ROB VERBIST

D.10.1 Port healthcare

Introduction

Port healthcare is a niche in medical practice. The proximity of a port, ships and those on board leads to specific demands on health care.

Port clinics are often part of a

• General Practice clinic near a port
• Occupational Health service within a port
• Institute of Tropical and Maritime medicine, or a
• Travel Clinic.

This depends on the kind of medical service that is most needed in an area, both by the port itself, the industry and the seafarers and passengers coming into the port by ship.

The practice of port maritime medicine demands specific knowledge and skills. It is not a recognised speciality in medicine and encompasses many different aspects of medicine. It needs an organisation and structure that meets the needs of the seafarers as patients or clients and the industry they work in. An all-round port clinic combines aspects of general practice, occupational medicine and tropical medicine, and may include a telemedicine service for care at of the patient form a distance.

The vulnerability of seafarers

Seafarers on board ships are among the most isolated people on the planet regarding access to medical care, both for primary care and in case of an emergency. On a large, slow merchant vessel, in the middle of the ocean a seafarer may be several days away from qualified medical services. In the interim the officer responsible for medical care provides any necessary care, with advice from TMAS where appropriate, utilising only a limited range of medication and equipment from the medical chest. More information on the care on board is available in other sections of this chapter. If required there may be the possibility of an evacuation but this is not always possible and not without risks. More information is available in Ch.5.9.

Of course, there may be a doctor or other health care providers on board but this is often limited to passenger ships. More information on cruise ship medicine is available in Ch. 2.13

Regulations

The Maritime Labour Convention 2006 (MLC)^[1] states that ‘each Member shall ensure that seafarers on board ships in its territory who are in need of immediate medical care are given access to the Member’s medical facilities on shore’ and that each Member shall

• give seafarers the right to visit a qualified medical doctor or dentist without delay in ports of call, where practicable;
• ensure that, to the extent consistent with the Member’s national law and practice, medical care and health protection services while a seafarer is on board ship or landed in a foreign port are provided free of charge to seafarers; and
• are not limited to treatment of sick or injured seafarers but include measures of a preventive character such as health promotion and health education programmes

However, the availability and quality of the healthcare found in ports around the world varies hugely. Some ports may have nothing and medical care must be sought from the general medical facilities outside of the port environment where there may be little or no knowledge of maritime medicine or the needs of seafarers or passengers travelling on board. On the other hand, some ports, such as Antwerp and Hamburg, have dedicated medical facilities within the port environment with a medical service dedicated to the needs of the seafarer and the shipping industry. These may be private practices, tailored to serve the needs of seafarers and shipping, or governmental port health services including clinical care. In other places, such facilities may be available but require a journey out of the port to access such care.

D.10.2 Barriers to health care

To contact or visit a doctor during a voyage a seafarer will initially inform the officer responsible for medical care or the Master. By contract and on the basis of international conventions the

company will most often take care of the costs and therefore any arrangements should be made this way. In most cases, this implies that the Master’s permission is necessary for the seafarer to

get medical advice.

The role of the Master

The role of the Master is complex:

• Confronted with a medical request by a member of the crew he will seek the advice of a
• medical professional, either by radio medical contact or in the next port of call.

• If a medical referral is necessary in a port, he will seek the assistance of the ship owner’s
• representative in the port to help him find an appropriate medical practioners or facility. This representative is usually the shipping agent.

• The Master’s position is that of the owner’s representative on board, he is first of all
• responsible for the safety of the ship, the well-being of the crew and for safe manning. But he is also responsible for the costs incurred.

• He will also have to be informed of the decisions taken and the need for additional medical care, restricted duties etc. His responsibility is for the safety of the vessel and the crew and he will need to assess the impact of the outcome on both the seafarer and the ship.

The role of the agent

Port shipping agencies have a relationship with the ship owner on a commercial basis and provide a range of services for the vessel and those on board. However they are usually non-medical and their choice of practioners or facility may be dictated by other factors apart from the medical condition of the seafarer. They will also often be the point of contact with the physician and provide the Master with help in line with his demand, attempting to ensure a proper assessment of the case, a swift response and clear report with regard to the safety of the patient, the ship and the rest of the crew. To do this they may have access to medical information that may be sensitive and should be treated appropriately. Further information on ethics and confidentiality is available in Ch xxx.

