D) Medical care at sea and beyond

D.11 Repatriation

Details

RYAN COPELAND; RENÉ DE JONGH

Introduction

Repatriation means returning the individual to his or her usual social, cultural and medical environment. If, after disembarkation for medical reasons and an appropriate initial clinical review, the seafarer is not fit enough rejoin the ship, the voyage or the fleet for the near future, repatriation may be necessary.

In certain medical conditions, this may represent the best chance of preserving a productive career for the individual, as well as retaining skilled and trained seafarers in the industry. Even if neither of these outcomes is feasible because of the severity of the underlying pathology, timely repatriation can help ensure the best possible outcome for the seafarer.

There will be individual cases where the patient returning to their home country will not result in the best outcome because of the standard of medical facilities and care in the patient's home country. Fortunately, these are rare and it is important to find the right balance between the benefit of ongoing relative isolation of the patient in excellent clinical facilities, and the inevitable disadvantage of staying overseas without family and social support and struggling to recover in an unfamiliar culture.

All stakeholders involved in making the decision as to when to repatriate a seafarer must be aware of the advantages of staying, and the advantages of going home.

Fitness to fly

Before travelling, all patients must be assessed as to whether or not they are “fit to fly” - whether they are to move by air, ferry, train or car.  This is a risk assessment and must take into consideration the patient’s medical condition along with the medical capability of the current treating facility, wherever that may be. For example, if a patient is continuously bleeding in a location where there is neither surgery nor blood available, yet is deemed 'unfit to fly', they will inevitably die; if transport can be safely arranged then the risk of moving is less than the risk of staying. Conversely, if they are hospitalised in a location where surgery and blood are available, the risk of moving them closer to home before they have surgery is of course far greater than the risk of not moving them until after surgery and transfusion.

The risk-benefit calculation for repatriation is quite different. Patients should be medically stable before repatriation, and that is a clinical assessment.

Physiology of flight

Fortunately, modern air travel imposes relatively minimal medical stress on travellers and patients. The cabin of a commercial aircraft is pressurised to a maximum altitude of 8000 feet (2440 metres)[1], [2] with a subsequent drop in pressure from 1 atm at sea level to 0.75 atm when flying. This fall in pressure has two significant physiological effects in humans:

  • There is a fall in oxygen saturation i.e. the amount of oxygen carried around by the red blood cell. Whilst the air at altitude is still 21% oxygen the partial pressure of oxygen is reduced in line with the fall in atmospheric pressure and becomes 0.75 x 0.21 = 0.16 atm. Hence, a reduced amount of oxygen enters the lungs and consequently, the level of oxygen circulating in the blood is lower than at sea level. This fall in circulating oxygen is scarcely noticeable in normal passengers but may affect those who have an underlying cardiac and/or respiratory condition or where end organ oxygenation is critical. Fortunately the degree of that fall in saturation in people with pre-existing medical conditions is predictable, and can be corrected by having the patient breathe supplementary oxygen.
  • . Boyle’s law states that at a constant temperature, the volume of a gas is inversely proportionate to the pressure’. Hence, in an aircraft cabin any gas will expand in volume as the pressure falls compared to at sea level. In the context of commercial aircraft this represents an increase of volume of any gas by approximately 30% at cruising altitude. Note the effect on a bag of crisps or a bottle of water. Drinking gassy liquids at altitude has a result that is predictable but manageable on a personal level. However if air is trapped inside the head, chest, abdomen, tooth or other places where it shouldn't be at all, or where it is present at larger than normal volumes, difficulties can result.

Clinicians aware of the physics and physiology of commercial flight can readily foresee the potential results of these changes. After assessment by suitably qualified physicians, appropriate recommendations for the transport of people who may suffer ill effects in flight can be made. Staff to be included in this risk assessment, after appropriate briefing, include the patient’s treating physician, the airline medical department, others responsible for the ongoing care of the seafarer and assistance company staff, if they are involved.

