Despite preventative measures aimed at reducing the risks of illness, injury, incapacitation and death in seafarers, incidents requiring medical care do occur at sea. The aim of all provisions for medical care of seafarers, both at sea and on shore, is to mitigate the harm from such incidents. This involves both immediate actions to relieve pain and anxiety and to resuscitate and stabilise the patient and longer-term requirements for evacuation or continuing care on board as well as for shore-based care, rehabilitation, and speedy return to work whenever possible.
The challenge addressed by all the contributors to this volume is how best to achieve these aims using the forms of intervention that each describes. For each element of the maritime medical care system risk management is a key component. Current approaches have slowly evolved over the years, often in response to improved treatments for specific conditions or because of improved communications, for instance in telemedical support or helicopter evacuation.
Many elements are legal obligations derived from international conventions. As such they are only infrequently modified to take account of developments in care and, when they are, joined up thinking to link the various elements of care together is often absent. This is because each element forms a part of a different convention and these are the responsibility of three different agencies: ILO, IMO and WHO. Improved international consistency in arrangements for care has become ever more important with global crewing, where the seafarer may be trained in medical care in one country, be on a ship with a medical chest that meets the specifications of another and accessing telemedical advice from yet a third one.
Risk and mitigation
The basis for a risk-based approach is valid data on the frequency and severity of incidents requiring medical care coupled with information on the effectiveness of each form of intervention in reducing the immediate risks and in securing a full recovery in the longer term. This information is limited for both medical incidents in seafarers and for the effectiveness of most forms of medical intervention in a maritime setting (see chapters on knowledge base). Important topics on which better data is required range from rare but life- threatening incidents to common minor illnesses and injuries that can limit a seafarer’s ability to work, enjoy any leisure time and sleep.
A finer grained aspect of a risk-based approach is to examine the benefits of enhancing each element of medical care and better co-ordinating one element with another. However, the costs of each enhancement also need to be considered, for instance should costly medications for situations that rarely occur be carried, given that in most instances they will be discarded as time-expired without being used? Similarly, how many procedures should officers be taught when undertaking medical care courses, and how long do courses need to be to create an adequate level of competence, however defined. These can be hard decisions to take and may well also interact with other elements of prevention and care. Thus, the medical conditions that are accepted as suitable for service at sea may determine which medications are required to deal with any complications. Likewise, real time video access to telemedical advice may mean that fewer procedures need to be taught as the responsible person on board can be shown exactly what to do when an intervention is needed. It may also bring operational benefits by reducing the frequency of evacuations and diversions to obtain onshore medical care.
Because of the fear surrounding a serious illness or injury at sea it is important to have clear systems in place for managing a situation that may only occur every year or two on the average cargo ship. Such clarity provides essential reassurance and all concerned need to have confidence in them. This means that debates about the balance between benefits and costs of enhanced care arrangements need to be informed by the best available sources of data and take place at national or international level. Such decisions need to be taken in a way that grows consensus between seafarer representatives, ship owners, insurers, health professionals and maritime authorities. A good example being the scope of telemedical services; do they focus just on the management of major medical emergencies, or do they provide primary care advice either to responsible officers on board or direct to seafarers?
The adoption of risk-based approach in several parts of the maritime health care system could be improved by better data collection, with analysis and publication of findings:
Studies of ships’ medical logbooks to determine frequency and consequences of common conditions on board.
Investigation of medication and medical equipment use, derived from requirements to replenish ship medicine chests.
Calls to telemedical services, are the one source that is widely available. However, follow up of cases to evaluate the outcomes of advice given would help improve care.
Referrals of seafarers for medical and dental care in port
Repatriations and the frequency of return to work as a seafarer
Deaths from illness or injury on board, or immediately after referral for onshore care, with investigation of the scope for survival.
Perceived adequacy of training, medical chest, medical guides and telemedical advice by those who have just responded to an incident.
D.2 Impact of a medical incident on board
The outcome of a medical incident, in terms of costs and effects or impact, is very difficult to predict. The impact can vary greatly and does not always show a proportional relationship between the severity of the incident and the sum of the effects. It is always important to consider the following, as there is usually some impact in all of these:
Impact on the seafarer
Physical impact on the seafarer
Psychological impact on the seafarer
Financial impact on the seafarer
Impact on the colleagues
Physical impact on the colleagues
Psychological impact on the colleagues
Financial impact on the colleagues
Impact on the ship’s operations
Practical impact on ship operations
Productivity impact on ship operation
Impact on the families of sick or injured seafarers
Physical impact on the families
Psychological impact on the families
Financial impact on the families
Impact on the company
Physical impact on the company
Psychological impact on the company
Financial impact on company
There is no script to follow and all impacts can vary in different scenarios. The scenarios and best practices are to be considered as a framework and not as a bible.
Impact on the seafarer
Physical impact on the seafarer
The physical impact on the seafarer ranges from minor to very painful and even permanent impairment.
The treatment of the physical symptoms of the seafarer obviously take priority and starts with assigning a medical officer on board who will remain available to the injured seafarer on a day to day basis. The role of the medical officer is described below. Other publications such as the International Medical Guide for Ships, or a national equivalent describe the purely physical treatment of a sick or injured seafarer, and this is beyond the scope of this book.
Major injuries or severe acute illness will be reported immediately and treatment instigated at the time of the incident. However, minor injuries and illness, which can lead to more severe injuries or other symptoms later, are not always reported and addressed immediately. Therefore, it is important that staff and coworkers remain vigilant as to the health of their colleagues.
Psychological impact on the seafarer
The injured / ill seafarer will have multiple feelings that all need to be addressed to enhance the healing process. These may include one or more of the following:
psychological discomfort due to uncertainty of the
lack of physical presence of professional help
anger towards himself about the injury or illness – self blaming
anger towards the ship / company / colleagues
embarrassment / loss of professional face towards co workers
humiliation by co workers
fear to sign off or not to be re-employed, hence a financial impact
fear of not signing off in time to get professional help
fear of financial consequences once at home
fear for the future
the feeling of being disconnected from the incident, colleagues and the surroundings
Seafarers are not trained psychologists and cannot offer professional help. However, it is recommended that the sick or injured seafarer be assigned a confidant who will visit them throughout the day, on a frequent but irregular basis until professional help ashore is available and even beyond. The role of a confidant is described below.
The feelings and emotional state of the seafarer will change over time and initial feelings can even conflict with feelings experienced in a later phase. The seafarer may initially feel supported but subsequently feel resentment towards the colleagues / staff / company.
The use of social media and fast communication is a blessing in terms of support, but can also cause additional pressure. It can have a huge emotional impact and the parties involved should consider this.
Although seafarers differ in their reaction to illness or injury, best practice would usually be to keep the seafarer on board to complete his Contract of Employment, provided of course that he is fit for duty (even after several days off duty) and does not pose a threat to the safety or health of the vessel or other crew. This will ensure a normal closure of the contract and the seafarer will often not experience further negative feelings.
Financial impact on the seafarer
The financial impact on the seafarer is mitigated by the fact that the company will bear the costs of the medical treatment, as stated in the Maritime Labour Convention 2006. However, there may still be a financial impact on the seafarer because, for example,
less to no overtime during the off-duty period
less income while on sick leave at home
less job / promotion opportunities after illness or injury
loss of job
Impact on colleagues on board
Physical impact on colleagues
The physical impact on colleagues is limited to the potential higher workload required to cover the sick or injured seafarer’s tasks, and, where necessary provide care for the ill or injured seafarer. This can add to fatigue and difficulties in physically performing some of the tasks required.
Very rarely, cases of serious injury or death of a colleague have caused psychosomatic disorders in colleagues and have led to the resignation of these seafarers.
Psychological impact on the colleagues
The psychological impact on colleagues can be significant and vigilance among seafarers to observe and report any symptoms is important.
Colleagues can have a range of feelings:
Initially, most colleagues will show compassion and emotional support to the sick or injured seafarer. However, it is not unusual that negative thoughts towards the ill / sick person develop over time due to the higher workload or assumptions that the affected crewmember is exaggerating for personal gain.
If the colleague was directly involved in the accident leading to the injury then he may also develop feelings of guilt and later, if the accident is being investigated, colleagues might develop a fear of involvement and a fear of blame.
Financial impact on the colleagues
Generally, there are no direct negative financial impacts on the colleagues of a sick or injured seafarer. Conversely, there may be positive impacts due to extra overtime and potential promotion.
Rarely there may be a long-term negative impact on promotion or employment if colleagues are found to be involved in the root cause of an accident.
Impact on the ship’s operation
Practical impact on ship operation
The practical impact on operations is due to the additional workload on the medical officer in treating the sick or injured seafarer and the additional workload on colleagues in covering tasks - watches may have to be reshuffled, organization changed, etc.