The relationship with the seafarer

This reality is the main reason why seafarers very often cannot or do not consult their own choice of doctor for advice but are referred to port medical clinics or a doctor chosen by the company or the agent on the company’s behalf. There is an argument that by signing a contract of labour, the seafarer voluntarily limits his freedom of choice with regard to medical advice with the benefit of not having to bear the financial consequences of any illness or injury he might acquire during the time of the contract. However, this way of working is often surrounded in mistrust for many reasons including but not limited to:

• fear of losing their job if they are unfit to work,
• concern that their medical condition becoming known to many,
• cultural differences,

language issues

A port clinic functions against this background. Medical advice is given to seafarers on direct request of the Master. The port physician works for the patient but on the request of the owner. He therefore becomes part of the work relation between the seafarer and his employer.

D.10.3 The Port Health Physician

As mentioned above the port health physician requires a number of skills, both medical and non-medical. Key to fulfilling his role effectively is knowledge of the patient, usually a seafarer, medicine, and the maritime environment.

Konwledge of the seafarer or patient

There was a time when seafarers came to port physicians with vague complaints and minor

ailments, in fact one could think that often the seafarer was just looking for some

tablets, some reassurance, and the possibility to go to a doctor for free or even to get a

free ride into town. Those days are over. Seafarers have complicated tasks to perform in both operational and managerial functions, they are trained people capable of making judgements and often aim to take decisions themselves. They are better selected and they are in better condition when they come on board. That, combined with the decreased number of crew on board and the shorter stay in port, makes consultations by seafarers less numerous but often more complicated in nature.

The approach to the patient must be empathic and open. Seafarers come to a port maritime physician often with a problem that has occurred on board and with which they have been alone for several days, thinking and often worrying. They may have attempted to self-diagnose and this can lead to many misinterpretations and it can take a lot of time and good communication to get these out of their mind. They may have been unwilling to seek assistance on board and therefore have had the problem for a while, or may have been unable or unwilling to access medical care ashore in previous ports. Hence, the cases that maritime physicians see these days are often more complicated.

The seafarer may need referral for more complex investigation and treatment. In this situation, appropriate arrangements must be made and additional communication with other medical professionals will be required to coordinate the care of the seafarer, his return to the ship or his ongoing stay ashore and subsequent repatriation.

In order to assess whether or not a seafarer can return on board and fulfil their duties the port physician must also have knowledge of life on board, the working environment, the tasks associated with the different positions and the medical care available on board. More information on many of these areas is available in this Textbook.

The physician has to keep an extensive record of cases and there is much time and energy needed for each case. Documentation may be required by many parties, with the consent of the patient, and if the seafarer is to return on board he needs good information and instructions on how to continue treatment and when, where or what complications indicate the need to seek follow up.

Knowledge of Medicine

General medicine

The port maritime physician should be able to work independently with an appropriate level of

competence, using evidence based medicine and with a broad knowledge base covering many specialities. He must be skilled in history taking and clinical examination as there is often not time for additional tests. If further tests are necessary, they must give the most useful information possible and referrals for specialist care should be appropriate and add value. Time is a very limiting factor in patient care and this time-pressure becomes a key element in decision-making.

The port maritime physician gives a patient-centred and community-oriented comprehensive and integral service that is responsive as well as anticipatory and includes treatment, prevention, health education and promotion, help and assistance where necessary. However, a characteristic element of general practice that is less present in the port medical practice, is the continuity of care. Seafarers often use the services on an occasional basis, maybe only once in their seafaring career. This requires special attention with regard to reports and plans for follow-up that may occur in another port. The port physician has to assist the patient on how and where to seek follow-up.

Occupational medicine

In a maritime environment a medical decision will always have to take the specific working and living situation of the seafarer into account. The success of the treatment depends on the conditions on board and the implications such treatment has on the individual seafarer and on the safety of the ship. When the professional circumstances of the patient are of such importance in the medical

decision, occupational medical training is very important for a good maritime port physician.  