Practicalities of travel

The decision that the patient is fit to fly also needs to take into consideration

  • the underlying nature of the medical condition, the response to treatment and ongoing care requirements.
    • Is the condition as stable as can be expected in the near future?
    • Has there been a good response to treatment to optimise the condition at the current time?
    • Can any ongoing care requirements be met during the journey e.g. wound care, administration of medication, monitoring.
  • the mode of transportation and length of transfer.
    • How long is the total journey time and therefore the total time away from full medical care?
    • Can appropriate care be received in any destinations en route if necessary?
    • Can the patient’s needs by met in transfer airports, ports etc.
  • the mobility of the patient and their ability to self-care, see below.

Who should make the decision?

There will often be several stakeholders involved in making the final decision and each will have an opinion. That said the final decision as to whether someone is fit to fly is always that of the seafarer - or the relatives if the seafarer is unable to give informed consent. It is both fair and appropriate that he should be informed about the options and risks, and give informed consent. In addition, that the transport should be carefully arranged from logistics’ and medical points of view, to keep the seafarer safe, comfortable, and eliminate avoidable risks.

Relying solely on the treating specialist for his or her opinion about the seafarer’s fitness to fly home can be problematic.  There is no specific training during undergraduate and postgraduate medical education for doctors and nurses about transporting patients by air and/or over long distances, unless they have specifically obtained experience in aeromedical transportation. The treating doctors’ medical expertise on the condition he or she is treating the patient for must be respected. However, recommendations for the timing, mode, routing, and medical or non-medical accompaniment on the repatriation flight should be made by people familiar with risk assessment in these circumstances and with the knowledge of the logistics, aviation and clinical limitations of flying patients. This is important because there is a considerable inconsistency even among specialists in their own field of expertise, about appropriate timing of travel after medical procedures.

Options for repatriation

When medically appropriate and feasible, utilisation of scheduled airlines is typically the preferred method of repatriation. Repatriation planning includes assessment of the medical condition and related inflight monitoring and treatment needs, any mobility related restrictions and any airline specific medical acceptance guidelines. Repatriation options could include:

  • Commercial airline seated and unescorted
  • Commercial airline seated with a non-medical escort
  • Commercial airline seated with limb elevation, with or without a medical escort
  • Commercial airline with flatbed, with or without a medical escort
  • Commercial airline with stretcher, medical escort/s mandatory
  • Air Charter flight with appropriate escorts
  • Air Ambulance flight

 

Airline guidelines

Well-managed airlines are understandably averse to unpredictable medical outcomes on board their flights. In the interests of helping people travel for whichever reasons the traveller desires - including travelling to medical care, and travelling home after care – airlines usually have their own comprehensive guidelines on medical fitness to fly. Since there is plenty of time to plan repatriation (as opposed to an emergency evacuation) there is always time to get airline medical department clearance for repatriation of the ill and injured seafarer.

The majority of the top-tier airlines publish online the forms that are required for the assessment of the intended patient transport by their in-house or out-sourced medical advisors. In addition, they also provide online a set of guidelines accessible to all doctors involved with the seafarer's care, and of course, easily read by seafarers themselves, family and friends. The guidelines do differ quite considerably between different airlines even for identical pathologies, so it is best to identify the preferred airline early in the process and meet their requirements. Generally, using the airline of the seafarer's own country is a good idea if it is feasible. Many airlines see helping citizens get home as part of their duty as their nation's flag carrier. It also means that the seafarer will be back in a somewhat familiar language and cultural environment once they board the aircraft.

Usually, the airline requires the treating doctor to complete the MEDical Information for Flight Form (MEDIF) and that doctor carries the responsibility for ensuring the airline medical department has all the information they need to approve travel.

The International Air Transport Association also publishes a medical manual that provides a very detailed overview of some these considerations and specific airline clearance recommendations.3

Mobility and assistance issues

As well as any medical issues that may affect the passenger on board, the airlines are also concerned with the mobility and independence (or lack of) of travellers and patients. Airlines advise that all travellers need to be responsible for their own safety as well as health on-board. Cabin crew are not medically trained, the very basic airline medical kits are not available for access by passengers on demand, and very specifically, passengers need to be either independently mobile, or have a travel companion who can assist them physically in and out of their seat and moving around the cabin.