However, the ship is an entity that is used to coping with changes in the processes on board and it is very resilient in dealing with any necessary adjustments in work pattern. Hence, the impact will initially be manageable. However, the impact may be significant if the situation continues for an extended period. The company must avoid this and address the practical issues with additional or replacement staff. This is particularly relevant in the rare situation where the sick or injured seafarer is the only person on board with a specific skill set or qualifications. In this situation, urgent arrangements need to be made to replace him at the next port if he is unable to resume all of his workload.
Impact on productivity
The impact on productivity will depend on the severity of illness or injury to the seafarer. If the sick or injured seafarer is still able to perform light work, his productivity will be reduced but he will be able to carry out some tasks. This is also likely to be beneficial for the healing process of the seafarer hence to be fully supported by the ship and shore management. Alternatively, if the seafarer is unfit for duty then his colleagues will cover all of his tasks in addition to their own. Their workload will increase but at least in the short term, this does not necessarily incur a loss in productivity for the ship. As above, the impact may be significant if the situation continues for an extended period and this should be avoided.
Impact on the families of sick or injured seafarers
Physical impact on the families
Physical impact on the seafarer’s family will initially be rare to nonexistent but can increase if the sick or injured seafarer returns home and requires additional support and care.
Psychological impact on the families
In all cases, the psychological impact on the family is high. In the past families at home had little or delayed information from the ship. However, improved communications and the widespread use of social media mean that more and quicker information is often available to the families of seafarers.
The consequences are twofold:
increased support from home
increased concern from home
The additional emotional support has a positive influence on the healing process but families can equally create an additional stress on the seafarer. Family members are often over-worried and do not have insight into the ship’s organization or ongoing procedures. It is important that the ship’s staff is aware of the seafarer’s relationship with family members and that everybody is clear on what information should be released and to whom. In case of serious illness or injuries, the company must inform the family and keep them updated. They may also need to offer some sort of support or counselling.
Financial impact on families
The financial impact on the seafarer’s family can vary from nothing to a significant drop in income over an extended period. This may be due to less income because of less overtime (if applicable), earlier signing off and a potentially lower salary whilst on sick leave or in case of partial or permanent disablement.
Impact on the company and shore based staff
Physical impact on the company
The physical impact on the ship owner mainly consists of an increase in human resources on board as well as ashore.
Psychological impact on the company
Although the incidents happen at a distance, the owner may still feel guilt or anger. Shore-based managers and other operational staff may also experience such feelings and the company needs to offer appropriate support. Equally, the inability to take any positive action can be frustrating and stressful to shore based staff.
Financial impact on the company
The financial impact on the company can range from nothing to several million dollars depending on the severity of the illness or injury, the treatment required and any subsequent impact on operations. The effect of a single incident can vary from the single use of first aid equipment that was already part of the budget to the deviation of the vessel with commercial impact and human resources issues, to huge compensation to the victim.
In most of the cases, the costs are underestimated as any loss in productivity or breach of contract to the customer is not recorded or not in accounted for in full and is rarely directly attributed to the illness or injury.
At the very least, incidents result in a reduction in productivity but can extend to salary costs for human resources ashore (agent, operator assistance), salary costs for replacement crew, medical bills, travel costs, claim compensation, retraining of crew, incident investigation costs, negative commercial impact, etc. Some of these costs may be covered by the insurers and more information about the role of the P&I company is available in Chapter xxx
Accidents, including medical treatment injuries, lost time injuries etc. are also reflected in the company’s safety statistics and can have a negatively impact on the company image and future commercial commitments.
Best practice to mitigate the impact of a medical incident
Create a culture of trust
It is important that long before the incident happens an atmosphere of trust and no blame is created onboard the vessel. This is a lengthy process that starts at a corporate level ashore and should be demonstrated on a daily basis through
the availability of medicines and equipment onboard
the availability of professional assistance ashore 24/7
no discussion about a seafarer’s request for a doctor’s visit
accessibility of the officer responsible for medical care on board
confidentiality in medical matters onboard and in shore side offices
repatriation when required and the swift replacement of crew
Create a culture of abundancy
A seafarer should know and feel that there are no material restrictions when it comes to his health, firstly through an abundancy in medical supplies and the availability of ship and shore resources and secondly that there is an open atmosphere to express even his minor issues.
Although the abundancy of something is usually correlated to abuse, it is important that the crewmembers work and live in an atmosphere and know that any physical or psychological issue can be raised and will be attended to. In fact, often when the crew know and trust that there is an unlimited access of what is needed, the consumption/use is self-regulating and they will no longer feel the need for exaggeration or abuse as they feel comfortable.
Ship owners, operators, Captains and other interested parties all play an important role in creating the feeling of abundancy through
offering an environment of remote assistance
having a network of medical care providers available
supplying medical equipment and medicines
the availability of human resources to send replacement crewmembers, etc.
It should be clearly visible to the crew that there are no restrictions on the availability of medicines or doctors’ visits. This will positively influence any seafarer to bring issues forward.
However, a strict policy needs to be implemented to avoid abuse and every case should be assessed in a firm but fair manner. Once seafarers see and feel that their needs are attended to on board in a timely and correct manner and without blame, they will come forward with injuries and illnesses.
This is an important point of attention both shore side and on board ship.
Create a no blame culture
Due to the more stringent reporting procedures in Health Safety Environmental Quality (HSEQ) methodology and the consequent mandatory root cause analyses, seafarers are less forthcoming to report minor physical or emotional issues and illnesses. If illness or injury is the result of an accident or the working environment, it is important that all parties learn from the incident and appropriate risk management steps are implemented to prevent future similar incidents or to mitigate their effects. It is also paramount that the further reporting of an incident by the seafarer and Master to the operator or other party does not adversely affect the seafarer. This requires discipline from the company to ensure that the seafarer’s details are not disclosed and that the investigation is conducted in such a manner that the seafarer or colleagues do not feel under such scrutiny that they would withhold from future reporting. The ‘blame culture’ must be avoided.
Captain (and all ships personnel) to remain vigilant
The Captain and all of the officers and crew should remain vigilant and invest time to get to know one another through small talk and casual interactions, while mandatory inspections and meetings will remain at a corporate level. It is encouraged for the Captain to pass by the different departments at various times of the day or week. Casual chats about the crew’s interests might reveal small injuries, hidden illnesses or emotional problems. Equally, it may be that fellow seafarers reveal problems in colleagues that could develop into a serious injury or illness, with the potential to harm that seafarer, other crewmembers or ship operations.
Assignment of medical officer
It is important and mandatory to assign a dedicated officer responsible for medical care who is accessible to all crew. All crew signing on to the vessel should be made aware of the rank of the officer responsible for medical care during the initial familiarization procedures and the name should be displayed at a prominent place e.g. the door of the hospital or dispensary.
The officer responsible for medical care is trained to provide the on board treatment of injuries and illnesses, he reports to the Captain and will be assigned for continuous and formal medical observation of the patient.
Assignment of confidant
The ship is a closed entity with only a limited number of crew to ensure ongoing ship operations. Human resources can be limited. However, it is of the utmost importance that the injured or ill seafarer is not left alone but supported. Therefore, it is recommended that a confidant be assigned.
The choice of a confidant needs to be carefully considered and balanced. It should not be based on his or her medical skills, experience, rank, nationality, religion or race. The confidant can be one person or multiple persons regularly visiting the injured or ill seafarer. The confidant does not need to have a formal task but can be used as a way of talking to the seafarer and getting additional information on their physical and emotional state through small talk, bringing some food, sharing a movie, etc.
A few minutes of real interest can seriously contribute to the healing process.
Care and support culture
The treatment of the injury or illness is obviously paramount. Secondary but still very important is showing real care about the general health and welfare of the seafarer. Assigning a confidant and having other crewmembers visiting and chatting with the ill or injured person are very important. Social media contact can also contribute - not only with people ashore but also with others on board, particularly if the seafarer is isolated for any reason.
It is equally beneficial to integrate the injured or ill person into the ship’s life again, as far as is reasonably possible. Too often, seafarers declared ‘unfit for duty’ are put in their cabin until they are healed and declared fit for duty again or until they are disembarked, with others assuming that ‘watching movies’ is the best way to get better. Physical rest is important but social interaction is equally important and once a seafarer is deemed fit to return to work, a phased approach may be appropriate to encourage their reintegration to the crew. This must be done in compliance with any medical restrictions in place. Rendered support and a support culture reduce the psychological impact whereas a blame culture increases it.
Death on board
Although no specific difference has been made between accidents and illnesses throughout the chapter, it is important to highlight one specific situation, death on board.
Death on board has a more significant impact on the colleagues of the seafarer than any other illness or injury. The impact will depend whether the dead person was a member of the crew or not and whether he died from a professional accident or from a natural cause.
If the dead person was not a member of the crew then the influence and emotional commitment will be lower but still exist. If the dead person was a member of the ship’s crew then the atmosphere is depressed and it is beneficial to keep the communication lines open between the crew and to seek professional and potentially religious / spiritual help.
