D.9 Evacuation of the sick or injured seafarer

SUE STANNARD

D.9.1 Introduction

Although the evacuation of a seafarer or passenger from a ship is not a common occurrence on many vessels, it does occur. In 2017, Radio Medico Norway treated 1316 patients, of which 15% or 200 were evacuated.

Evacuation options include:

evacuation of the patient at the next port. This can either be the next port of call in the normal trading pattern of the vessel or the nearest appropriate port involving diversion of a ship from its planned route.
ship-to-ship evacuation, for example the patient can be transferred to a ship with a doctor or other health care professional on board or onto a fast rescue craft or other vessel heading to shore. This depends on the presence of such a ship in the vicinity and appropriate weather conditions.
ship-helicopter evacuation. This relies on many factors, included but not limited to weather, availability of a helicopter, the range of the helicopter and position of the ship, see below.

Every evacuation, whether ship-to-shore, ship-to-ship or ship-to-helicopter is associated with complications related to physical movement from bed to stretcher and from one place to another. These may range in severity from the pulling out of intravenous lines or dislocation of immobilization splints to life-threatening ones such as the pulling out of endotracheal tubes or accidents involving the entire stretcher and patient during the transfer. There are well documented incidents of more harm done to the patient in transfer than in staying where they were^[1].

D.9.2 Risk assessment

Whether or not to evacuate and if so, the appropriate method of evacuation depends on multiple factors and must be determined on a case by case basis. These factors include the following.

Medical factors

These should be the primary factors in the risk assessment but they cannot be taken in isolation. In general, the reasons to initiate the evacuation of a patient from a sea-going vessel are:

Serious injury or illness that may cause invalidity or death and that requires care that cannot be given on board before the scheduled arrival in the next port of call. The risk of potential invalidity needs careful assessment. For example, the decision whether and by which mode a patient is evacuated may differ depending whether a critically injured finger is the fifth or the second one, and whether it is on the patient’s dominant hand.
The need for further investigation that cannot be performed on board and that cannot wait until the next port of call and the results of which would change the management of the patient, for example, radiology investigations.
Management of a seafarer with an infectious disease who cannot be appropriately isolated on board and whose ongoing presence on board may infect others and threaten the safety of the ship. If the patient is suspected of having a disease that may come under the International Health Regulation, 2005 for communicable diseases, it is essential for the TMAS doctor to notify all parties concerned, namely the respective MRCC/JRCC and the evacuation organization. The Master, under these circumstances, is under a legal obligation to notify the Port Authorities of the next port of call using the Maritime Declaration of Health. More information on the International Health Regulations is available in Vol VIII.

Other factors to consider include but are not limited to:

Clinical condition of the patient. The old saying of ‘never move an unstable patient’ should not be dismissed. However, this must be taken alongside consideration of what medical care can be given on board and what medical care is necessary. Is the patient as well and stable as they can be given the limitations of care and their surroundings?
Need for care in transfer. What care is necessary in transfer and can this be delivered must be considered. The care required in transfer will depend upon a number of factors including the medical condition of the patient, the length of transfer or time to port if the ship is diverted, the number and experience of staff accompanying the patient and what equipment will be available. If appropriate care cannot be delivered is this the best option?
The time window for receiving specialist investigation and treatment in order to improve the outcome for the patient must also be considered. For example, thrombolysis after a cerebrovascular incident must occur within a certain time after the onset of symptoms for the benefit to be worth the risk.
Fitness to fly. Although less of a consideration in helicopter flights than fixed wing aircraft due to the lower altitude of flight, the potential effects of changes in air pressure on the volume of entrapped gasses in the body and a relative lack of oxygen in the unpressurised helicopter should be taken into account.
Psychiatric patients may become uncooperative or even violent during the evacuation process. This can be particularly dangerous at the point of transfer or in the confined space of a helicopter. Appropriate personnel may be necessary to use restraint or medication as required.

