ELIAS VAN HAVAERBEKE; ARNE JOHAN ULVEN – FROM 2ND EDITION.
Telemedical maritime assistance services (TMAS) are remote medical advice services designed to provide medical assistance to seafarers and others on a ship. Quick and easy access to such a service is a key element of medical care on board and these services are primarily used by seafarers on board ships without a physician. Ship’s doctors or other health care professionals may also seek assistance when necessary. The service may be organized and sponsored by member states of the International Maritime Organisation (IMO), or may be a private enterprise. Legally, every member state of the IMO is obliged to provide a TMAS at all times, to all ships and free of charge. The Master or the officer responsible for medical care on board a ship should request remote medical advice from a TMAS centre, as and when they consider it necessary. It should be noted that TMAS provides an advisory service and that the final decision and responsibility for the treatment of the patient, including evacuation or diversion etc. is always for the Captain on board.
TMAS forms an integral part of the Search and Rescue (SAR) capability of many nations. Medical evacuation of the patient can be required and in this case, a Maritime Rescue Coordination Centre (MRCC) or Joint Rescue Coordination Centre (JRCC) can assist in organising this evacuation if available. Good cooperation between TMAS centres and MRCC/JRCC is key for this kind of operation. More information on Search and Rescue is available in Ch. 5.8.
D.7.2 Regulation of TMAS
TMAS is regulated by a convention that is the product of the cooperation between the IMO and the International Labour Organisation, convention 164 of ILO Health Protection and Medical Care (Seafarers) Convention. As TMAS is seen as integral part of SAR, additional requirements are set in the IAMSAR (International Aviation and Maritime Search and Rescue) manual.
The Maritime Labour Convention 2006 (MLC) also makes reference to TMAS and states that ‘the competent authority shall ensure by a prearranged system that medical advice by radio or satellite communication to ships at sea, including specialist advice, is available 24 hours a day; medical advice, including the onward transmission of medical messages by radio or satellite communication between a ship and those ashore giving the advice, shall be available free of charge to all ships’.
D.7.3 Differences in provision around the world
Despite the regulations, the provision of TMAS varies hugely around the world with significant differences in the availability, capability, range of services and quality. In Europe, almost every country provides remote medical assistance through a TMAS centre. In other parts of the world far less countries meet the obligation of establishing a TMAS centre. For example, India, a country with approximately 13% of all officers at sea, does not offer this service.
TMAS providers differ in some aspects, such as whether they are part of a hospital organisation or if the center is manned 24/7 by dedicated doctors. Some countries choose to provide the bare minimum whilst for others, no effort is too much to create a professional organization. Some services only offer advice and guidance if the case needs to be evacuated from a vessel whilst others offer ongoing medical advice for any concern.
In Denmark, there is an exception to the rule that the Master remains responsible for the ongoing care of the seafarer. Upon calling the Danish TMAS centre and agreeing that a sick or injured seafarer should be evacuated, the medical responsibility is transferred to the treating physician.
Private vs state providers of RMA
TMAS can be a governmental service funded by the state, or a private service. Private providers are often, but not always, a regular doctor doing a consultation over a certain distance from shore. Large assistance companies with 24/7 manned operation platforms may also offer telemedical assistance to ships around the world.
There are two key differences between private and public providers of TMAS:
- Public providers organized by the state work within the IMO-set legal frame for TMAS centres. Private providers do not have to follow any rules or guidelines set by the IMO.
- State run providers are supported financially by the flag state whereas the state does not support private providers in any way.
For survival, a private organization needs consultations and the shipping company must usually pay for access to the service. Payments may be annual or per consultation. It is vital for a private organization to provide a quality service, otherwise companies will take their business elsewhere. A state organized and funded TMAS service does not have this need for a minimum number of consultations because the income is guaranteed by the state. Therefore, both systems have a different way to guarantee the quality of the service provided; state run facilities because they follow a minimum set of requirements set by the IMO and private providers simply because they still exist and retain clients.
There is an increasing desire to improve cooperation between TMAS services to ensure quality and consistency in the service. Closer cooperation would also offer improved information about the diagnoses etc. of cases that are handled on board.
Communication is key for a quality and efficient TMAS. It may be spoken or written and pictures and videos can be sent to clarify certain symptoms. Establishing this communication is possible by multiple available means including VHF, HF, MF (satellite) telephone, e-mail and INMARSAT.
