Ah, life on the open waves: a place to relax, get away from it all and watch the world go by — literally.

Millions of travellers love cruises precisely because of their blend of remoteness and comfort. But what is a much-needed break from the real world when you’re feeling well can be trickier if you fall ill or have an accident onboard.

Break your leg hundreds of miles from the nearest hospital or have a heart attack and you might not be so pleased to be offshore.

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Of course, every cruise ship has a medical centre — but how big is it? And what do they do in there? Are the doctors general practitioners or is it more like the ER? And, if worse comes to worse, what happens if a passenger dies onboard?

Dr Aleksandar Durovic, who has spent the past 20 years as a medic on cruise ships, says a doctor’s life on the high seas is very different from one on terra firma.

“Watching The Love Boat you think it’s just going around having dinner and drinks with guests, but it’s really not like that,” he says.

“It’s a job full of stress and responsibility. The medical side can be very demanding.

“Most of what we do on big cruise ships is emergency services, like in an ER, but we are also general practitioners for crew, and take care of chronic medical needs.”

Amy White, director of medical operations for Vikand, which provides medical services for more than 150 ships on 33 cruise lines, says medical staff are cherry-picked to have a background in emergency medicine of at least three years.

“The reason is you can have any and all types of medical emergencies,” she says.

“You need highly trained staff to do that. Lots of vessels have one doctor, so you’re it — there’s no backup other than us (shoreside). So, you need to be able to work alone.”

The other thing you’ll be tested on before boarding is your bedside manner, says White.

“On ships you have to have hospitality — guests are always right,” she says.

Durovic spent 13 years working in his native Montenegro before moving onto cruise ships. He spent two years with MSC, and 17 with Carnival. Now he’s taken a job unlike any other in the industry: he is the sole doctor onboard Villa Vie Odyssey, the ship that is making its way around the world on a three-year voyage.

White, meanwhile, started as a nurse working in emergency departments in her native South Africa, and was lured into cruise ships by two co-workers “who’d been on ships and talked about it all the time”.

In 2012, she joined Royal Caribbean as a nurse, then moved to Viking where she worked up to the role of fleet nurse, before joining Vikand as medical operations manager.

Whether a cruise is for three years or three days, the set-up is usually the same using guidelines laid out by the American College of Emergency Physicians (ACEP).

Cruise lines that are members of CLIA, the Cruise Lines International Association, must have at least one onboard medical professional available 24/7, as well as two medical rooms — one of which must be for intensive care treatment. They must also have onboard equipment for monitoring vital signs.

Many large cruise ships have at least one other doctor, as well as a small team of nurses although this is down to company policy rather than legal requirements. White compares it to a “small community urgent care or emergency department — we have a treatment area, one or two ICUs with a ventilator, cardiac monitoring capabilities and a defibrillator”.

From 2026, ultrasound capabilities will also be mandatory on CLIA members’ vessels.

Large cruise ships also have a morgue onboard for when the worst happens.

The onboard team is backed up by shoreside staff, including doctors with extensive emergency medicine experience.

“The big companies — Carnival, Royal Caribbean, MSC — have a medical department in the office giving you full support,” says Durovic.

Smaller cruise companies, such as Villa Vie, work with external providers to get the same service. Vikand is one of these companies, providing medical services for more than 150 ships on 33 cruise lines, including the staff onboard, and an on-the-ground team to help with logistics.

Then there’s the ship’s captain, who is ultimately responsible for all the souls onboard. They get involved with logistics if a patient needs to be offloaded or in the case of a death onboard.

But otherwise, the medical team is all at sea — alone.

‘Similar to any ER’

For Durovic, working on a cruise ship is a great combination of adrenaline-fueled emergency medicine and general practice, where doctors can build a relationship with their patients.

While most interaction with passengers will be of an emergency nature, when it comes to dealing with the crew onboard doctors become general practitioners, helping them with chronic conditions, building a relationship and even overseeing their mental health. That’s also the case on Villa Vie, where some passengers plan to remain as long as they are physically able to.

The vast majority of cases cruise doctors see, however, are emergencies.

“Respiratory problems are the main thing, but anything can arise,” says Durovic.

“Heart attacks, heart failure, cardiac arrest. Strokes, injuries, fractured bones, spine injuries and head injuries. It’s similar to any ER around the world, and some ships can be very busy.”

