TIM CARTER

D.1.1 Introduction

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.

D.1.2 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:

1. Studies of ships’ medical logbooks to determine frequency and consequences of common conditions on board.
2. Investigation of medication and medical equipment use, derived from requirements to replenish ship medicine chests.
3. 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.
4. Referrals of seafarers for medical and dental care in port
5. Repatriations and the frequency of return to work as a seafarer
6. Deaths from illness or injury on board, or immediately after referral for onshore care, with investigation of the scope for survival.
7. Perceived adequacy of training, medical chest, medical guides and telemedical advice by those who have just responded to an incident.