Whilst the body remains on board e.g. while transiting to a safe haven for disembarkation, the atmosphere will be very low, as the mourning process is unlikely to start as long as the body is physically on board. This is likely to improve once the dead body has been disembarked. More information regarding the practical aspects of dealing with death on board are available in Ch. 9.6
The physical, psychological, financial and commercial impact of a medical incident on board is determined (to a certain extent) long before the actual occurrence, through corporate decisions ashore and on board and through the general company and shipboard culture.
There is no common impact or approach to an incident on board and every event is unique with a different impact and requiring a different approach to the issues that arise.
The best practices described here can serve as a tool to mitigate the different impacts of an incident.
 International Medical Guide for Ships. ISBN-13: 978-9241547208 ISBN-10: 9241547200
D.4 Medicine chest
All of the medicines, medical supplies and equipment, that ships without a doctor on board are required to carry whilst at sea is commonly referred to as the ‘medicine chest’. This is because historically, the medicines carried on board during the age of sail were kept inside wooden chests.
While international requirements to carry a medicine chest are in place, no single formal list that specifies its contents exists, except for ships carrying dangerous goods. In 1944, the International Maritime Organization (IMO) mandated this in their Medical First Aid Guide for Use in Accidents Involving Dangerous Goods (MFAG) publication .
This lack of standardization was first addressed by the World Health Organization (WHO) in 1967 with the publication of the first edition of the International Medical Guide for Ships (IMGS) which included a list of the minimum recommended medicines, medical supplies and equipment that must be present on board . However, this list was only a recommendation and has remained as such in the subsequent 1988  and 2007  editions of the IMGS.
The required contents of medicine chests relate to the treatment needs of seafarers on board in emergencies. They do not include medicines needed for the long term treatment of disease, nor do they necessarily meet the needs of passenger vessels, in particular for the treatment of children
International Statutory requirements
The following lists, in chronological order, the international standards, requirements, regulations and recommendations that apply to the ship’s medicine chest.
1947: The International Labour organization (ILO) in its Accommodation of Crews Convention  states in Part III, Article 14.7 that ‘An approved medicine chest with readily understandable instructions shall be carried in every ship which does not carry a doctor’.
1958: The ILO in its Ships' Medicine Chests Recommendation  contains an annex which details the contents of the medicine chest as well as requiring the presence of a guide to explain how the contents of the chest are to be used.
1966: The ILO in its Accommodation of Crews (Fishermen) Convention  states on Article 13 that ‘An approved medicine chest with readily understandable instructions shall be carried in every vessel which does not carry a doctor
1987: The ILO in its Health Protection and Medical Care (Seafarers) Convention  states the requirement for the carriage of a medicine chest, the labelling specifications of its contents, the requirement for inspection at regular intervals and the obligation of specific antidotes to be carried on board when dangerous cargo is carried.
1994: The IMO published its Medical First Aid Guide for Use in Accidents Involving Dangerous Goods (MFAG)  with subsequent revisions of the guide being reproduced in the Supplement of the International Maritime Dangerous Goods (IMDG) code. This guide is meant as a chemicals supplement to the IMGS published by the WHO.
2006: The ILO in its Maritime Labour Convention (MLC 2006)  states in standard A4.1 the requirement for the carriage of a medicine chest, the requirement for inspection at regular intervals, the presence of specific antidotes depending on the cargo carries as well as the determination of the medicine chest’s contents by taking into account the recommendations of the IMGS published by the WHO.
2007: The WHO published the 3rd edition of the IMGS  that was followed up by the publications of a Quantification Addendum in 2010  which listed the medicines, medical supplies and equipment as well the quantities that are recommended to be on board ships without a doctor on board and calculated for voyages of one month.
2007: The ILO in its Work in Fishing Convention  and Work in Fishing Recommendation  established minimum standards for the medical care of fishers at sea.
In summary, ships must have medicines, medical supplies and equipment on board which must be:
Adequate in quantity that depends on, the distance travelled from the closest shore, the duration of the voyage, the number of crewmembers and the nature of the cargo being transported.
Kept in good condition, clearly labelled in a language understood by the crew (usually English) and readily available for use.
Be periodically inspected in intervals not exceeding 12 months by a competent person.
If the ship meets all of the above requirements, the supplying pharmacy issues a Medicine Chest Certificate (MCC) of compliance. This is signed by a maritime pharmacist who is also responsible for the inspection of the ship’s medicine chest.
1. Medical First Aid Guide for Use in Accidents Involving Dangerous Goods. London: International Maritime Organization; 1994.
2. International Medical Guide for Ships 1st ed. Geneva: World Health Organization; 1967.
3.International Medical Guide for Ships. 2nd ed. Geneva: World Health Organization; 1988.
4. International Medical Guide for Ships. 3rd ed. Geneva: World Health Organization; 2007.
12. Quantification Addendum: International Medical Guide for Ships 3rd Edition. Geneva: World Health Organization; 2010.
Regional, National and Industry requirements
In Council Directive 92/29 , The European Union (EU), specifies the contents of the medicine chest in terms of the classes of medication that need to be included but has left the individual member states to specify the generic substances and quantities of the medicines, medical supplies and equipment that must be carried on board the vessels of each flag state.
Other countries outside the EU that have regulated the contents of their medicine chests with country-specific legislations are the United Kingdom,  Australia and Norway with the latter also having specific requirements for offshore fixed installations & standby vessels.
Countries that have not passed specific legislation, usually comply with the recommendations set out in the IMGS 3rd edition  and the Quantification Addendum  as published by the WHO. Examples of these countries are Panama, the Marshall Islands and Liberia.
However, apart from regional and national requirements, industry requirements or recommendations also apply, as for example in the following sectors:
Cruise line sector, where the American College of Emergency Physicians (ACEP) Cruise Ship Medicine Section (CSMS) has established industry specific guidelines in cooperation with the Cruise Lines International Association (CLIA) . Further information on cruise ship medicine is available in Chapter A.4.10
Oil & Gas sector with specific additional requirements for offshore fixed installations & standby vessels. Some of the countries that have adopted these are Denmark, the Netherlands, Norway and the United Kingdom (6).
1. European Union. Council Directive 92/29 On the Minimum Safety and Health Requirements for Improved Medical Treatment On Board Vessels. European Economic Community; 1992.
3. International Medical Guide for Ships. 3rd ed. Geneva: World Health Organization; 2007.
4-. Quantification Addendum: International Medical Guide for Ships 3rd Edition. Geneva: World Health Organization; 2010.
Medication for known health conditions
It is the responsibility of seafarers and all those travelling on board to ensure that they take sufficient quantities of their own medication to last for the duration of their trip. It is also important that they bring a copy of their prescription as supporting documentation for local authorities and in case they need to obtain additional supplies of medication for any reasons.
It is almost impossible to include medications for all eventualities within the medicine chest whilst ensuring the chest is of a reasonable physical size and not over complicated to be managed on board by the officer responsible for medical care. In addition, international seafarers have many cultural differences and this includes their expectation as to what should be available on board in case of the need for treatment. Examples are Chinese traditional medicines and various folk remedies. Oher challenges in the management of the medicine chest include but are not limited to:
Contraband medications brought aboard by crew.
The problems with different proprietary names, packaging and tablet sizes, and with poor quality medication or fraudulent products in some countries. Hence limitations of purchase through local agents or by using web-based pharmacy services.
Managing expiry dates and the safe disposal of expired medicines, especially controlled drugs.
Variable restrictions on some controlled and related drugs in some countries. Dangers for individuals, ship masters and ships from non-compliance with local rules.
Role of the maritime pharmacy
This includes all activities involved in supplying ships with medicines, medical supplies and equipment in order for them to comply with their flag state medicine chest requirements.
Usually, a maritime pharmacy is located in close proximity to a harbour or a major shipping port and supplies vessels with medicines, medical supplies and equipment either by:
Directly selling them to the crews of the vessels that visit the actual premises.
Dispatching them to the vessels that are docked in the port close to where the pharmacy is located.
Dispatching them via air, land or sea freight to vessels calling in ports around the world.
The last method of dispatch is the most challenging as the logistics involved must be very precise since the ‘vessel-customer’ is constantly on the move and many factors must be perfectly synchronized in order for the supplies to arrive on time. Other difficulties faced are the supply of controlled (narcotic), refrigerated or hazardous items which have different supply and transportation restrictions depending on the country of destination.
Further information on the role of the maritime pharmacist is available in section A.6.10.
D.3 Training of officers in medical care
Text from 2nd edition by SANDRA ROBERTS, revised and updated by Nebojša Nikolić
International Maritime Organisation courses
The International Convention on Standards of Training, Certification and Watchkeeping for Seafarers (STCW) Code Part A, Chapter VI sets out the legal basis for the training of nautical officers in first aid and medical care on board. It provides the mandatory minimum requirements/standards of competences necessary for the officer responsible for medical care on board. They are specified as ‘competences, knowledge, understanding and proficiency and the methods for demonstrating achieved competences’ and ‘criteria for their evaluation’ are outlined. After the adoption of STCW in 1978, the IMO designed a series of model courses detailing training requirements in accordance with the objectives set out in the Code.