In the event of an emergency, all personnel and passengers must completely evacuate the cabin within 90 seconds. The crew will be more than fully occupied getting the passengers moving, and cannot be responsible for helping individuals to the exits. Although this is a highly unlikely scenario, it is a significant part of the reason why passengers who cannot manage their own mobility must provide a medical or non-medical escort to help them.

More likely, individual travellers may require assistance with normal in-flight activity such as getting to and out of the seat to go to and from the lavatory or galley. This can be challenging for people who are long-term disabled but not convalescent; it can be much more difficult for people who are acutely immobile and convalescent. Many such patients also require access to the lavatory more often than usual, plus physical help inside the lavatory, as well as medication inflight. An experienced, competent and willing person travelling in the same class as the passenger and seated next to them must provide any assistance. It is not the responsibility of cabin crew.

Outside the aircraft cabin, physical assistance is readily available. Both by law and by custom, airlines are well set up to provide on the ground assistance to people who find it difficult to move about an airport easily. Special assistance is easily available to passengers who may need help such as the elderly, those people with a physical disability, such as wheelchair users and people on crutches. This help should be requested at the time of booking, and is especially but not only useful during layovers or short-time connections.

A small but not trivial percentage of repatriations involve surface transport by boat/ferry, plus train and car. Mobility and hygiene issues do not disappear because the patient is not in an aircraft; so the plan should account for every support and activity needed for the patient to travel safely and comfortably, just as for air transport.

Medical care in flight

 In certain circumstances a medical escort may be recommended to accompany a returning seafarer depending on the medical condition, mode of transportation and geographical distance to be travelled. Medical escorts are recommended for specific medical needs that may include:

  • Administration of intravenous and/or oral medications
  • Monitoring of key vital signs typically during flight to assess any changes due to the physiological challenges described previously
  • Support with medical interventions during transportation (such as suctioning of secretions, changing of wound dressings, administration of intravenous fluids)
  • Supervision and support of safe mobilisation for those seafarers with reduced mobility

Role of medical assistance companies

Numerous considerations need to be addressed when planning for the repatriation of a seafarer. It is critical that the coordination of these steps is carried out in a methodical manner to allow for the safe, considerate, coherent and cost-effective transportation of seafarers from the hospital of first admission after disembarkation, to their home. The seafarer, family, employer and receiving medical team also benefit from effective, frequent and accurate updates to ensure a successful transfer of care. The key decision points that need to be addressed include:

  • Confirmation that repatriation is medically appropriate and reasonable
  • Confirmation of fitness to fly/travel recommendations
  • Consent for repatriation
  • Identification of the most suitable mode of transportation
  • Confirmation of medical clearance for travel
  • Allocation of appropriate medical escort/s and any equipment that may be required during the repatriation
  • Arrangement of appropriate receiving care in the home country if the seafarer cannot return home
  • Confirmation of required travel documents including visas if required
  • Financial approval for repatriation

To ensure continuity of care it is very important to confirm that appropriate arrangements are in place for the returning seafarer. The requirements will vary depending on the nature of the underlying medical condition and the need for ongoing care. The seafarer’s family doctor may fill this function, or, more acutely, the arrangement of an inpatient admission to a ward with an appropriate specialist and/or multidisciplinary medical team to resume both active treatment as well as long-term placement and rehabilitation, may be necessary.

The role of the arranging physician and team needs not only to focus on the medical needs of the seafarer and the resultant recommendations around the requirements and rationale for repatriation, but also taken into account numerous logistical and insurance related considerations.

Medical assistance companies are in a unique position to arrange and manage such events. They often have offices and agents around the world, access to appropriately trained medical escorts with the necessary equipment, extensive knowledge of the logistics required and, of course, this is their business. Without this expertise, the risk of a step being missed or poorly coordinated is much higher, as care is often fragmented and responsibilities are scattered through different countries and across different time zones.