He says that on large ships, doctors tend to deal with around one death per cruise, while White reckons it’s at least one per quarter. “It’s pretty common — more common on lines with more elderly passengers,” she says.

White says that while emergency medicine on dry land tends to involve a lot of accidents, on a ship the caseload is different.

“It’s not necessarily trauma — we saw a lot of chronic heart disease patients in acute cardiac failure,” she says, remembering how she had to put patients on ventilators in her on-ship days.

The other thing they see a lot of is stomach flu and respiratory diseases — not a big deal on land, but crucial to contain onboard.

“You come into the ER with diarrhoea, we get you on a drip and send you home. On a ship you get isolated for 48 hours — those kind of things they don’t teach in nursing school,” says White.

For Durovic, his early experiences with MSC Cruises, when it was still a young company with a handful of ships, taught him how resourceful ship doctors can be.

“I saw the scale of medicine that you can do on the ship, with support from the land,” he says.

“You don’t have CT scans, you’re in the middle of the ocean and need to stabilise the patient long enough to reach the next port, or transfer to a helicopter to a facility on land.”

So, what happens if you have an accident or feel ill onboard — and are your chances of recovery as good as they would be on land?

What actually happens below decks?

Firstly, here’s hoping you bought travel insurance — because cruise ship medical care is expensive. Be sure when buying your policy that it includes cruise cover, which usually costs a little extra, and to detail all the countries you’ll be calling at as port stops.

“The likelihood of falling ill while on a cruise is low, but when you travel — by air and land as well — there’s always the chance that it could happen,” Cruise Critic executive editor Adam Coulter says.

He has only had to use a medical facility onboard once — for sunburn for a family member.

Whatever the time of day or night, you can call for assistance — ships are mandated by law to have at least one member of the medical team on duty 24/7.

If you’re able to, you’ll make your way to the medical centre — usually on a lower deck. If you’re unable to move, staff (usually the nurses, says White) can come and see you in your cabin, and can help transfer you downstairs.

Certain members of the housekeeping team on every ship are also trained to be emergency transporters and CPR responders, taking clients on backboards or stretchers downstairs.

You might see the doctor immediately — or the nurse might book you in, sometimes running blood tests so they can have the results ready by the time the doctor gets involved.

Yes, blood tests. Although ship medical centres might be small, they can run a barrage of tests, from bloods to X-rays, and can carry out small surgeries, put casts on broken bones, insert catheters, and even intubate and put patients on ventilators.

They can reinflate collapsed lungs and stabilise heart attacks. They can even do blood transfusions, appealing over the loudspeakers for volunteer donors among the other passengers.

“You’d be amazed what kind of things we can do,” says Durovic.

Surgery is not possible, however. Patients requiring that will need to be offloaded from the ship to an onshore medical facility.

And even for relatively straightforward surgery, the logistics can be trying. For a burst appendix, for example, doctors can give you antibiotics and stabilise you with pain medication, then evacuate you to the nearest onshore medical centre for a CT scan and surgery.

But getting patients onshore takes planning. The onshore medical teams help, says Durovic.

“They work with you on the best route, they co-ordinate with the navigational team to see where the ship can be diverted, and the weather conditions — a helicopter can’t fly if there’s dust or if it’s too windy.”

The captain has the last word on logistics, liaising with the nearest coastguard. If the ship is at sea, depending on the situation (both of the patient and the ship), it might make a diversion to offload the patient by pilot boat or helicopter, if time is of the essence. This is where travel insurance becomes crucial because the patient will be sent the bill.

“I can’t explain how many people who need a helivac don’t have medical insurance,” says White.

“It’s very important that you do — it depends where you are, but the cost can be up to $50,000.”

And while passengers are able to decline, she says, “they need to understand what the risks are if we don’t get you off the vessel”.

Heart attacks at sea

Cardiac arrest is one of the most common incidents medical teams deal with onboard, but while having heart failure at sea sounds like a recipe for disaster they can often save patients’ lives.

Teams can’t do an angiogram onboard — but not all hospitals can either, says White. What they can do is administer thrombolytics — medicines that break up a clot in the event of a stroke or heart attack.

“We can mitigate any further damage” before getting patients to onshore care if they need, she says. The same goes for a stroke or a bleed.