Each model course includes a
course framework detailing the scope, objective, entry standards, and other information about the course
course outline or timetable
detailed teaching syllabus including the learning objectives and competences that should be achieved
guidance notes for the instructor.
Three model courses related to training in first aid/medical help on board are fully compliant with the relevant sections of the Code, including the Manila amendments 2010. However, the course contents have not been revised for many years and do not necessarily reflect current good practice in casualty management. The model courses relating to medical care are:
ELEMENTARY FIRST AID
(Model course 1.13)
This model course provides training in elementary first aid at the support level and is based on the provisions of table A-VI/1-3 of the STCW Code. It includes medical emergency and basic training for all seafarers who are to serve aboard sea-going merchant vessels and consists of up to 15 hours of training.
MEDICAL FIRST AID
(Model course 1.14)
This model course provides more advanced first aid training aimed at those seafarers designated to provide first aid on board. It is based on the provisions of table A-VI/4-1 of the STCW Code. The course consists of approximately 20 hours of teaching and will give sufficient knowledge and skills for effective action in the case of accident or illness, until the person who is in charge of medical care arrives.
(Model course 1.15)
This model course provides the most advanced level of training and is required for those designated to take charge of medical care on board. This should enable a seafarer to have enough knowledge of illness and injury and of the medical stores and equipment on board, to be able to
diagnose medical problems
provide medical care to the sick and injured while they remain on board
communicate effectively with telemedical assistance services ashore
participate in coordinated schemes for medical assistance to ships.
It is based on the provisions of table A-VI/4-2 of the STCW Code and provides advanced medical care training for the person in charge of medical care on board a ship. This is usually the Master, the Chief Officer or the second mate. In order to achieve this competency, seafarers must have completed all 3 courses and have to participate in refresher medical training at least every 5 years. This course consists of approximately 40 hours of training. Other ranks and departments on board may have to complete this training once or more depending on the flag State requirements.
In addition to being required for specific roles on board, different levels of training are required to achieve Certificates of Competency. There are also different requirements for deck and engineering officers. Further information is available in Ch. 4.3.
The duration and content of the training may be extremely variable, influenced by the requirements of the maritime administrations, depth and quality of training provision, and the seafarer’s level of engagement with the training.
Theoretical knowledge is limited, with poor retention. The efficacy of training is dependent on the level and quality of practical instruction and exercises during the course and is further influenced by the medical equipment available for use on board.
Different national practices
First aid training is similar all over the world and follows the requirements, guidelines and standards of major organisations such as the European Resuscitation Council, the International Red Cross, or the American Heart Association.
In contrast, the medical care training given to nautical officers varies hugely from country to country. In the majority of places, training is given in the format of intensive courses; in some, the training hours, are included in other training programmes in nautical schools. The total amount of medical lessons and practical exercises varies a lot from country to country, with the majority only including the minimum requirements as stated in the international regulations and presented in the IMO Model Courses.
Many experts have questioned if the medical care course, when limited to 40 hours as suggested, is sufficient to fully meet the requirements of STCW. There are institutions that have found it necessary to extend the duration of that course to 70, and even 100 hours, trying to improve the skills of the trainees. Some nations have produced not only their own medical guides but also designed their own training programs that are surpassing the requirements of the Code, using IMO Model Courses only as the development tool they were intended to be. For example, in Finland, training courses are of 19, 20 and 40 hours duration,theory and practice, depending on the position of the seafarer. The Master, who is responsible for the medical care of his crew, undertakes a 5 day training course in medical matters and refresher training every year. In Spain, from the “Instituto Social de la Marina” there are three courses, FORMAC I, II and III (20, 30 and 40 hours respectively) and a refresher course every five years as recommended in the STCW Convention. Refresher courses on line are also used. In Croatia, medical training of future officers is provided in maritime academies as one year semester subjects with a total length of 52 hours, and also in the form of 3 courses of 12, 21 and 40 hours, in various educational facilities approved by the Ministry of Transport. A 5 year refresher course is given according the international regulations. In the USA, a course of Elementary first Aid is 7 hours of teaching, Medical First Aid, 35 hours and the Shipboard Medical Person In Charge Course is 77 hours of training.
One of the major factors in the successful treatment of a sick or injured person on board ship
is the extent of medical knowledge of the ship’s officer in charge of medical care.
Each teaching method has its own advantages and disadvantages, with no single best way of teaching and learning. To be effective, learning must involve constructive mental activity and should not exceed the capacity of novices. Effective curriculum development requires moving away from didactic teaching methods towards a practical learning pathway based on experience, placing emphasis on knowing how rather than knowing all.
Current courses demonstrate that it is possible to adequately train designated providers to a certain level. The main obstacle is that officers must sometimes perform procedures outside of their usual scope of practice. They must use complex telemedical technologies to communicate with medical practitioners on shore to perform an unfamiliar task whilst also continuing to monitor the patient and communicate the patient’s status. All of these factors lead to a potential increase in errors. One possible solution is to use simulation in the medical training of marine medical practitioners. Contextualised simulation practice minimises the demands on the working memory by facilitating the development of automatic schemas in the long-term memory. This has been shown to improve performance in real-life settings. Students set great store of knowledge/competences by simulation-based learning on a mannequin in contextual settings, and the opportunity to apply theoretical knowledge in a safe and realistic setting. However, the most important factor in generating learning using simulators is to construct scenarios that provide an opportunity to generate and maintain needed competences in emergencies for example, a health incident on board, evacuation techniques and the transport of casualties.
Therefore, in many maritime schools with an extended course, simulation becomes an important part of the training of medical personnel on board ships.
Revision if the IMO Model Courses
Rapid scientific advances and the subsequent changes in recommended medical care require frequent adaptation in the training and education of professional as well as non-professional first aiders. The curriculum for medical training courses should reflect any change in medical guidelines and therefore model courses are revised at regular intervals. The Revised guidelines for the development, review and validation of model courses (MSC-MEPC.2/Circ.15) set rules for such a revision and these apply to IMO model courses 1.13, 1.14 and 1.15.
Until recently, the main obstacle in creating a universally acceptable training program was the differences in training programs and methods of education between different countries. Outcome oriented learning is a system where different parties with different teaching traditions agree not on the training programs, but on the learning outcomes. Therefore, all students leave the training course with the same competences regardless of the program they underwent. Several methods can be used to define the learning outcomes. In the MEDINE 2 project on medical education in Europe, the concept of Miller’s pyramid was used to define the learning outcomes for the first three years of medical training. Miller’s Pyramid has four levels: Knows, Knows how, Shows how and Does. In recent years, this framework has found a third dimension to incorporate the domains of Bloom’s taxonomy. It is the universally accepted approach used in the teaching syllabus composition and it classifies the teaching goals into six levels (Remember, Understand, Apply, Analyse, Evaluate and Create) from the perspective of cognition.
As the Model courses are essentially medical training courses that result in clinical competences, it may be possible to use this in the process of defining learning outcomes / competences in those Model courses too. If the learning outcomes are defined, each country will be able to design its own training programs or textbooks to achieve the same learning outcomes as the IMO model courses.
The medical facility (or sickbay) on board a ship may have many different functions. A few decades ago the focus was on accommodating the ill or injured but today there is more focus on the sickbay as a treatment facility. The most obvious function of a sickbay is as a place to examine and treat a sick or injured crew member. This may require the ‘patient’ to be lying down or, more commonly, the patient will walk into the sick bay and require somewhere to sit whilst the consultation takes place. The sick bay may also function as a store for medical equipment and as an isolation room for sick seafarers with infectious diseases e.g. influenza, norovirus or chickenpox. As a worst case scenario and an incident with multiple casualties the sick bay may need to focus as a triage area or an area to receive others from the sea or less well equipped vessels.
The function and requirements of a sickbay will vary depending on the size and type of vessel. On a chemical tanker, emergency showers need to be available to decontaminate personnel exposed to chemicals, and on rescue vessels a shower can be used to provide cooling to burn injuries, or to warm people rescued from the sea. Vessels used to support diving operations may have a permanent mobile pressure chamber. Purpose built ships such as cruise vessels, naval ships or mercy ships, may even have larger medical facilities, all the way up to a full-scale hospital on board.
This chapter concentrates on the ships with the requirement for a traditional sickbay with reference to ships of a different size or purpose. There is very little detailed and specific regulation in this area and the recommendations given are based on personal experience from using and designing both sickbays and larger medical facilities on board, feedback and experience from telemedical maritime assistance services, and perception of current best practice within this field.