Reference list:

(1) Civil Aviation Authority. CAP 393 Air Navigation: The Order and Regulations. London: Civil Aviation Authority, 2003

(2) Federal Aviation Administration. FAR Code of US Federal Regulations. Parts 25, 121 and 125. Washington, DC: US Department of Transportation, 2004

(3) International Air Transport Association. Medical Manual 11th Addition. IATA Publications, 2018. https://www.iata.org/publications/Documents/medical-manual.pdf

[1] Civil Aviation Authority. CAP 393 Air Navigation: The Order and Regulations. London: Civil Aviation Authority, 2003

[2] Federal Aviation Administration. FAR Code of US Federal Regulations. Parts 25, 121 and 125. Washington, DC: US Department of Transportation, 2004

D.12 Rehabilitation of repatriated seafarers

Details

PASCUALITO GUTAY 

Why repatriate

The seafarer may be repatriated for ongoing care at home if:

  • a seafarer’s illness or injury may worsen with work,
  • the disease may spread to affect coworkers on the ship,
  • recovery may take longer than a few days or
  • the disease may affect the productivity of the seafarer,

Additionally, some diseases that occur on board can wait for treatment in the seafarer’s home country at the end of their contract or the seafarer may need to continue treatment started on board or overseas after they arrive home. 

The many and varied nationalities and cultures of seafarers offer various challenges to their medical management. Treatment in the home country is advantageous as seafarers

  • have a better opportunity to be treated in an environment where they can more easily relate their signs and symptoms,
  • can be treated customary to their beliefs and medical treatment exposure, and most importantly,
  • can heal with the help, care, and support from family members in an atmosphere they are familiar with. 

Whilst the seafarers are treated far and wide (within the city or in another region) with varied costs and modes of treatment, the control of the seafarer’s medical care at home by their employer is usually centralized through a company designated physician in coordination with the company’s medical department or an appointed claims handler. 

Medical Care at home

Seafarers go home to many different countries and ensuring that their ongoing medical care is in line with the contractual obligations of the employer and is appropriate, based on globally accepted treatment guidelines, presents a difficult task. 

Expectations

Medical management at home should proceed based on currently accepted international clinical practice parameters. However, it must also take into account what is available in the home country. Exposure to the internet and the availability of voluminous medical information – old, new and experimental – may influence the expectations and demands of patients and their families. It is not uncommon for patients to request procedures or materials available in a different country, however it is always advisable to use locally and customarily available procedures and materials as much as possible.

Contractual obligations

Contractual, work related agreements between the seafarer and the company are taken into account when planning the care of repatriated seafarers. Because of this, care may differ from that which may be received in ‘regular’ medical care. Company designated physicians are utilized in the huge majority of the ‘crewing’ countries to coordinate the seafarer’s medical management,  treatment schedule, report on their care, and provide for their medical needs. They regularly update the local ship owner representatives or P & I Clubs on the progress of care, including attendance and non-compliance of seafarers to medical advice. These coordinators are critical to ensuring the facilitated and proper management of the seafarer based on policies agreed between the seafarers and the companies. 

Cover for medical expenses

Determination of whether or not the injury or illness is work related helps employers determine the company or insurer’s liability for cover and their potential cost exposure for the total care of a seafarer until they are able to return to work. The financial cover for care may be restricted to a certain time period, whilst ship owners, their Insurance or Protection and Indemnity Clubs, or their manning agencies must usually approve the total cost.

Some non-work –related diseases that can resolve quickly and where patients are likely to completely recover without any limitations of their activities may be covered by the company depending on an assortment of factors including the length of employment of the seafarer with the company, generosity of the employer (ex gratia), as well as local government laws and regulations. On the other hand, other companies will over the costs for a seafarer’s treatment for any condition that occurs on board regardless of its relationship, or not, to work.

The payment for and management of sick and injured seafarers’ care is limited to treatment only for the medical issue related to the reason for the repatriation. Comorbid diseases such as hypertension or diabetes mellitus in a seafarer with, for example, a fractured finger needing surgery, will also need treatment because control of these diseases is essential to the success of the management of the fracture. Otherwise, diseases that seafarers complain about during treatment that are unrelated to the primary reason of referral will need to be evaluated for pre-existence before employment and their relationship to the main medical condition currently being managed will need to be investigated.

Medical Coordination

Coordinators of medical care are common in the so called ‘crewing countries’ and their role is to ensure that the costs of treatment and the timeline involved is beneficial to both the seafarer and the employer. It is advantageous to have a country coordinator who has a medical background but they also need to be aware of local and national legal policies and the policies and guidelines of the shipping company or ship owner and the relevant P&I club in order to ensure effective coordination.

