You never know who you are going to meet on a cruise. There are sick people and then there are the Barons who are driven to mime disease and trick doctors. Have you ever met one? Dr X has. Then again, you probably have one in your family

Ship Physician's Log: Day One, Cruise V, Santiago to Buenos Aires

My first day in the clinic was with Fae. We chatted about her family in the Philippines. Fae had some interesting insights into life. "You are lucky, Doctor." You have lived your life and know what has happened. The rest of us are young and don't know what the future holds." That seemed so existential, I was so impressed.

Then she broke into 'Money Changes Everything' with her soprano voice, which really wasn't a bad voice at all. I told her my Dad had been a voice teacher and performer and that I was sure he would have complimented her. She smiled broadly. "How do you think I got to be lead soprano in my high school choir, I was the best soprano." She started 'Boy Blue' but forgot some of the lyrics, finishing by humming.

When she was done, I complimented her once again, then went about exploring the medical center. There were a total of eight rooms plus two waiting rooms, one for guests, the other for the crew.

I went to the pharmacy room where I would dispense medicine - Yes, suddenly I was a pharmacist. The code room, used for critical patients, was right off the doctor's office and had just about everything one would need to run a code or a cardiac arrest. Then next was a so called procedure room where one could suture or apply plaster. The x-ray was there.

Then two so-called "ward rooms" which resembled hospital rooms. These were for that rare patient too sick to be in their cabin. Then walking back to the front of the Center I passed through a lab/communications room where the nurses would perform lab tests. Here was the FAX/Printer machine that kept us in touch with our offices in Miami, and a carefully protected Sea Phone that could call anywhere on the globe.

It has a super-secret password Tal finally trusted me with. I decided to not use it at all, I had no need for it but nursing might need it to call ahead to the next port if we needed to medically disembark a critical patient. She would call the hospital and then our company's port agent who was the Jack-of-all-trades for moving people around once onshore.

I had once, while with another cruise line, trusted a Russian girl to use a seaphone I had access to. I left her for a meeting or something and she bade good bye with a promise to not talk for more than 5 minutes. It was something going on with her Mother back home. Next day I learned she had been on 30 minutes! It's easy, sometimes, to trust too much.

It was after 8:00 AM and the clinic was open. Patients would be seen according to who came first. It didn't matter if they were guests or crew. Some cruise lines will have a separate doctor for the crew. But here Tal and I would take care of any and all the patients.

Tal showed up to see if I had any questions. Then he started talking about how much he missed his wife. He had been at sea for nine months with no vacation. He was due to disembark in Buenos Aires at the end of this cruise. His anticipation was palpable. And he looked sad, too. "I miss my wife," he said, sadly, several times.

Sometimes the nurse, Fae, could handle a problem, like handing out Meclizine for motion sickness. Other things I took care of, like lacerations, prescribing antibiotics for whatever, strains and sprains requiring x-ray, and of course anyone that was short of breath or having chest pain.

Morning clinic was from 8:00 AM to 11:00 AM. We were about to close for lunch when a 20- something African-American male came in quietly and announced he had a dislocated shoulder. He said he had bumped it on the wall after stumbling on the stairs of Deck 5. His wife showed up and told a slightly different story, saying he had actually fallen down the stairs, several steps. He told us it had happened three times before, first with a serious injury, a motorcycle accident, then with minor trauma.

The major observation I made was that he was in virtually no pain. None. I was beginning to suspect that he was either a drug seeker faking a fall, or this was an old friend come to visit me again: The Baron. Any emergency doctor knows about or has met The Baron. I have met him in many disguises. Sometimes he's old, at other times he's young. He comes as different races, almost always a male and his sole purpose in life, his.

He could care less about lawyers, accountants, mechanics, or cooks. He is driven to mime disease and trick doctors into doing unnecessary tests and often times surgeries. Many have multiple surgical scars. Many have chest pain. They feign anger if confronted or found out. I had one storm from my ER yelling at the top of his lungs "You're the craziest doctor I've ever seen. You're nuts." We call that, of course, projection. But that's another story.

There was a real Baron and he lived in Germany in the 1700s and was undoubtedly an anti- social personality with an infamous inability to tell the truth. There are many types of anti- social personalities but they all share, among other things, not only an inability to tell the truth but also a compulsion to make up stories about themselves.

And a certain type of 'Von Munchausen' patient chooses doctors and hospitals as victims of his ruses. Like all antisocial personalities they don't think anything they're doing is wrong at all; they have an underdeveloped sense of morality. No sense of boundary or border. They offend and annoy guiltlessly.

If you ask them for their doctor's contact information they will gladly give it to you and when you speak to their doctor he will invariably say something like, "I get calls on this guy all the time. I've worked him up and his tests are always normal. People call from all over the country." Von Munchausen patients also tend to travel a lot. It would seem they would have to since they would be so easily remembered.

Fae was concerned. "Doctor, there's something strange about this guy."

"You're wondering why he has no pain and why his story seems to change?"

"Yes."

"I'll explain later, Fae. Stick with me and get the Ketamine ready."

I examined him, his name was Adrian. I could tell without an x-ray that his shoulder was dislocated. Once I made sure he wasn't a common, ordinary drug seeker, my diagnosis would be certain. Von Munchausen patients aren't in it for the drugs, although they may ask for some as part of their scheme.

"I have good news, Adrian. I can get this back in without using narcotics and sedatives. I'm just going to put you to sleep with a medicine we call Ketamine. You'll wake up in a few minutes all fixed. You won't be all groggy. You can go home right away."

Ketamine, or Ketalar, is probably the most commonly used agent to induce unconsciousness and muscle relaxation in patients undergoing painful procedures.

"Are you sure, Doc?" Then he added, "I've had this about 20 times and it's really hard to get back in the joint." A true drug seeker would have gotten angry or argued. Adrian took it in stride. His story was morphing.

His count had gone from 3 to 20 prior episodes. Was he trying to unnerve me?

Fae decided to dose him with an IV and a small bag that allowed her to adjust the dosing. I told him to count backward from a hundred and he didn't make it to 98. This is the same class of drug that Dexter uses.

The shoulder reduced with one small tug, Fae had given half the dose when he dozed off. He woke up and moved his shoulder around. "Thanks, Doc." I doubted his sincerity. He and I both knew he could pop his own shoulder in and out at will.

"You know," I said, "They can fix your shoulder with surgery."

"Yeah, I have one doctor who wants to do that. Maybe I should," he said, looking away.

Another fact left out of his initial history. These people were chronic liars about everything, not just their health. He left with a sling he probably didn't need and some Ibuprofen he wouldn't take. As he walked away I suspected he was planning his next adventure.

Fae and I closed the shop and went to the officer's mess. She usually would go to the crew mess because she preferred Filipino food, but she wanted to hear what I had to say about my old friend, The Baron.

The rest of the day was uneventful. Tal covered me in clinic while I went to another safety meeting where we had to learn where the different Muster Stations were, how many lifeboats and life rafts we had onboard. And next week I would learn how to right a capsized life raft. I think I may get wet.

I was on call for the night with Fae and we both slept undisturbed. Guests needing medical help would have called 911 and talked with the guest services person on duty who would call Fae. If Fae needed me she would call me to the medical center. But nobody needed us.

I couldn't get that Cyndi Lauper song out of my head.

Cruise day One, Ship's time 2230 hours, By Dr. X, Ship's Physician

About the Author:

Come aboard as Dr X's Private Sea Journal reveals with great story telling and wit the practice of medicine on the high seas including some of the deep dark secrets of maritime medicine, as well as Dr X.