Not only to have an idea about safety and the ability to continue to work on board, but also to identify aspects of work that may cause injury or disease to a seafarer. Hazard definition and risk management, how to modify work activities and monitor trends in health are subjects that a port physician should be familiar with. More information is available in Ch. 2.5.

Knowledge of so called tropical medicine, expanded to all kinds of pathology common in

other areas of the world but less frequent in the country of the physician, is important.

Vaccinations related to work and travel have to be available in the port clinic and travel

advice that takes into account the specific characteristic of the ship and voyage is

certainly a necessary element of the work in a port clinic.

Knowledge of the maritime environment

Ideally, a port maritime physician should have sailed on board a ship. He has to feel, hear and smell life on board. He should experience the way seafarers live on board and the way they work, note the psychological strain of watch systems, feel the physical strain of some work on board and the monotony in other tasks. At the very least physician should have a good idea about the different tasks on board ship and insight into the functional demands of each task. He should have a profile of each function on board and must know particular hazards for health and wellbeing in each of these jobs. More information on this topic is available in Ch 4.3.

It is also important that the physician understands many of the stressors that exist in both living and working on board. These may include the short passages between ports, the numerous tasks to be done while in port etc.… and the isolation from family and friends, little time off and restricted diet and exercise facilities. More information about life on board is available in Ch xxx.

In addition, the physician must also understand aspects of the shipping industry, its regulation and its operations. More information is available in Ch 4.4.

D.10.4 The Port Health Clinic 

Services

Many seafarers remain on board, unwell, worried and afraid, longing to get professional assistance as soon as possible, ideally in the next port of call. In order to best assist seafarers port clinics should provide a wide range of services and should be:

• able to assess and manage a wide range of acute and chronic medical problems or other issues
• able to access secondary care for further investigation and management of more complex medical conditions
• able to provide a wide range of other services including pre employment medical examinations (PEME), vaccinations and diagnostic tests, both laboratory and radiological, among others.
• assist in questions of fitness for duty and other work related health issues

This requires a well organised referral system both to and within the clinic and to all kinds of specialised consultations and care if required.

Availability

The availability of a physician and work in a port clinic has to be organised in relation to work in the port. Although work at night and during the weekend may have declined in some bigger ports, activities almost never stop. The port maritime physician should organise his work in a way that maximal presence is possible and ideally provides round the clock availability, seven days per week, 24 hours per day. Generally, this is only possible in an association or in a network of port maritime physicians. It is therefore important that the port clinic organises or participates in a regional watch system for the port area.

A port clinic should have physicians available prepared and at all times ready to go on board a ship to provide treatment or advice, not just to receive patients in the clinic. This may happen alongside or at anchor or even while the ship is on its way to or from the port. This may be physically demanding, for example, boarding a ship from a pilot boat and may take many hours if the ship is still some way out of port.

Location of the clinic

The clinic should be

• the easiest way for a seafarer to get medical help on arrival in a port.
• nearby and easy to access.

In the evolution to the shorter and shorter stay of the ship in port, the location of the clinic or reception of the seafarers in or nearby the port area is important. A clinic should at least be within easy reach of transport coming from the port area and to a certain extent it may need some visibility in the port area itself.

For ease of referrals, the port clinic should be close to an emergency medical care unit and other specialized medical services. The seafarer will not have the time to take long trips to and from these services. Equally, a port pharmacy in the local vicinity, that understands seafaring and is aware of how to deal with maritime patients, is almost a pre-condition to permit the fast and smooth treatment of the seafarer.

Facilities in the clinic

The reception and waiting room must be clean and comfortable and decorated in a way that the seafarers feel at home.  A poster or some leaflets in their language, magazines or even newspapers make the seafarer feel recognised in a foreign port.

Health information relevant to their profession should be available so that seafarers recognise the special focus of the clinic to their profession, leaflets and booklets about health at sea should be available to them, free of charge.