Countries without coordinators rely on the seafarers themselves to update them of their health status. In addition, the company designated physician regularly updates the company’s approving person and other stakeholders of the progress of the case management in line with data protection and confidentiality rules and guidelines. Further information on this complex area is available in section xxx.

Seafarers are referred to medical and surgical specialists and subspecialists for proper and facilitated medical treatment. Coordinators can assist in guaranteeing the timely treatment of seafarers by scheduling their medical appointments and acting as triage or medical evaluators ensuring the comprehensive and proper management of the referred condition. They also safeguard against the fragmentation of treatment by subspecialty care that has the risk of overlooking the whole. Company designated physicians ensure reliable, cost-effective and facilitated management of repatriated seafarers. 

Financial support

Repatriated seafarers receive financial assistance whilst they are receiving medical care. This includes sick pay and/or maintenance pay. They may also get financial support for medications, transportation and accommodation, if they are receiving care far from home. Reimbursement of expenses for treatment and other expendables that the seafarer may be paying for themselves becomes necessary. Fortunately, with advances in technology and communication, online payments may be made to the seafarer and these can be arranged even before their disembarkation.

Maximum Medical Improvement or Cure

The aim of ongoing medical care at home is obviously the return to work of the seafarer. Nevertheless, for some, it may become apparent during their treatment that they will be unlikely to obtain a fitness certificate for work at sea at any point in the future due to their health. Fit or likely to be unfit, the time will come when all diagnostic and therapeutic modalities have been exhausted in the medical care of a sick seafarer and any further treatment will not change his medical condition or his fitness to work at sea. That is, the point at which maximum medical improvement has been reached, whether or not the seafarer is cured. This point signals the termination of cover by the employer and needs to be clearly defined. 

Discussion between the attending physicians, the company or its representatives and the seafarer is critical and the seafarer must be included in his care throughout. The active participation of seafarers in their care, especially in defining the direction of their management, should make reaching and explaining the point of maximum medical improvement easier. This is especially important for seafarers likely to be permanently unfit for sea service. Even for seafarers who are likely to be fit, they may feel more confident proceeding towards a medical examination by the appointed pre-employment clinic, if they have been involved in their care. 

Further Medical Selection Examinations

After receiving ongoing medical care, medically repatriated seafarers are required to undergo a new Pre-Employment Medical Examination (PEME) before they can return to work at sea. This will include a flag state medical and may involve an examination and tests required by the government in jurisdiction, the respective principal/ ship owner, the employer and the P&I Club. Further information about the medical selection of seafarers is available in Ch. 4.8.

The Doctor conducting the PEME evaluates the reports from previous specialist consultations, especially the latest results, for an understanding of the present condition and the capability of the seafarer. Further, comprehensive history taking and thorough physical examination with reference to the general health of the seafarer but also to the cause of the medical repatriation will determine any additional diagnostics, consults and or procedures needed in order for the Doctor to make a fitness decision. This medical repatriation illness or injury focused examination and the truthfulness of the seafarer in his declarations during PEME, are in addition to the appropriate medical examinations and eventual determination of the seafarer’s fitness to go back to work.

In a population of over 100,000 seafarer PEMEs between October 2017 and September 2018 at SuperCare Clinics in the Philippines, 1.7% had been repatriated for medical care. The following (in order of incidence) were the top ten most common conditions.

 

 

TOP TEN REASONS FOR MEDICAL REPATRIATION

 

PERCENTAGE of REPATRIATED PATIENTS

 

ADDITIONAL INVESTIGATIONS REQUIRED

1

Various kinds of Injury e.g. Fracture, dislocation, ligament tear, etc

20%

Functional Capacity Evaluation

Xray of affected area

MRI of affected area

2

Inguinal Hernia s/p Repair

4.3%

-

3

Gallbladder stone s/p Cholecystectomy

3.7%

-

4

Musculoskeletal (Back pain, muscle pain, muscle strain)

3.5%

Functional Capacity Evaluation

X-ray of affected area

MRI of back

5

Urolithiasis (Nephrolithiasis and Ureterolithiasis)