The List of Radio determination and Special Service Stations contains contact details for the state organized TMAS services. This list is on board and available in the ALRS Vol I. For most of the TMAS-centers, communication channels mean all possible modern ways of communication: via (satellite) telephone, INMARSAT, e-mail, VHF, HF and MF. A TMAS service can also be reached by contacting a MRCC/JRCC.
Some TMAS services work in a different way. For example, only one or limited ways of communication can be used. In Portugal for example, the only way to establish contact is by using VHF channel 16. Another possibility is that a TMAS service can only be contacted by first contacting an MRCC/JRCC or another organization such as the coast guard.
Ship’s officers generally use their own language when they contact their national TMAS. For all other communication and to other centres, English is generally used. Every medical consultation must be recorded in accordance with the national regulations of each TMAS centre.
Communication with ships in morse code on long and medium waves became possible from 1906. The coverage was mostly near coast areas until after World War II when short wave was also used and the coverage became worldwide. Despite its superior efficacy, the use of morse code decreased during the late 20th century. It was finally replaced completely by the Global Maritime Distress and Safety System (GMDSS) on February 1st 1999. Now clear text could be transmitted without the need for interpretation, the predecessor of today’s email. However, the advent of the internet in the 1980s made telex obsolete and the telex networks closed down around 2000. The satellite era and the advent of the internet allowed for the development of the e-mail system that is the predominant mode of written communication ship/shore today.
The advantage of written communication is that the communication is well documented and any language issues or misunderstandings may be reduced. The disadvantage is the slowness of the process. Pictures, video and vital data can also be transferred and add great value when appropriate.
Radio communication with ships today is rapidly declining except for VHF in coastal regions. Telephone communication via satellite is by far the most used mode for long distance communication in the shipping industry. The signals pass from the land-based telephone net, or mobile net, via an earth station and a satellite to the recipient, and back. The audio is usually of a high quality, even if some echo or delay may occur.
The important advantage of voice communication is the speed of information exchange. When immediate aid is necessary, written communication can be far too slow. Voice communication can be supplemented with written communication as necessary. Documentation of voice communication is possible by means of voice logs. In addition, other important aspects of medical consultations, such as reassurance, are easier to deliver by voice. However, voice communication is not without pitfalls, the most important being language problems. Some ship’s officers do not have the necessary knowledge of English and this can cause huge issues in establishing the medical problem, its severity and advising on appropriate care and action. Some nations have online interpretation services for civil purposes. The establishment of an international service of this kind would be a natural task for the future cooperation among TMAS services.
Standards of communication
Both the TMAS doctor and the ship’s officer should have an appropriate level of English and the TMAS doctor should be careful to use plain language and refrain from professional jargon.
The use of standard forms may also improve communication and these can be found on the International Medical Guide for Ships 2007. Officers would benefit from consulting these forms before calling the TMAS service and TMAS doctors should be familiar with them.
Difficulties in communication
In practice, the English vocabulary of many seafarers is not good enough to communicate about medical problems. In addition:
- Medicine is not practiced the same around the world. The trust of the officer responsible for medical care and the TMAS doctor is a critical factor.
- Different cultures have different ways of communication. Non-explicit links can be even easier lost in the communication. The communication is already of a basic form with many obstacles between the doctor and the patient.
D.7.5 The TMAS physician
Although the conventions stipulate that doctors who give tele medical advice to ships shall receive proper training and be aware of shipboard conditions, ‘proper training’ is not defined in any detail. It seems fair to suggest that the advising doctor should have appropriate knowledge of
- Spoken and written English
- Ship types and positions on board
- Dangerous cargoes and their potential health effects
- Medical facilities around the world and the variation in services and quality
- The variations in the content of medicine chests on different vessels
- The variations in medical knowledge, training and skills on board a ship
- The variation and limitations in the ship’s medical centre
- The role of Maritime Rescue Coordination Centres (MRCC) and Joint Rescue Coordination Centres (JRCC) and SAR services
- The implications of culture, hierarchy on board, economy and possible consequences of getting ill or injured for further employment of the seafarer
- The options and risks of medical evacuation
D.7.6 TMAS in the offshore industry
The operators in the international oil industry will normally be obliged to arrange and finance their own TMAS and SAR services due to national regulations. Ships serving the offshore installations will normally not be included in this service and will have to contact the regular TMAS services unless they are within a very short distance from the installation, as defined by the operator.
 International Medical Guide for Ships. 3rd edition. Geneva: World Health Organisation. 2008