Treatment rooms have to be clean and well equipped with separate rooms for treatment and consultation. Rooms should allow the seafarers to have a private and confidential talk with the attending physician although translation or assistance by a third person may sometimes be very important.

Instruments and equipment necessary are basically the same as in general practice but in view of the many accidents on board a focus on the treatment of small wounds and trauma may be necessary.

D.10.5 Specialist care for seafarers.

The Maritime medical unit

Although general medicine is the basis of port healthcare, it is of the utmost importance to have access to other specialities, often in other facilities. The selection of the service, department or individual specialist to refer a seafarer to should be done on the basis of accessibility of their service for seafarers. Ideally a number of specialists and facilities will have been identified by the port physician and they, alongside the port clinic will form a maritime medical unit with focus on the maritime aspects of the seafarer’s life and work.

It is of the utmost importance that the responsible and treating doctor understands seafarers. For an optimal service seafarers require immediate access to a specialist so a rigid appointment system is therefore not good. In reality many specialists who provide this extra service have a link with seafaring, the port, or the maritime world.

Some of the specialities that are most important to have easy and rapid access to are:

• Radiology particularly ultrasound,
• Orthopaedics and Trauma
• Ophthalmology
• Dermatology and

Dental care is also critical for seafarers and although dentists often have their own port service it is most important for the port physician to be familiar with that system and to know how to access urgent dental care.

Hospitalisation and ongoing care of seafarers

Whenever a seafarer is hospitalised the maritime physician should closely follow-up the case and actively participate in the process of diagnosis and treatment, making sure that the necessary care is given but also no more than the necessary care.

The role of the maritime physician is to bring up elements of interest for the diagnosis and treatment that relate to life on board and the particular history of a patient. He has to make sure that the hospital specialists and their assistants get background information on the patient and their living and working environment.

The port physician can usefully take an intermediate position between the hospital care and all

agencies and individuals that take an interest in the health of the seafarer and assist in helping the seafarer to get back on board or to get the home as safely and quickly as possible.

Managing the ongoing care of a seafarer landed into a port also involves the

• Guarantee of payment for or pre-payment of the hospital costs. It is advised that appropriately trained staff monitor the treatment and costs incurred, in order to ensure that care is appropriate and necessary. This may be the port physician, the agent on behalf of the shipping company or insurer, or an assistance company.
• Liaison with the patient, his employer/manning agent/insurer and next-of-kin while he is in hospital. Care must be taken to ensure medical confidentiality.
• Practical support of the patient in terms of basic needs and to ensure communication etc. to family and friends. This is often done by the agent but welfare centres and other organisations may play a role.
• Arranging for repatriation home back home once the treatment in hospital is complete or a further evacuation for a higher standard of medical care if required. This may involve many different people with different interests and good communication and coordination is vital. More information is available in Ch 5.11 (Repatriation)

D.10.6 Patient management strategy 

Introduction

Time is a critical element in medical care for seafarers and therefore it is of the utmost importance to organise an efficient care strategy.

From process-analysis we now understand and use the term ‘critical path’. For medical practice this is called the ‘clinical path’. Such a clinical path is the result of the collaborative effort of many to determine what might be the best way to treat the seafarer.

A clinical path, patient care strategy is built on a quality-first attitude that includes steps to:

• Analyse the different steps in a process of diagnosis
• Try to find time consuming elements
• Try to improve efficiency and quality
• Select methods that give faster and more accurate information

This should be done for the more frequent types of care that seafarers need. But the introduction of a path-based management may be easier if it is first applied to types of care where problems are encountered frequently. A good knowledge of a seafarer’s life and likely medical problems is necessary to start this analysis. An example is given below.

The possible clinical path of a seafarer patient

1. Reporting of the problem on board

This first step in the process is already problematic. A seafarer on board may be in a position that he

does not want to report his problem, for example, because of a poor social protection system, a conflict with a superior, or fear of losing  his job.

2. Permission of the Master to send him to the clinic / hospital

Some Masters do not want to send their crewmembers on land. They think the seafarer is using the

complaint as an excuse to get off the ship for a few hours. They need all hands on deck for work to be done in the port. They may have too limited medical knowledge to judge the situation.