2.7%

Kidney, Urinary Bladder Ultrasound

6

Hemorrhoids s/p Hemorrhoidectomy

2.5%

Digital Rectal Examination

7

Acid Related Disease (Gastritis, Esophagitis, Gastric/Duodenal Ulcer)

2.3%

Endoscopy

8

Infection (Abscess, various)

2.1%

Complete Blood Count

9

Gouty Arthritis

0.83%

Blood Uric Acid

10

Hypertension

0.73%

Blood pressure recording 

(part of PEME)

Return to Work

The aim of rehabilitation for repatriated seafarers is recovery to a physical capability that is compatible with continued employment. Some rehabilitated seafarers however cannot return to work if they do not meet the PEME standards applicable to them. The ILO/IMO Medical Examination Guidelines for Seafarers (2011)[1], requires that seafarers are medically fit to resume their duties and do not suffer from any medical condition that would be aggravated by work at sea or endanger the health of their fellow crewmembers. For other industry stakeholders such as the ship owners and the P&I Clubs, guidelines that are more stringent apply. This accounts for the stricter PEME guidelines and enhanced post repatriation screening schemes required by these organisations.


Of 2,028 seafarers considered to be completely rehabilitated or recommended as maximally medically improved and referred to SuperCare clinics for PEME, 94.67% were eventually declared fit to return to work and received a certificate of medical fitness. Looking at the different guidelines, 11.61% had the basic Philippines’ Department of Health PEME, 7.3% underwent a P&I Club PEME whilst 81.09% were part of other PEME schemes. With the different applicable standards the 5.33% who were not found fit to work at sea based on their applicable PEME standards, are not necessarily unqualified to work for other employers. 

During the PEME and before the release of medical certificates, seafarers who have been repatriated are advised on their medical conditions and the health measures to be taken to reduce the likelihood of recurrent problems and to maintain their health to ensure their safety on board, and the safety of others.   

 

[1] The International Labour Office. (2011). Guidelines on the Medical Examinations of Seafarers. The International Labour Office. https://www.ilo.org/wcmsp5/groups/public/---ed_dialogue/---sector/documents/normativeinstrument/wcms_174794.pdf

D.13 The role of the P&I club

Details

CHRISTOPHER PETRIE

Introduction

Medical treatment of seafarer’s on board the world’s ocean-going vessels, and ashore if they require additional medical care, often involves a class of specialized insurance firms, Protection and Indemnity (“P&I”) Clubs, especially if the costs are likely to be high. P&I Clubs are mutual associations that provide insurance to shipowners, operators and charterers facing third party liability claims from a number of diverse parties, including seafarers, passengers, stevedores, nautical pilots and others.

Seafarer medical cases represent the largest single category of people claims handled by the P&I Clubs. There are roughly twice as many illness cases as injuries and only a small proportion of these result in death.

Seafarers come from all parts of the world. However, the majority are Asian, with Filipinos representing the largest single group by nationality. As any type of medical event could potentially occur at sea, P&I Clubs must be generalists when responding to emergent events on board and be ready to work with medical service providers who take the lead in treatment, medevac when necessary (and possible) or disembarkation to the nearest hospital or clinic when the vessel reaches port.

A Small, Specialized Insurance Community

The P&I clubs that underwrite this business are limited in number and pool their risks under the auspices of EU law, in order to reinsure jointly very large liabilities on an as needed basis. Presently there are thirteen P&I Clubs operating in what is known collectively as the International Group of P&I Clubs, ‘The IG’. Eight are based in the UK, three in Scandinavia, one in Japan and one in the United States. Together they insure roughly 94% of the world’s ocean-going tonnage. Many individual Clubs also insure local fishing fleets, small coastal tonnage and even fresh water fleets.

It is important to remember that there is no direct insurance relationship between the people who may require medical attention and the Club. The Club simply insures the liability that the Member, that is the ship owner or operator, has to each individual when illness, injury or death occurs on or near the vessel. The Club becomes involved with medical care issues because it will inevitably pay for them when the Member submits its reimbursement claim. Additional information on liability is available in Ch.2.10.