Location of the medical facility
In the process of designing and building a ship, there is always a competition for space for different purposes. Space inside a ship costs money for ship-owners ordering a new vessel and they need to maximise the space available for the main purpose of the ship, for example, cargo, containers, fishing, lane meters (roll-on-roll-off), oil or chemical tanks, passengers or other “money making” functions. Space necessary for the day to day running of the ship should be kept to a minimum.
A skilled ship designer will look at the functions of the different areas, and integrate them so that all spaces, including the sickbay and facilities for medical purposes are placed to best achieve their functions. Less skilled designers may fail to recognize the functions of areas such as the sickbay, and therefore from time to time we see that the sickbay on some ships has been placed far away from the bridge on the lowest decks with difficult access, or designed as just another sleeping quarter rather than a sickbay. Sometimes sickbays are even without proper communications. All mistakes that are easily avoidable without any significant additional cost, if the right considerations are made early in the design and building process. Factors to include when deciding on the location of the medical facility include, but are not limited to, the following.
Access to the medical facility.
Access to the sickbay from other areas of the ship is important. The day the sickbay is needed most is when a shipmate must be moved on a stretcher from some distant place on the ship to the sickbay in a hurry. Therefore, if there is a choice on a ship with a large superstructure, it may make sense to place the sickbay closer to amidships. However many ships have superstructures and accommodation quarters in the front or aft of the ship, and the sickbay should then be placed there. In this situation, consideration should be given as to whether there is a need for one or more first aid stations elsewhere on the ship. In large ships with many decks, access is usually easier if the sickbay is placed on one of the middle decks rather that at the very bottom or the very top.
Passages and ladders should be taken into consideration. Moving a stretcher around narrow corners, up steep or narrow ladders or through hatches takes time and may even be harmful to the patient. If there are main passages or stairways on board, ideally they should be used to access the sickbay. Some ships also have elevators, and the sickbay should then be placed close to the elevator. It is also an advantage if passages leading to the sickbay have few doorsteps and other obstacles. This should also be considered for the passages between the sickbay and the main extraction points of the ship.
Proximity of the ship’s extraction points
Transfer of an ill or injured person off or onto the ship will occur at one of a small number of places. If someone falls over board, they will enter the ship again where the man over board (MOB) boat is located. Sometimes a sick seafarer can also transfer to shore or other ships able to assist, using the MOB or other small boats on board the larger ship. Large ships may have helicopter platforms for use if the patient is to be taken off the ship by helicopter, although most vessels will have to do a lift from the deck. Access to the MOB deck, helicopter pad or to deck spaces from where winching can be done without interfering with masts, wiring etc. needs to be considered. Preferably, the sickbay should be on the same deck and close to all of these points with the passages between the sickbay and the extraction points wide enough to carry stretchers, with few if any corners and free of doorsteps and obstacles. If unavoidable, stairways between the sickbay and extraction points should also be designed to easily move a stretcher patient.
Proximity to the bridge and communications
The Captain is the person on the ship who is responsible for the medical care of a sick or injured person on board. He may delegate this role to another member of the crew, usually the first officer or a medic. For many cases, there will be the need to contact a Radio medical or telemedical maritime assistance service (TMAS) and frequently the bridge will be the natural place to communicate from when shore assistance is contacted. In some cases it is possible to make direct contact from the sickbay to shore based services.
If communications from the sickbay to shore without going through the bridge are not possible and communication from the sickbay to the bridge is insufficient, people may find themselves running between the patient and the bridge in order to discuss the situation with the TMAS. This may need to occur once or on many occasions depending upon the severity of the situation. For these reasons, the sickbay should be close to the bridge and have necessary communication capability for both internal and external communication. Good communications can to a certain degree, reduce the need for immediate proximity with the bridge.
At sea things go wrong at the worst of times. People are seldom injured on shiny days with calm seas and low activity. They are injured or become acutely unwell when the weather is bad and the workload is high. There is therefore a good chance that the sickbay will be most relevant in bad weather and at busy times. In bad weather a ship pitches and rolls, and the movement on board the ship may differ quite significantly between different parts of the vessel. Usually the movements are smallest midships and in the lower parts of the vessel.
There are two reason for movements in the sickbay to be minimized, one is the wellbeing of the patient, and another is the ability to perform more advanced medical procedures. This is easier when the patient and the medical provider aren’t being tossed around the room. However, this is more relevant for bigger ships with bigger medical facilities such as cruise ships, larger coastguard and rescue ships, where it is more likely that more advanced medical procedures will be performed. This factor may also be in conflict with the other considerations as to where to locate the medical facility, and should only be prioritized above other factors when designing larger medical facilities intended for providing advanced medical care by healthcare professionals.
Layout and function of the medical facility
To have a functional medical facility requires more than just locating it in the best position on the ship. The interior must also be designed to provide a comfortable and reasonably functional area for treatment. This is challenged by the fact that there is no hospital room or doctors’ office that is optimal for the assessment and treatment of all patients.
An important consideration when designing the sickbay is possible integration with other areas that can be used for medical purposes when necessary. Rules demand that ships of a certain size have a sickbay, but do not define in detail what functions the sickbay should cover or how it should be designed. In the strive to minimize costs, it may be tempting to put all medical functions relevant to a ship in one room and make it as small as possible. However this is never the best solution, and the end result will be a sickbay with limited function, not suitable for its purpose. On the other hand, if there is dedicated space for all of the possible functions a sickbay should fulfil, a lot of unnecessary space will be used.
Some of the functions in the sickbay demand dedicated areas, like the “emergency room” that must be instantly available at all times. Other functions are easier to combine with other areas of the ship that may also be used for other purposes. For instance a “doctor’s office” can easily be combined with a regular office function by, for example, having a sliding door in front of a bulkhead making a space that houses a cabinet and a workbench to be used for the medical purposes. There are also areas that may be used for other functions classically associated with the medical facility. On such example is an area for prioritizing and attending several injured (Triage or staging area) in case of larger accidents, for instance a fire. Having the dining mess area designed so that it also is suitable for this purpose and in proximity to the sickbay allows the medical facility to be designed to function well in areas that cannot be done elsewhere whilst not being compromised to provide a multipurpose area.
The layout of the medical facility is largely dictated by the functions that the space must fulfil.
The function as an emergency room is the heart of a modern sickbay. In an emergency department on shore there is an examination room, resuscitation room and other specialized areas (The American College of Emergency Physicians, 2008). On board the sickbay has to fill most of the requirements for examining and treating the patient in an emergency. To function as an emergency room the layout of the facility should prioritize examination and treatment of severe illness or injuries. Even though this is the least frequent use of the sickbay, this function cannot be achieved elsewhere and must be immediately available at all times.
The room should have an examination table rather than a bed, preferably in the centre of the room. This is because the officer providing medical care must be able to access the patient from all sides, including the head. If the table is placed next to a bulkhead it should be easy to move it in order to achieve access, and it must be possible to secure it in in all positions.
There are a number of hospital beds and examination tables available, with various capabilities, and also solutions that can be used as both. The table that is chosen should, as a minimum, have the possibility to place the patient lying down and sitting half-upright and have the choice of elevating the head and foot ends to the best position for a severely ill patient. It should also be possible to adjust the height to provide the best possible position to carry out detailed medical procedures in a moving environment, if this is required. As the patient may have to remain in the emergency room for some time whilst waiting for evacuation, a very basic examination table is probably not appropriate on most ships.
In addition to the ordinary lightning of the room there should ideally be an examination light that can be positioned to provide working light in a small area. The best solution is to have a lamp mounted in the bulkhead ceiling, rather than a standalone solution on wheels… The best examination lamps meet the standards for surgical lighting (IEC Standard 60601-2-41) and although the ship owner is not obliged to provide this, the surgical lighting standard is a good aim for what to achieve.
The emergency room requires storage space for some of the equipment. Typically, this includes the medical examination equipment, dressings and first aid equipment and drugs for emergency use. The equipment and drugs that may be needed in a hurry should be easily accessible and easy to find. In general, it is a bad idea to store medical equipment under a bed or in a sofa drawer, where crewmembers will have to spend time looking for the “right medical gadget”, not really knowing what they are looking for. If the emergency equipment cannot be placed in line of sight or in glass cabinets, proper labelling is essential (See section below on medical storage).
Most medical procedures involve equipment of different kinds, and usually it makes sense to prepare the equipment before you start the procedure. Therefore, there is a need for working space. This can be solved in a variety of ways, with fixed benches, fold down solutions or mobile trolleys or over bed tables. If the workplace is insufficient, the room will soon be inadequate for emergency purposes. Typically the room needs at least one large working surface (bench, wall mounted table), and a smaller one close to the examination table/bed (Mobile tray).
Basin, surfaces and cleanliness.
Inside the room, there should be a basin, both for hand washing, but also for cleaning the patient and equipment. The room should also be easy to clean and keep clean. That includes the choice of surfaces on deck and bulkheads and interior. Openings between the interior and deck/bulkhead ceiling should be closed, and narrow corners kept to a minimum.