3. Transport / Access to the clinic / hospital

In a big port, the clinic or hospital may be far from the ship. Often taxis have to take the seafarers and that may take a long time. This may contribute to valuable time lost in the treatment and management of the patient. If the transport service has not been instructed properly they may take the patient to any doctor or a hospital which does not have knowledge of the seafarer’s condition.

4. Reception

It is of the utmost importance that a seafarer is well received in the clinic. The reception must give the patient confidence with regard to the care he is expecting and language barriers should be handled with patience. An accompanying person from the ship to help with translation is sometimes necessary. The reception staff need to be trained to recognise urgent cases and inform the doctors.

5. Waiting time

Waiting time should be short in relation to the pathology or the schedule of the vessel. Appointments are good for routine consultations but there should be room for an emergency or an urgent onsultation if the ship is about to depart.

6. History taking and communication

Always take the cultural background of the seafarer into account. For some it is impolite to givenegative answers or deny. Some have different attitudes towards pain. Always give the patient thechance to express his worries or anxiety.

7. Clinical examination

Although this is not usually hindered by language problems, it may happen that the response to a est is different because of cultural behaviour. It may also be delicate for some to have to undress nd they may want chaperones to be present. Any uneasy situation may lead to omission of mportant aspects and information. The patient must feel confident and respected.

8. Laboratory tests

In the selection of an appropriate laboratory test the choice does not only depend on the ifferential diagnosis but also on what can be done before the ship leaves. Relevance of the lab test is mportantbut also more exceptional or ‘tropical’ pathology should be reminded.

9. Medical imaging

In this respect the selection of the most appropriate test is important, a method that issufficiently sensitive and specific to support the clinical findings and differential diagnosis.Sometimes an ultrasound may give a better chance of obtaining the relevant findings than a CT scan or MRI, sometimes precious time is lost by first doing an ultrasound if in the end an MRI / CT is necessary, etc..

10. 10Communication of results

All results should either be in English or in the native language of the seafarer. If not, an English summary of the reports should be added to the seafarer’s documents. All results should be typed,  and written notes are to be avoided. Services that cannot provide immediate protocols of this kind should not be used.

11. Assessment

It is not unusual in a primary care setting not to come to a diagnosis. Most conclusions are working hypotheses. It is essential and sometimes enough to advise the seafarer about his capacities and risks with the safety of the ship as important reference. He should be advised of things to look out for and how, when and where to seek appropriate follow up.

12. Explanation

As in every consultation it is a critical to explain the findings and summarise the plan and treatment. Information can be misinterpreted, the seafarer can get lost in technical details or can be frightened by the medical language. Make sure the ideas, concerns and expectations of the seafarer are clearly identified in the history and well explained at the end of the consultation.

13. Reporting

Reports sent to the ship should hold essential information about the duty status of the seafarer and the safety of the vessel. If the seafarer has to be repatriated or hospitalised it may also be necessary to involve the agent, the company, the insurer and the consulate. Medical and sensitive information should be handed over to the seafarer only and all results of investigations including x-rays are to be given to the seafarer to allow follow up and avoid repeated tests in other ports. In general, the rules of privacy, confidentiality and professional secrecy apply as in any medical activity. More information on this is available in Ch 2.9. The officer on board responsible for medical care may however participate in the treatment and become part of the confidentiality on the condition that they respect the rules. Sharing information with persons not involved in the treatment is not possible.

14. Medication

Medication has to be given with an explanation in English or the native language of the seafarer. This should include information about dosage, length of treatment and possible side effects, how and where the medication should be kept and how and when to use it. Reports and instructions should always mention the generic names. Pharmacies that can deliver on board are preferred and the seafarer should never pay for the medication, in the first place, the agent, the captain or the insurer should handle this.

15. Transport back on board

Convenient transport back to the ship should be arranged and assist the seafarer until he is back on board. The transport provider may accompany him to explain further arrangements and follow-up consultations or wait at the gangway to get the seafarer back off the ship to the hospital or airport if appropriate.