Additionally, the shipowner often does not have the staff or expertise to deal with an unfolding medical event in real time, so the Club is brought in from the outset to handle the matter as it unfolds and to follow up with medevac companies, tele medical providers, clinics and hospitals, as necessary.

The IG Clubs have staff who specialize in handling medical issues on board vessels and who work with medical providers when incidents occur. But the insurance cover extends beyond crew and passengers to other persons who board merchant ships world-wide. For instance, there is P&I liability cover for stevedores, pilots, inspectors, security guards and the many other third parties who board working vessels. It even extends to stowaways on vessels who may be injured, become sick, or die while on board.

A typical day for a claims handler at a P&I Club might include responding to a stevedore injury in Japan, a seafarer’s heart attack in New Orleans, an injured stowaway off the coast of West Africa and a passenger illness in the Caribbean. Each Club has a world-wide network of correspondents working in ports around the world who act locally on their behalf.

Thus, the hospital or clinic receiving the patient will, on most occasions, work directly with the local correspondent rather than  with the P&I Club itself. It is not uncommon, however, for Clubs to become directly involved with medical providers if and when necessary and depending on the part of the world where the incident is unfolding.

Medevac

P&I Clubs and ship operators have access to medevac providers world-wide, both private and public. How the event will be handled depends on the seriousness of the medical incident, the need to launch a helicopter or fast sea-launch and the location of the vessel at the time of the incident. Further information on the evacuation of a sick or injured seafarer is available in Ch. 5.9.

The costs associated with a medical evacuation vary greatly. Many Coast Guard authorities do not charge for their services, while others may charge ‘full rates’. When charges are billed to the shipowner, the liability is covered by the P&I Club.

Treatment in overseas port

Treatment will vary to a large degree depending on the type and extent of the illness or injury, on whether the hospital or other medical facility is a private or state-owned facility, on the methods of treatment employed, and on the country where treatment and care is provided. This can range from acute treatment, diagnostic measures, surgery, post-surgery treatment to nursing care and medicines. However, insurance cover is available for the costs of the level of medical treatment and maintenance which is necessary to ensure that the crew will receive proper treatment and care bearing in mind the type of illness and injury, the location of the vessel when the need for medical treatment arose, the urgency with which immediate treatment must be given, and the standard of treatment available in the country where the crew is domiciled. Proper treatment and care is a relative term, but the medical treatment facility where it is given should be certified and accredited for the type of treatment that is needed unless the urgency of treatment combined with the particular location makes it impossible to find such a facility. More information on medical care around the world is available in Ch 5.9.6. 

Repatriation

Many physicians who are unfamiliar with the standard of care in foreign countries are sometimes reluctant to release a patient who has suffered serious injuries or is being treated for a significant illness to their homeland for continued care. In response, the P&I Club can appoint a local healthcare professional to act on the Club’s behalf and who can be in direct communication with the treating physician.

Working as a team, the three parties arrange in advance for the receiving hospital to be ready for the repatriated seafarer when he or she arrives and so that treatment can begin immediately. This helps streamline the medical care and alleviates the first responding physician’s concern as to whether the patient will receive proper care once repatriated. Further information on the repatriation of seafarers is available in Section xxx.

Contractual Benefits for Disability and Death

After the immediate medical concerns are addressed and the seafarer is repatriated home, P&I Clubs remain involved with follow up care and the assessment of disability. This is important work because most employment contracts contain disability compensation clauses which pay out a US dollar amount to the seafarer depending on the extent of the disability and whether it is temporary or permanent.

Often there is a difference of opinion on the disability rating provided by the treating physician and the ship owner or employer. In this situation, the case may end up in arbitration or the local court system depending on the jurisdiction involved. When a ship owner or employer is forced to defend a legal claim from a seafarer, the costs and expenses associated with the defence are covered under the P&I cover.

Sick Wages

Seafarers are also entitled to the payment of sick wages for a contractually defined period of time following the medical incident. Once repatriated, the payment of sick wages is based upon confirmation from the treating physician/clinic that the patient remains sick or injured, i.e. not fit for duty. P&I Clubs (through their network of local correspondents) therefore also work in close cooperation with these medical providers to ensure that the seafarer is reporting to the clinic and that wages are being paid by the local manning agent.