Even straightforward accidents and injuries can be repaired onboard — teams can X-ray then splint, stabilise fractures and even do full casts.

“If it’s a femur fracture we have a traction splint — we can position you properly and get you off in the next available port. It’s the same with a hip fracture,” says White.

Death onboard

Of course, sometimes the unthinkable happens and a passenger dies. Urban myths abound — supposedly, a sudden influx of ice-cream being offered on the menu means someone has died and their body has been stored in the freezer.

Shockingly, that was indeed the case until about 40 years ago, says White : “Before they had morgues, they put them in the ice-cream fridge.”

Now, though, most vessels have a morgue, with the exception of expedition ships which rarely have room. “Sometimes the body is put outside, when you don’t have any land for three days, or (the possibility of) a helicopter,” she says.

Today, says Durovic, there are tight procedures around passenger deaths.

The medical team must immediately inform the captain, as well as the medical team offshore. They must bathe the body and notify the authorities on dry land. In the US, that means the coastguard and the Centers for Disease Control, says Durovic.

“The decide what to do. Sometimes medical examiners will come onboard and take the body for an autopsy. It depends case by case.”

Security is stepped up around the body while it rests in the onboard morgue. White adds that usually police will board the vessel at the next port, to take notes and sometimes interview the doctor.

“But I’ve never been on a vessel where there’s suspicion,” she says.

Local funeral directors usually offload the body in port, since most authorities don’t allow ships to set sail with a body onboard. The only exception, she says, if it’s a US-Mexico return cruise, where they might be allowed to depart Mexico to bring the body of an American citizen back to the States.

But before all that, says White, there is a moment of silence.

“Obviously the doctor pronounces the death but, for most medical teams, the person is given some respect. There’s a moment of silence before the body is prepared.”

If the person has been in an accident, they must keep all the medical devices used on the patient as testament to their recovery efforts. If, as usually happens, it was a natural death, they are taken to the morgue.

“There’s a lot of administration, and we also speak to the family if they’re not there (onboard),” says White.

“Guest relations take good care of the family arranging flights or trauma counselling if they want to stay onboard. And if any crew need mental health support — because sometimes it’s crew who passes — we provide mental health support to crew, too.”

And although your mind might go straight to a Hollywood-style scenario of a passenger dying of a communicable disease, Durovic says that in his 20 years in the industry, it has never happened (although he’s had several patients in a critical condition with COVID since the start of the pandemic).

All the deaths he has handled have been from natural causes.

“It’s not a nice feeling for the whole ship,” he says of a death onboard.

“Ships are supposed to be fun places, for people to enjoy their vacation. Any event like that is really stressful for everyone — but at least we have training.”

Dealing with a cardiac arrest, he says, is the most stressful event for him and his team.

“Sometimes you manage it, sometimes not,” he says about CPR.

White has never forgotten one of her onboard losses. Once, she had to deal with a man who was on his 40th wedding anniversary cruise when he went into cardiac arrest.

“All he’d wanted to do was see the Panama Canal and we had just left it the day before,” she says, the emotion still in her voice.

“It was just a few minutes before New Year’s Eve. We resuscitated him but we didn’t get him back.”

Crew cleaning rashes and diabetes

While passenger incidents can be the most dramatic duties for a cruise doctor, what’s equally important is general practice for the crew, from long-term support for chronic diseases such as diabetes and hypertension, to acute problems.

“We get lots of galley teams who have rashes from the chemicals they use to clean, and they’re cleaning all the time,” says White.

Durovic says crew can have psychological help online as well as an evaluation in ports of call.

“Being at sea is very lonely – you miss out on a lot of things,” says White.

“My mother became very ill and it took me three days to get home. You’re at sea, there’s nothing you can do. I got to her — but many don’t.”

She says that getting a good team together is crucial: “On ships you have to learn a lot more than just medicine.”

And the teams tend to endear themselves to the rest of the crew.

“The medical crew parties are the best,” she says. “You put stuff in syringes and dress up as nurses.”

The fast pace, distance from friends and family isn’t for everyone, but Durovic is in no hurry to give up.

“People say it’s time to come home, and I eventually will, but I learn a lot about what people are doing around the world,” he says.

“There’s always something to take with you.”

His patients on his current three-year cruise will be hoping he sees it through to the end of their own odyssey.