The ‘doctor’s office’ is the function of the medical centre that is used most often. Most seafarers or passengers seek advice for minor things, and are in need of neither emergency treatment nor hospitalization. A challenge on ships is the close connection between the patient and the medical provider. The medical provider is usually the patient’s boss, but is also a colleague and often even a friend. Every ship is different, but keeping the talk about peoples medical needs away from dining, recreational and workspace areas is generally a good idea to ensure confidentiality. Also the quality of care improves when medical consultations are done in a designated medical facility, rather than in the hallway or on the bridge. Therefore this function should be provided in the medical facility alongside the emergency room, or in a specified office next door. Medical providers on ships are seldom health care professionals and often need more time to find and access information and prepare. In an emergency, it may make sense to be able to go to the next room to access information, or discuss the situation privately with the TMAS providers, the bridge or the Maritime/Joint Rescue Coordination Centre (MRCC/JRCC).
The doctor’s office should have a chair for the officer responsible for medical care and for the patient so they can sit in front of each other. The chairs must be able to move, to allow access, for example, to the patient’s back. During a consultation, it may also be necessary to access information from the internet or to call a doctor ashore. A desk and access to communication should therefore be included in the room. The computer screen should have a position where the patient cannot see the screen at all times (See more under Communications). This space and function can be integrated with a more ordinary office/working desk function or small meeting or communication room for senior officers. If one had to choose, this function may be easier to place in a multifunctional area than, for instance, the emergency room or hospitalization capability.
When international regulations on medical facilities on board ships were first created, hospital accommodation was the key demand. Hospitalisation serves the purpose of giving the ill or injured seafarer a place to rest, not having to bother about and be disturbed by other crew members sharing the same sleeping and living quarters and it also has a purpose to stop the spread of possible contagious infections by isolating the sick seafarers.
However, accommodation for seafarers has improved dramatically over the past decades. Many sailors today have their own cabins often with their own toilets and showers. Because of this, the need for separate hospital accommodation on board is less. On ships where people still share cabins and/or toilets and a bathroom, the need for hospital accommodation is still as valid as ever. Equally, even if the hospitalisation of people on board is usually better solved elsewhere, a very sick or severely injured patient may have to stay in the ‘hospital’ for quite a period before they can be evacuated.
There are no concrete international regulations or guidelines as to how many people the ship should be able to hospitalize on board (cruise ships are an exemption from this). If there may be a need to hospitalize several seafarers at the same time, having several cabins, with the possibility of flexible use should be the preferred solution.
If there is no other solution, hospitalisation can be done in the same room as the emergency function and doctor’s office, but this is always a poor solution. Such a solution is seldom able to comply either with the need for an emergency room when that is needed. Other solutions should be sought.
It is a demand that “the entrance, berths, lighting, ventilation, heating and water supply shall be designed to ensure the comfort and facilitate the treatment of the occupants”. Combining comfortable accommodation for many days for seafarers who are ill with suitable treatment facilities is very hard, if possible at all. Today, many ships therefore solve this with “cabinlike” accommodation alongside the emergency room/doctor’s office, or one or several cabins next to this facility.
Cabins or facilities intended for hospital accommodation must have their own basin, toilet and shower/tub separate from the rest of the crew. This includes the emergency room if seafarers are to be kept there whilst waiting for an evacuation.
It should be possible to control the temperature of the medical facility (emergency room and ‘hospital’) independent of the rest of the ship, and ventilation must be sufficient. It is also preferable that the sickbay/hospital ventilation is directed so that it vents to open air and not into the rest of the vessel.
Medical storage is another function that should be solved by the medical facility. Many factors need to be taken into consideration when planning the area to ensure that the drugs and equipment are stored safely and correctly whilst still being easily accessible when they are needed.
There are some drugs and items of emergency equipment that may be required quickly and as such should be easily accessible at all times, paying due regards to security. In addition, there will be additional medications and equipment that are needed for “everyday” medical cases. This is usually for cases seen in the “doctor’s office” function. Unlike the emergency medicines and equipment, it is acceptable to store these items in the next room or within a locked section (multi functionality).
Access is not only about where things are stored, but also about having a system for where things should be. Arranging equipment and medications in groups so that they are easy to find is a part of this. Different publications suggest different systems for organizing the drugs. For ships in international trade, medications should be stored in accordance with the ATC-system, since this is an international worldwide system known to all doctors. Some ships also have logistical systems to keep track of expiry dates and location. Drugs and equipment should be clearly marked within their storage space and according to the system chosen.
In the ship’s medicine chest there are also drugs like analgesics and sedatives. These are addictive, and there are rules around how they should be stored. Other non-addictive drugs can also be dangerous if taken incorrectly or in the wrong dose and these shored also be stored appropriately in a locked cabinet. Regulations on how and which drugs need to be secured are defined in national laws and may vary with the flag.
The two largest oceangoing classes of ships, have demands about separate lockers for drugs. These lockers need their own keys as only the Captain or his delegate shall have access to the drugs. In vessels with a medical facility, the lockers shall be inside the facility and it is often advisable to have a separate locker inside the other for narcotics, since these must be treated and registered differently from the other drugs. There are also regulations about the storage of drugs for rescue boats and rafts. These are usually kept in watertight container at or close to the bridge.
Some medications like ointments, but also eye drops, suppositories and pessaries should usually be stored in a refrigerator. In order to ensure that the storage temperature is within the required limits, the refrigerator should have a thermometer that registers and stores the peak high and low temperature.
It is important to store all medications in a dry place, and out of direct sunlight. In the locker of a sickbay, this is no problem. In a smaller ship or boat, keeping the medications in a locker next to the outer hull where you may have condensation is a bad solution. The shelf life of drugs is influenced by light, air, humidity and temperature, so storage must be arranged so the different drugs can be stored in accordance with any specific instructions.
All large pieces of equipment on a ship, including in the medical facility, must be secured to prevent movement in times of bad weather. An additional challenge in many sickbays or medical lockers, is that everything inside the locker moves. The well-arranged drugs are often in chaos when they are needed next if they are not stored appropriately. Solutions such as smaller drawers, shelf separators etc. are a must to ensure a functioning sickbay or medical locker. It should be possible to adjust separators to manage different quantities in lockers. An alternative for some medication may be a custom made bag which is then itself stored appropriately.
In the old days, ships had to manage by themselves, also in regards to medical care. This was, and still is to a certain extent, reflected in the education and training of the Captain and navigators. In older ships, this is also the case in the design of the medical facilities, which sometimes are without proper communications to shore.
Today’s reality is often that all medical treatment on board that exceeds ordinary self-treatment, is teamwork with the officer responsible for medical care or health trained professional, being a remote practitioner cooperating with a doctor ashore. Current international regulations and flag state rules require care on board to be ‘as comparable as possible to that which is generally available to workers ashore, including prompt access to the necessary medicines, medical equipment and facilities for diagnosis and treatment and to medical information and expertise.’ Treating severe illness or injuries on board today, without the support of a doctor, may be regarded as malpractice.
To be able to function efficiently as the remote practitioner in a medical team with shore based expertise, the medical facility or workstation must be equipped and designed to work efficiently with the doctor ashore. This is maybe less of a priority if the vessel is sailing close to shore and doing short crossings, for example across a fjord or to islands a short distance from the mainland. Here the need for communication may be limited to a phone line to be able to call an ambulance to the pier upon arrival. However if the ship is crossing oceans, and is out of range for helicopters, the officer responsible for medical care may have to perform advanced medical procedures under the guidance of a TMAS doctor. In these cases communications cannot be too good. This is reflected in the International Maritime Organisation (IMO) polar code that requires ships travelling in artic waters to have a telemedical solution exceeding the minimum requirements according to GMDSS. However it is not stated, what this solution should consist of.
Voice and phone
The most basic communication that needs to be in place is a voice or a phone line. Examining a patient and having to leave the medical facility to go to the bridge or somewhere else to talk to the TMAS doctor, then having to return to do additional or repeat examinations or to ask new questions and then having to leave to talk to the doctor again simply does not work. In ships where the medical facility is without basic communications, it is simply never used and does not work according to its intentions.
Having a phone line from the medical facility that can be used with the different communication systems on the ship is the basic solution. When an emergency arises, reaching a TMAS service on the phone is always the fastest way to get assistance. The value of this increases if it is also possible for the officer responsible for medical care to have a hands-free solution, being able to talk to the doctor ashore whilst attending the patient. The optimal solution is to have freedom of movement so that it is also possible to call from other areas of the ship such as a crew cabin, but also from working areas like the engine rooms, deck or cargo holds. People do not always become ill or injured in the medical facility!
E-Mail and internet
In many situations, communicating on e-mail, and also using attachments such as pictures or information from more advanced medical equipment, for example, ECG, ophthalmoscope or ultrasound, is a more effective way to communicate. A picture can easily convey detailed information about for instance a wound, a swelling, a rash or an injured eye that it is hard to describe in words. Pictures are an excellent tool to document changes in different conditions and can also sometimes help in overcoming language barriers.