In short, the Club acts as a type of manager, not only in relation to the treatment but also of the financial restitution resulting therefrom. This helps the entire system run smoothly and is of great benefit to the industry as a whole.

Passengers


A majority of the world’s ocean-going ferry, passenger and cruise vessels are insured by the IG Clubs. Insurance for liability to this category of persons, whether arising under statute, contract or in tort, is important for vessel owners and operators. This category of vessels represents an enormous risk for P&I Clubs as many modern vessels can carry up to a thousand passengers and crew, and some carry even more.

Responding to passenger incidents can be quite different from seafarers on merchant cargo vessels because many passenger ships have doctors and nurses on board who attend to the matter on an immediate basis. As such, immediate medevac may not be necessary and the vessel operator tends to take the lead in the medical case management.

However, if the medical incident is life threatening, involving many people or otherwise complex, the Club may be contacted to assist in the management. Injured or sick passengers, especially in cases involving ship-wide infections can be quite litigious. Resulting medical malpractice lawsuits against medical staff almost always include the vessel owners as a defendant. Clubs therefore work closely with medical professionals and other expert witnesses when defending cases in court.

Others

There are numerous other people who work or attend on board merchant vessels and who thereby expose themselves to risk while doing so. Most P&I Clubs divide these groups into three: those carried on board, not carried on board and ‘saved at sea’. The main distinction between the first two groups is whether the vessel is moving or not. If moving, then such persons are ‘carried on board’. If not, then such persons are ‘not carried on board’.

Persons carried on board

Navigational pilots are a good example of persons carried on board. When a merchant vessel enters the waters surrounding a port it must radio ahead to the port authorities and request a pilot join the ship in order to take command of further navigation. In order for the pilot to gain access to the vessel, he must take a small pilot boat alongside the ship and climb a long Jacob’s Ladder to reach the deck of the vessel.

During this time, the vessel is either drifting or at slow speed, and the pilot boat is constantly maneuvering to maintain its position under the ladder. Unfortunately, many accidents occur when the pilot is ascending or descending the ladder. More information on pilots is available in Ch 3.2.9.

Persons Not Carried On Board

When the ship is tied up at berth all third parties who board are not carried on board. The most well-known group in this category are the stevedores who load and discharge the cargo.

Many different types of accidents can happen when the stevedores are working the cargo. As the vessel is already in port, land-based medical first responders will be called to the berth immediately, thereby increasing the probability of a successful outcome. P&I Clubs are almost always called soon after the incident. The Club will then notify the local correspondent. Many hospitals will want to know within 24 hours who is going to be paying the medical bills for the injured person. The local correspondent will confirm that there is a P&I Club involved who will pay on behalf of the vessel owner and this tends to have a positive effect on subsequent medical case management. More information on health care in ports is available in Ch. 5.10

Persons Saved at Sea

Ocean going vessels are required by law to alter course and attempt to save life at sea when they are near a marine casualty or other marine incident. This usually involves orders from the nearest coast guard or other maritime authority. It could also involve an injured or seriously ill person aboard a nearby vessel which does not have the ability to land a medevac helicopter or steam quickly enough to the nearest port in order to save the person affected.

In these types of cases, the vessel may make direct contact with its P&I Club. Many of the costs and expenses associated with saving lives at sea are covered by the P&I insurance policy, so it is natural for the Club to be closely involved from the outset. More information on such incidents is available in Ch. 5.8 and on the requirement to respond in Ch. 9.10.

Stowaways, refugees and migrants
Stowaways too may fall ill or suffer injury while on board. Indeed, it is not uncommon for stowaways to be seriously injured or killed on board, for instance when hiding in enclosed spaces with limited air supply or being crushed by heavy equipment or anchor chains. Additional information on stowaways is discussed in Ch. 9.10.

Refugees and migrants often take unsafe pathways due to large numbers of people setting out to cross the sea in overcrowded and unseaworthy vessels. Many who survive need medical treatment for injuries or conditions which have arisen during the transportation, such as hypothermia and gastrointestinal illnesses. Additional information is available in Ch. 9.10.