the elusive seventh continent is unique. It has icy mountains, vast glacial ice sheets, and incredible, other-worldly wildlife. It is enough to make anyone overlook the daunting prospect of being the only doctor looking after 200 people with variable degrees of health, in what can be a challenging environment for a host of reasons.
With the wobbly finger in mind, I thought about the kit I had to tackle the problem.
When arriving on the ship there should be a handover from the disembarking doctor. This doesn’t always happen due to travel logistics. I hadn’t met the previous doctor, but they had written me a handover note including their challenges, some tips, and equipment/medical shortages they had encountered. The reality is that with less than 12 hours before cast off, kit shortages are not easy to rectify unless the previous doctor has had the insight to arrange an order/collection of any necessary kit in the days leading up to docking.
After checking in with the captain and meeting the rest of the team (usually a hello in the corridor as they make their way hastily to land), you are shown to your doctor’s office and left to it.
It can feel a little daunting looking around the room. This shoebox has to accommodate everything from minor GP-type consultations to full-blown trauma, extrication and evacuation. It’s definitely not a resus room, but it has some of the equipment you’d find there. There’s a hospital bed, a trauma scoop, some bottles of oxygen, a dodgy manual suction device, and an AED which may or may not give you a 3 lead ECG display if you know which buttons to press in the right order. Everything else is stowed in cupboards in a haphazard sort of way, almost as if it had exploded across the floor in high seas and been packed away in a hurry… I got fairly good at catching bits of medical equipment as they slid off a surface mid-consultation. My first few minutes at sea in this windowless room gave me sympathy for the cupboard packer. The movement sent me green around the gills, a serious consideration if you are to spend any protracted time in the ship’s ‘hospital’ in high seas.
To minimise time in the room at sea I review the equipment whilst docked: what there is, where it is, and how I can get it when needed. There are two grab bags that I repack. One for day to day landings and the other for ‘excrement vs. fan’ type scenarios. To be honest, even the day to day one has to have a degree of fan-type kit. I repack these in a modular priority system, with the ‘catastrophic haemorrhage’ pod immediately accessible, airway kit underneath and so on. Then I go through ‘worst-case scenarios’ to ensure I have them covered.
What is the worst-case scenario? Well, it firstly depends on how remote you are. Throughout the expeditions the ship’s distance to land varies, evacuation time ranging from 6 hours to 2 days. If the weather is poor, a helicopter/fixed-wing extraction may be off the cards, potentially putting you a bumpy 2-3 day sail across the Drake Passage to Argentina.
In a funny sort of way, the worst-case scenarios aren’t necessarily the worst medical predicaments.
A cardiac arrest would be bleak, but it’s fairly black and white. With evacuation sometimes days away, there’s no ability to manage CPR for long periods.
I think the more challenging cases are where there is diagnostic doubt. I once received a handover from an outgoing doctor who was a little traumatised having managed a bowel obstruction as possible gastroenteritis before diverting the ship and evacuating the patient. There had been several cases of diarrhoea and vomiting on board. At handover, the patient was in Intensive Care in a Southern American hospital and had been to theatre twice already. Hindsight makes these cases easy to judge, but with no investigations available and no help nearby it’s important to do a worst-case analysis. The added pressure to keep the ship on course for the benefit of the other 199 paying passengers also means it is important to be aware of the influences that you are under that may affect your clinical decisions.
So what kit and medication do you actually want available to you for this finger?
The stock is governed according to the Regulations of the Shipping Inspectorate – this also meant most drugs were labelled in other languages!
As I examined this passenger’s finger, it was obvious my quick ED management of Nitrox, a nice manipulation and splint was going to take slightly longer than it would in my day job. Not to mention the language barrier that often comes with these cohorts of clients.
Needless to say in ED I’d start with an X-ray, obviously not available on the ship… so what’s the risk-benefit of pulling a deformed MCP with or without a fracture as opposed to leaving a deformed MCP as it is?
Documentation and discussion with the passenger/patient are paramount.
All of these passengers and crew are supposed to know the risk of the expeditions and they are given strict information about what medical care is available.
I attempted to explain this scenario and the options to the patient who was keen to just ‘get it fixed’. This also aligned with my opinion of ‘it needs reducing regardless of whether it’s fractured’. MUA here we come. I had a ring block and he had the grit of his teeth. Clinically I felt it was reduced. Seeing him at dinner that evening reminded me of my less than good splinting and bandaging job. Adequate, but I still have no idea how ED nurses make them look so neat!