This example highlights a number of essential moments and events in a normal consultation that may be decisive for the quality of care a seafarer gets. A real maritime medical service or port clinic is organised in a way that these elements are taken into account and maximal effort is made to overcome the barriers for the seafarer. This can only be done if all partners have knowledge and insight in their roles and tasks from the taxi driver to the receptionist, the nurse and the doctor.

D.10.7 Other health related organisations in ports

Welfare organisations

Very often seafarers are reluctant to trust the port maritime physician because they think they might have links to the Master, the agency or the company. Therefore a seafarer sometimes does not

report personal and more delicate problems for treatment.

Good contact between the port clinic and the welfare services for seafarers in the port is very important so that seafarers that report such issues to the welfare workers/ship visitors get proper treatment and do not lose their rights.

Welfare organisations also play a very important part in visiting hospitalised seafarers and there should be a system to report hospitalisations to them. Often a team of volunteers will visit the seafarers regularly in the hospitals, to offer them newspapers or a telephone services to reach their families.

Sports activities in ports are organised by welfare centres and seafarer’s clubs and medical

support for these activities is important. It should be provided by the port physician and include some guidance and a small medical chest for first aid.

More information on the role of welfare organisations is available in Ch 3.8 and 4.6.

Port Authorities

Because a port maritime physician is operating in their area the port authorities should be aware of the activities in the port clinic. Permission may be needed to enter certain port areas, to go on board ships and to enter specific installations like locks and terminals according to the appropriate rules.

Even if the port clinic is a private initiative the port authority should know about the activities and services given.

In case of a major health problem in the port, the port clinic may be asked to help and

assist in a specific task. It is important to be prepared for such actions and have regular updates and meeting with public health, port health services and port authorities.

Port Health Authorities

Port health authorities are often part of or work closely with port authorities. There main roles are:

• Inspection / deratification. Port Health Authorities have the duty to control the ships and port area as regards hygiene and the presence of infections or vermin. They have the authority to fine or detain ships if required.

• Control of outbreaks. The port clinic is often the outpost for this service and can be the first to detect an infectious disease on board. Examples include a case of open lung tuberculosis or a positive test on COVID-19. Close collaboration with the Port Health Authority is necessary in these circumstances to organize further examination and care and reduce the risk of further propagation of the infections. Further information is available in Vol VIII.

• The port health authority also handles vaccinations and controls the vaccination cards where necessary. In some ports the vaccinations are given by port maritime physicians and therefore a close relation with the port health authorities is necessary.

• Maritime Declaration of health. The International Health Regulations, 2005^[2] apply to ships and ports and the port health authority ensures/enforces the application of the rules. Every port maritime physician should know these rules and assist the public health authorities to apply them. Further information is available in Vol VIII.

• Disaster planning. Ports are very complicated areas when it comes to goods and chemicals stored and handled. In the case of a fire or an explosion, the Port Health Authority is at the core of the rescue planning.

Emergency services

Emergency medical centres in or around the port area should cooperate with port clinics and port maritime physicians. Procedures and protocols may be installed to allow a good communication between these services and the port clinic. Should a seafarer be brought to such a centre directly, the port physicians must be informed about it and contacted to organise follow-up and further care.

A system could be that in such cases the emergency centre is responsible for the

diagnosis and instigating treatment, but that the port physician is involved in writing a report for

the seafarer and ship and has input into the decision on duty status and eventual disembarkation or repatriation of the seafarer because of their knowledge of the work on board and the specific demands for each task on the ship.

Fire brigades and the providers of ambulance transport in the port are also most important partners to locate, rescue, evacuate and transport injured seafarers. The port maritime physician has to keep good relations with these services to find a seafarer who has been evacuated to a hospital urgently.

Maritime Rescue Coordination Centres

In case a ship has announced a medical problem before arriving in the port through the Medical Declaration of Health (MDH), or asks for immediate assistance by a doctor on arrival, it is very important that maritime rescue coordination centres (MRCC) are aware.