For some Telemedical Assistance Services, mail is the preferred way to communicate. Some private providers of medical assistance services or telemedical support also have systems that require an online login before it is possible to communicate properly with a doctor onshore. Be aware though, the issues this raises around patient confidentiality. Further information on ethics and confidentiality is available in Ch. 2.9. As a source of information, the internet is also vital to find information about drugs, how to perform procedures etc. and should be available in a medical facility.
Video and bandwidth
Another useful communication tool is video consultation. The possibility for TMAS to interact with the officer responsible for medical care on board and for the doctor to see the reaction of the patient is invaluable in some situations. For instance, many diagnoses are considered more or less likely on assessing the patient’s reaction to pain, their vigilance or their reflexes. All oceangoing vessels today have the requirement to carry satellite communication with sufficient bandwidth to perform basic video consultations. A video consultation works perfectly well with a bandwidth on 128kb, which is the smallest Inmarsat solution. For vessels limited to littoral operations, they do not necessarily have satellite communication.
Video consultations with more developed TMAS providers is performed without any additional equipment or software as long as you have a computer, pad or phone with a camera and an internet connection. Then the embedded WebRTC protocols in most browsers are used. A portable webcam that can be handheld or fixed in various positions relative to the patient increases the value of such a system tremendously, and pre planned positions for the camera makes this even better.
More and more ship-owners also choose to equip their ships with compact tele medical kits, often consisting of a PC or pad, connected to a camera and basic electro medical equipment. Again, positioning of the equipment and camera should be pre planned to get a desirable solution. The most advanced solutions have several preinstalled cameras, giving the choice of different angles and zoom.
When prepositioning a camera for a video, positions should include a view from above with the choice of a frontal or a profile view of the patent and the surroundings. Additional positions so that it is possible to also zoom in on the patient’s upper body and face, abdomen and extremities to guide procedures should be available if possible. In addition, there should always be the possibility with a portable camera to have close-ups of details like an eye, a nail or a wound.
Even though all oceangoing ships are obliged to have satellite communications with sufficient bandwidth not only for phone calls and for using email, but also for basic video conferencing, a lot of them are unable to implement video consultations. This is often because the bandwidth is used for numerous purposes, there are firewalls to stop the running of large applications, or the crew is not aware of the possibility. Designing and furnishing a sickbay should therefore include making systems for prioritizing bandwidth in an emergency, and installing easy to use video solutions. Be aware that some providers of video consultation equipment provide end-to-end solutions that require that the same equipment or protocol is used at the other end. For a ship moving between regions and countries, this limits their possibility to talk to different TMAS providers and is therefore a bad solution.
Sanitation and surfaces
For all areas in the medical facility and areas used for the accommodation of sick crew members, extra attention should be paid to surfaces and design in order to make sanitation easy. Luckily the sickbay is not the area that is most frequently used on most ships, but that also means that it needs to be easy to clean and to keep clean so that it is ready to be used when someone becomes ill or is injured. Also, if the ship has an outbreak of an infectious disease, there might be reason to clean at least parts of the sickbay between individual patients.
Detailed information about how to achieve this can be found in numerous places. Basic principles to consider include:
Made to stay clean
The design should not allow dirt and dust to build up over time. To achieve this for instance, lockers should continue to the bulkhead ceiling with no free space on top. Likewise, it is ideal if there is no free space under benches and lockers. Too many corners, small openings and spaces between benches, refrigerator lockers and other interior items should be avoided as far as possible.
Made to be cleaned
Where there has to be an opening under a bench, a bed or other interior item, the opening must be spacious enough to enable rapid and easy cleaning below. Surfaces should be as plain as possible, and fewer bigger surfaces are generally better than many small surfaces. All surfaces should be resistant to cleaning chemicals such as chlorine and disinfectants. Preferably, the use of textiles and carpets should be avoided, and any used should have a texture that makes them easy to clean as well.
Equipment for cleaning the medical facility should not be mixed with other cleaning equipment on board to reduce the risk of spreading infections. It may therefore be useful to have a separate cleaning locker in or next to the sickbay.
Basins and hand disinfection
All rooms with a medical purpose should have a basin or immediate access to a basin. The ideal is that all rooms with a medical purpose have their own basin next to the door, so it is easy to clean your hands when entering and before leaving the room. This can in many cases be hard to achieve. Then stations with hand disinfectant is a way to complement fewer basins. In rooms where patients may be hospitalized, the ideal is that the ill or injured does not share a basin with other crew or the care provider.
Requirements for specific types of ships
For ships in littoral traffic, there are large differences in solutions to provide medical care on board. For ships with a crew smaller than 15 or with voyages under 3 days, there is no demand to have hospitalisation capability. However these ships are required to have a medical chest. Many of the larger vessels in this category still have a medical facility, for instance, a passenger vessel with an overnight voyage may have a need for an emergency room facility. For the smallest vessels, a locker for the medical equipment may be sufficient.
To be able to make a functional and adequate medical facility on smaller ships, it is necessary to focus on the likely medical needs that must be met considering the ship’s route, traffic and operations. To include all of the above functions for a sickbay is not feasible nor necessary, but to have a clear idea of what should be covered, trying to combine the solutions with non-medical spaces, will give a better solution than merely including a medical locker or an emergency station.
Purpose built ships
Many ships also have needs that exceed the requirements of an ordinary medical facility. Here the solution for a medical facility varies dependent on the role and therefore the likely requirements for medical care on each specific ship. It is important to be aware that these often include medical functions usually found on shore and in hospitals. In most nations, the regulations for medical equipment, medical procedures, storage and production (for example, the production of oxygen on board), ventilation, sanitation etc. that you will find in the ordinary health care systems and hospitals, will also apply on board. To designs such vessels, it is essential that people with expertise on building ships, but also on building hospitals and hospital systems and expertise on the medical equipment that will go on board, work together to find the solutions.
Cruise ships have doctors on board, and usually they also have nursing staff. The size of the medical staff and of the medical facility varies from ship to ship depending on factors such as the number of passengers and crew and the itinerary. Although the sickbay may be referred to as the “hospital” on board, the capability of the facility is far from a hospital. It is usually a good “emergency care” facility with at least an examination room/doctor’s office, an emergency/intensive care room and a ward with at least 1 bed pr. 1000 passenger. Cruise ship medical facilities also include more diagnostic equipment, like ECG, X-ray, monitors for vital signs, capability to perform some laboratory test etc. Usually they are also capable of hospitalising a number of patients in the medical facility. More information on cruise ship medicine can be found in Ch. 2.13.
Research and expeditionary ships.
Research and expeditionary ships often carry an additional staff of scientists or workers that are not part of the ship’s crew. In that respect, they have similarities with cruise ships. However, they differ from cruise ships in that they often sail in more remote areas away from the ordinary shipping routes and in areas where access to evacuations and medical treatment on shore may be more limited. To mitigate that increased risk, many of them will have a medical facility, medical staff and equipment that exceeds the minimum requirements set by their national maritime authorities. Many of them look to the guidelines from the American College of Emergency Physicians (ACEP), the Polar code or military specifications to be able to provide prolonged emergency care. There is no consensus on what the requirements should be, and the solutions and capability therefore vary a lot from ship to ship.
Search and rescue vessels.
Search and Rescue vessels (SAR) are built with the purpose of assisting maritime incidents. They vary in size, from small patrol vessels used in littoral waters to oceangoing vessels supporting readiness on large oil fields with several platforms or coastguard operations rescuing refugees. The ships are therefore designed to pick up large numbers of people from the sea. Their medical facility will of course vary with the size of the vessel, but they will usually be designed with large and capable medical facilities, compared to the size of their ship and crew.
The main focus when designing medical facilities on a SAR vessel should be on areas to handle many casualties at the same time and how to make them dry, clean and warm, rather than on hospitalisation and prolonged care. Having rescue as their main task, focus on the emergency medical function must be strong. How to place the rescue areas and the medical facility, how to move people between rescue stations to safe areas or areas intended for emergency care and how to evacuate to a helicopter are important considerations when designing SAR vessels and often dictate how the other functions on board are designed.
Diving vessels are built to support diving operations. For professional divers, access to a hyperbaric chamber may be a part of the readiness. There are several ways of providing a chamber for this purpose. Both onshore chambers and portable chambers may be used, and the solution must be feasible for supporting the specific diving operation. Some diving operations cannot be performed without onsite access to a hyperbaric chamber, and for those operations purpose built diving vessels with permanent hyperbaric chambers are used. A special consideration when fitting a hyperbaric chamber on board, is the possible need to provide medical care to a patient whilst they remain in the chamber. Be aware that there are many “diving vessels” used for charter and leisure diving cruises. These usually have no extra medical support or hyperbaric chambers.
