AGNAR STRØM TVETEN
D.5.1 Introduction
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.
D.5.2 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.
Movement
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.
D.5.3 Layout and function of the medical facility
Overview
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.
Emergency room
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.
Examination table
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.
Lighting
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.
Storage.
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).
Working surfaces.
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.
Doctor’s office
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).
Interior
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.
Hospital function
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.
Comfort
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.
Environmental controls.
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
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.
Easy access.
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).
Systematic approach.
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.
Secure storage
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.
Storage conditions
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.
Communications
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.
Cleaning equipment
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.
D.5.4 Requirements for specific types of ships
Smaller vessels
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
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.
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.
Ambulance boats.
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.
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.
Hospital ships.
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.
Naval vessels.
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.
D.5.5 Rules, regulations and guidelines
Overview
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.