They can give the ship priority to enter the port and if necessary they can put it in a special quay or berth for easy access. The centre can advise the doctor and emergency service on the exact time

and place to go on board. Also in case of departure with a medical case that is not finished or if it is necessary to put the seafarer back on board at the last minute, the coordination centre may give important information about the exact time of departure, possibilities to put the seaman back on

board in the locks etc.…

Hospitals

Not many ports have a special harbour hospital or a service for seafarers only and

the port maritime physician should carefully select the hospitals and departments to

cooperate with for specific cases. The geographic position of the hospital may be important not only in respect of the port or the ship but more in relation to the agencies and the welfare

centres so that they can visit a hospitalised seafarer regularly.

Universities

Some departments of a University Hospital may be of importance for port maritime

physicians. The department of Tropical Medicine for example is very important and particularly useful in some cases. The department of the University Hospital where a seafarer is eventually hospitalised should again be briefed about the special procedure for seafarers by the port maritime

physician. Close relationships with such facilities can be beneficial for all.

Port Clinics in other ports

When a seafarer is sent back on a ship he should carry a report including all results and technical documents concerning his examination and treatment and a clear instruction to contact a port physician with these results in hand in case it is necessary. All printed material of a port clinic should mention something like ‘In case you consult a doctor in another port about the same problem, show him all results you have got from us…

D.10.8 Medical records 

Electronic patient files

An electronic patient file system should be used that works well with a database that has a large number of files but contains relatively small bits of information. This should all be compliant with data protection regulations, such as the European General Data Protection Regulations (GDPR), including a separate invoicing system in case the payment system for the seafarers is different from the national health system. Regular back-up systems and data security are necessary, as are separated access rights for different functions in the clinic.

Electronic files have the advantage of being portable and allow population analyses. Information should therefore be stored in a standardised way and port maritime physicians are to be encouraged to use, for example. ICPC2 (WHO International Classification of Primary Care, 2^nd Edition) to write down their assessment or diagnosis of a case. Even if the files have the purpose of diagnosis and treatment, data may be used for research if they are organised in a correct way and this is an important point at the setup of the systems.

Medical information

All medical information should be handed to the patient and is his property and responsibility. He should keep them safely as he may have to use them in another consultation.

Copies of the report and the result are to be kept in the medical file of the port medical service. Other interested parties like insurances, representatives of the company etc should given information as necessary and as allowed by national regulations etc and with the consent of the seafarer. More information on ethics and confidentiality is available in Ch 2.9.

The medical records should contain:

1. Identification of the patient
   1. Name and First name
   2. Date of Birth
   3. Nationality
   4. Gender
   5. Rank on board
2. Identification of the Vessel
   1. Name of the ship
   2. Type of ship
   3. Information of the voyage: trading area, cargo, next port, time in port, estimated time of departure.
   4. Shipping Agency and phone number
   5. Transport company to the vessel and phone number.
   6. Quay, name or number
3. History of the present illness / injury
4. Objective findings
5. Specialized examinations or test results
6. Assessment
7. Planning
8. Treatment
9. Duty Status

The duty status should indicate if a seafarer is fit with regards to the work he can do on board. Is he completely fit? Completely unfit? Can he do limited tasks? What tasks? Be as specific as possible.

It should also indicate if it is safe for the seafarer to remain on board. For example, a seafarer with a complicated bandage may be able to perform watch duties, but in case of an emergency, like an abandon ship alarm, this man would not be able to save himself and would depend on others. Such reason may be enough to sign him off and repatriate him. This decision must be made in the context of type of ship, kind of voyage and also social network of the seafarer.

Medical report for the Master

Information in this report should allow the Master to judge the condition in a way that he

can evaluate the risk of keeping a seafarer on board and also can estimate the abilities of

the seafarer to return to work. It may also be necessary to report whether a condition holds a risk for the rest of the crew, for example, in case of infectious disease. In that case, a further instruction how to handle the case has to be added to the report.

^[1] https://www.ilo.org/global/standards/maritime-labour-convention/text/lang--en/index.htm

^[2] https://www.who.int/publications/i/item/9789241580496