Another dimension of these jobs is the fact that you spend your days and evenings socialising with your potential patients. Someone who invites you to join them for dinner can be knocking on your door seeking your professional advice minutes after you’ve finished digesting dessert. It’s a dynamic that you have to be comfortable with and able to adapt to. You are always at work, so when that wine gets passed around, or you are offered drinks at the bar you have to remain able to deal with any medical emergency at any point, regardless of how insisting the passengers have become!
You’re given a radio on arrival with a spare battery and it is your responsibility to ensure it is always charged, not dropped in water (!!) and you are always contactable, any time of the day or night. The ship requires staff throughout the night to keep it running, and patients on board are no different from those in their homes. Getting up for a wee in the night is as risky on a ship as it is at home for some people!
The ship is a highly complex working machine. The engine rooms have more moving, bone-crunching parts than I care to look at, therefore trauma is a very real potential for the work crew. Add to this a cohort of passengers who may be on a frailer side and some high seas with the boats pitching side to side, a NOF or head injury/C spine injury is very possible, and often in awkward, narrow spaces. And we haven’t even left the ship…
The environment is the reason we chose to go on these trips, yet it is something most of the passengers (and possibly yourself) have never experienced before; cold exposure, the climate, wild animals, moving to and from speed boats, alongside all the communicable challenges of being in a confined space with a population from various countries and you have a recipe for significant medical problems.
It’s not exciting but there is a very real chance that gastroenteritis or heavens above a highly infectious respiratory virus, could spread through the ship.
So what qualities do you need?
You need to be a competent doctor; undaunted by the above. You should be happy to deal with emergencies independently, to lead and be the one who decides to change the path of a ship and cause a very expensive medical evacuation. You also can’t expect to be a good expedition doctor if you aren’t autonomous and competent in your day job.
Alongside this, it is paramount that you’re a team worker and you’re happy to muck in with whatever is needed. You’re on a ship, in a confined space with a limited number of people. You have to be able to simply, ‘get on’. If things change you need to be able to adapt and help out where it is needed. The majority of the time you won’t be doing anything medical and you can learn a lot by making yourself available to the rest of the team and being ‘keen’. I learnt about servicing rifles, Polar naval navigation, sea-level rise, driving Zodiacs, and shooting flare guns on my trips.
You need to be able to manage yourself and not increase the workload of the rest of the team. It’s your responsibility to be warm enough and have the kit you need. You need to be in a fit state to respond at any point: not too tired, or cold. Hands warm enough to put in a cannula and draw up drugs. Resistant to jet lag and the disorientating midnight sun.
And most importantly, you have to be able to manage your own seasickness, and to a level where you can cope with going below deck to see a vomiting patient when you feel like you may vomit at any point yourself. Rock and roll, literally!
If you can handle the above, the reward is truly spectacular.
Not only do you become part of a close-knit team, but they are also specialists from around the world: experts in climate change, wildlife, flora and fauna, oceanography, and glaciers. The team run lectures on the ship on a whole world of history and exploration that never gets taught at schools, learning about Shackleton, Scott, Amunsden and Peary. Due to the confinement of the ship, it gives you a good opportunity to reflect on your very comfortable life and ponder exactly how you’re spending your time!
You also get to experience all of these things first hand. Seeing these creatures in their home environment is truly breathtaking, both in the Arctic and Antarctic. Watching penguins waddle down their penguin highways, oblivious to your presence, bumping and sliding clumsily, styling out what was definitely a slip into an intentional belly glide. Seeing arctic foxes leap and jaunt from rock to rock while scouting for eggs, while polar bears trek across the ice in search of their next meal with tiny cubs trailing behind looking like cuddly teddy-bears! Seeing the largest mammals on earth bubble feed, taking huge mouthfuls of water and then fluke and slap their tails and trace them under the water until they’re in their own world again.
The list is endless: walruses burping and lounging their days away, huge albatross gliding through the sky, guillemots swarming and flying/falling into the water with surprisingly small amounts of grace. Seals that look like velvet popping up meters from the boat gliding and moving more elegantly than ballerinas and then launching themselves onto glaciers and transforming into the most cumbersome creatures you can imagine. All set against a backdrop of dramatic ice falls that pop and crackle as you steam past.
So whilst it’s different from the day job, you do become part of a very different kind of team, and it certainly shares that element of unpredictability. It’s a challenge and a privilege to operate in Polar environments. I came back with more tools in my kit to face the daily trials of Emergency Medicine, not to mention refreshed, re-enthused and keen to share my experiences to protect these vulnerable areas.