In some parts of the world, it makes more sense to run water ambulances rather than road ambulances. These boats are usually equipped to be the equivalent of a road ambulance. Since some of them also operate in remote places, they are sometimes combined and equipped with a primary care function. Ambulance boats come in many sizes, but a small boat is generally affected more by the forces of nature, than a road ambulance. Because of this, they are usually substantially bigger than the equivalent road vehicles and you may need a “ship” rather than a “boat” to be able to run in all conditions.
Humanitarian vessels are ships that are used to help people on shore during natural crises, wars and other humanitarian catastrophes. Typically they are ships taken from trade to support in a specific incident with simple but important things such as accommodation for rescuers, freshwater production (many ships are very capable of producing big amounts of freshwater from seawater), food supplies etc. Some are also used to enhance or substitute local healthcare services. If the ships are taken from trade, it may be necessary to make them more suited to their new role in a hurry. One way of achieving this is to have preplanned medical capabilities to put on board different ships. The principles for establishing an adequate medical facility remains the same, but focus on capacity on the different functions is just as important as capability. On board ships space is always a limiting factor and choosing which capabilities should be present and to prioritize against the capacity of the vessel, is a crucial exercise to make a system that will work as intended. There are also permanent humanitarian ships that usually have niche hospital capabilities to provide healthcare in a certain area based on local needs. Some of the most well known examples of humanitarian ships are “Women on waves” and “Mercy ships”. More information on providing maritime support for onshore incidents is available in Ch. 9.11.
Similar to humanitarian vessels, hospital ships are ships that support an operation with medical care at a hospital level, and where the hospital function is the ships primary role. Different to humanitarian ships, they are intended to be used for patients who are at sea, but can also be used to support onshore operations. Traditionally hospital ships have been used to support military operations or large scale merchant operations, where evacuation to onshore hospitals isn’t immediately possible. All such ships have an emergency room, operating capability, intensive care facilities, wards, a pharmacy and the technical solutions to support the running of such a hospital. However even on the biggest hospital ships, the range of medical care is limited to what is necessary to support the operation, before people are evacuated to hospitals on shore as soon as possible.
There are very few true hospital ships in the world today and those that do provide this role are usually naval vessels such as the American “USNS Mercy” and “USNS Comfort”, together with the Chinese “Daisan Dao”. The military hospital ships differs from other naval ships, in the sense that they have special protection under the Geneva Convention and have to follow certain rules. One of these is that they have to be white and clearly marked by red crosses. The Spanish “Esperanza del Mar” is an example of a hospital ship supporting merchant operations. She was purpose built and sails to support the Spanish industrial fishing fleet.
Medical facilities on board naval vessels differ from what you find on an equivalent civilian vessel. Typically, the medical function on board naval vessels is tailored to support the military operation. The best guide on how to design tailor made medical functions on board naval ships, is the NATO “Maritime medical planning guide” (MMPG). This guide assesses the risk based on proximity to other medical support, the size of the sailing fleet and the operational risk based on the type of military operation and suggests what level of support should be provided for that specific operation.
The MMPG divides the medical support into 5 levels, based on the medical capabilities that should be included. The capabilities include the function of the medical facility but also include functions relevant to support the medical facility, for example evacuation requirements, holding capacity and logistical support. Further information on naval medicine is available in Ch.2.11.
Rules, regulations and guidelines
Regulations on ship medical facilities are laid down by the flag state. For most flag states, the regulations in this area are limited and are usually in accordance with international minimum requirements. More variation and detail may be seen with regards to drugs and equipment, rather than concerning the medical facility itself. Compliance with medical regulations in the design stage is checked by the international classification societies and the ongoing maintenance and condition of the medical facility is subject to port state inspection. Relevant legislation includes the following.
ILO: C092 – Accommodation of Crews Convention (Revised, 1949 (No.92))
In 1949, the International Labour Organisation (ILO) adopted a convention on crew accommodation that also included the possibility to hospitalize crewmembers. This was the first convention to include the ships medical facility. It stated that ships with more than 15 people and voyages longer than three days should have separate hospital accommodation. To understand and exercise this rule today, it is important to remember that seafarers from that time usually lived on the lower decks and had to share their accommodation with many others.
The convention also states that the hospitals should have a separate toilet (isolation), and that it should be “suitably situated” so it is easy to access (placement), and that it should be possible to provide patients “proper attention in all weathers”.
The threshold for what is “proper attention” has changed since 1949. With improvements in medicine, it is also possible to provide better care on board today than it was at that time. Therefore the focus on the ability to treat people in the ships sickbay must be balanced against the need to hospitalise people in the same room for many days, given there are now possibilities on board to hospitalise, isolate and care for people in separate cabins.
It is important to emphasize that the demand to have hospitalisation possibilities that are not used for other purposes (storage, passengers etc.) is a legal requirement, as is the ability to be able to provide rapid care in an emergency. This demand is one of the main reasons many ships have chosen a sickbay medical facility with 2 rooms, one for examination and treatment and one “ward” with beds.
For ships in coastal trade, national authorities may relax the requirement for hospitalisation possibilities. It is also left to the same authority to decide how many people the vessel must be able to hospitalise. This convention now has an interim status since it is included in the MLC 2006, and may be denounced in 2023-24.
ILO: Maritime Labour Convention (MLC) 2006. Standard A4.1 – Medical care on board ship and ashore
In 2006, the International Labour Organisation published the MLC 2006, that entered into force in 2013. The convention aimed to cover the whole range of social health and welfare rights for seafarers. Therefore it includes the medical facility, but it also regulates the medical treatment on board in general and in more detail than the convention above. However with regards to the sick bay itself the MLC is basically the same as the 1949 convention, without any significant changes or improvements.
The differences appear in the guidelines included in the MLC, explaining how the regulations should be interpreted. In the guidelines MLC underlines the fact that accommodation should be designed to “facilitate consultations and giving first aid and to help prevent the spread of infectious diseases”. It also says that the arrangements in the medical facility should ensure comfort and treatment. In regards to the sanitary accommodation for the medical facility, it has added a shower or a bathtub, in addition to the toilet and sink. It remains a flag state decision as to the number of beds and size of the sickbay.
The MLC does not give specific requirements for ships with a Doctor on board, meaning that there are no general international, supra governmental regulations for medical facilities on a ship requiring more than a regular sickbay.
Directive 92/29/EEC – medical treatment on board vessels
In 1992 the European Union issued a directive on medical treatment on board vessels. The directive addresses the medical facility, medical supplies and quantities of these, medical training of crewmen, access to Radio Medical advice and more.
Like the ILO convention, it has a demand for a medical facility in ships with 15 people or more and three days voyage, but it also includes ships larger than 500 gross tons, independent of the number of crew. This change was made to ensure that ships with smaller crews, but still doing long voyages, should have the capability to take care of their crewmembers.
There is however, a large difference in how the EU directive describes the medical facility. The EU directive stresses that the medical facilities primary function is to be a place where treatments can be performed “under satisfactory material and hygienic conditions” and does not mention the need for hospitalization. This has resulted in medical facilities being designed as a “doctors office” including the storage of medical equipment etc., and then one room or part of the room having an examination table for emergency treatment, rather than a bed. In this solution, the examination table is used to hospitalize people for a short period of time in acute emergencies. The crewmembers staying on board with less severe illnesses, would then stay in their cabins. As stated earlier, this is a good solution, but only feasible in ships where the seafarers have single cabins, including their own bathroom.
Non-governmental guidelines for cruise ships.
Health Care Guidelines for Cruise Ship Medical Facilities Policy Resource and Education Paper (PREP)
There is no internationally agreed standard for medical care on cruise ships, other than those covering passenger vessels in general. Most large cruise companies in the world are members of “Cruise Line International Association” (CLIA) and are through their membership they are obliged to follow the ACEP/CLIA guidelines. More information on the medical facilities on cruise ships and the ACEP guidelines are available in Ch. 2.13.
The Polar code
International Maritime organization: International code for ships operating in polar waters (polar code).
The polar regions are remote and shipping, at least in parts of these regions, must be said to be expeditionary. The medical demands of the polar code are very modest and the only relevant demand in the code is “appropriate communication equipment to enable telemedical assistance in polar areas shall be provided”. The code holds no information about what appropriate means, and whether or not this exceeds the minimum requirements already stated for all ships in the Global maritime distress safety system. In practice, this means that ships must look elsewhere if they require guidance on how to improve medical capabilities on board for polar or expeditionary sailing.
Limits of regulations
International regulations on how to design and build a medical facility on board are generally limited. They offer few clear demands, and without a lot of explanation on the implications of these. Working solely to the regulations, without looking for guidance or listening to medical professionals can lead to too much space being used for an effective medical facility, especially on ships with demands for medical facilities exceeding the basic sickbay. This is a challenge, and it also leaves the question open for ship-owners, designers and shipbuilders as to what flag state authorities and class agencies will accept.