Economic factors

These may be of particular interest to the Master who may feel under pressure to keep any costs to be incurred and disruption to the ship’s operation as low as possible. Factors include but are not limited to the cost of:

the evacuation itself e.g. the helicopter or rescue craft with personnel,
land transportation and any medical expenses in the proposed destination,
These aspects will be cost free in some countries but may incur very large costs in others
port agent fees for assistance provided
additional fuel for any diversion or increase in speed to reach port or another vessel more quickly
additional berthing for the ship if a route/itinerary is changed and additional time in port or time at anchor in port limits is required
disruption to the ship’s operation eg fishing itineraries and length of voyage, loading or unloading cargo with the hire of extra gangs in port, port calls and tours for passengers

Geographical factors

These are often beyond the control of those making the decision and factors include but are not limited to:

distance to shore. This will not only affect the timeframe in which an evacuation can be done but also how it is done. Other ships may be limited by distance and cost and helicopters have a fixed range depending on their type.
weather conditions form a large part of the risk assessment in many cases. Certain weather conditions make helicopter evacuation or the transfer of a patient from one ship to another very difficult if not impossible. The decision as to whether or not to proceed with the evacuation in these conditions will depend on many factors such as the experience of the flight crew, wind direction, visibility, wave height etc.
distance to appropriate medical care. It may not be appropriate to reach the nearest land as the required medical care may not be available there, but only further along the coast. Any planning of an evacuation must include the actual destination of the seafarer, be that a medical facility or an airstrip for ongoing movement.

Practical factors

Appropriate planning may be able to reduce these factors, including but not limited to:

availability of other necessary assets e.g. ground ambulance to move the patient from where they are landed ashore to the medical facility
the availability of the necessary assets e.g. a helicopter. The number and location of appropriate craft varies hugely around the world’s coastlines.
Motion sickness. This can affect anybody on any ship but may be exacerbated in sick or injured seafarer, and any accompanying person, when on board a small, fast craft or in a helicopter. The act of vomiting may have a serious impact on the seafarer’s medical condition and consideration should be given to the use of anti sickness medication on the advice of the TMAS doctor.
Risks to ship and others on board. Helicopter evacuations place the ship, the helicopter and all on board at risk should the helicopter crash and land on the ship. Increasing the speed of a vessel may make others unwell with motion sickness and increase the risk of injuries on board.

Risk management

Many of the factors mentioned are unique to each case and in many specific instances, they are beyond the control of those involved in making the decisions. However, certain steps may be taken to ensure that the likelihood of an evacuation and an associated risk occurring is reduced or, should it occur, the impact is minimised. Further information on risk management is available in Ch 2.5.

Steps in the risk management of medical evacuations may include:

Appropriate medical selection of seafarers – the right seafarer for the right role on the right ship. Further information on the medical selection of seafarers is available in Ch 4.8.
Appropriate training of medical officers in medical care. A ship owner or ship manager must ensure that seafarers have appropriate certificates of competency, including medical care as outlined in STCW. More information on the training of seafarers in medical care is available in Ch 5.3.
Appropriate medical chest on board, suitably stored and checked as required. More information on the medical chest is available in Ch 5.4.
Appropriate medical guide on board in an easily accessible place. This is included in the MLC 2006^[2]
The use of Medical Emergency Response Plans outlining an appropriate TMAS, MRCC/JRCC, evacuation resources, shore based medical care etc. It may be very difficult if not impossible for this to be done for ships on worldwide trading routes but for other ships on routes that are more regular or limited in location it should be considered. The use of a Medical Emergency Plan could be incorporated into the voyage plan whatever the itinerary.
The inclusion of relevant policies and procedures as part of the ship’s safety management system to include communication with TMAS and other shore based organisation, documentation required for the evacuation of a seafarer or passenger, transfer of the patient on board the ship, helicopter operations, ship to ship transfer etc. Advice in these areas is available from many sources e.g. the International Chamber of Shipping Guide to Helicopter/Ship Operations^[3]
Regular training on board of crew in the practical aspects of the above policies and procedures.

D.9.3 Options for evacuation

Ship-shore

If the medical situation of the patient allows and the distance towards a suitable shore-based medical facility is within acceptable reach in distance and time, the safest and most comfortable mode of evacuation is often by the vessel itself delivering the patient. This may imply that the vessel changes its course/ itinerary towards a nearer port than the one that was scheduled. Arrangements will need to be made for appropriate land transportation to meet the ship and for appropriate receiving care for the seafarer. The TMAS doctor, the vessel’s shipping agent or MRCC/JRCC may be able to assist in this.

Ship-ship

It may be the most appropriate option to arrange to meet with another vessel and transfer the patient. This may have two different motives.

More rapid and easier transfer of the patient to shore. This may involve the use of a pilot boat, coast guard vessel, fast rescue craft from a cruise ship or other vessel, another vessel heading at greater speed for port, eg another fishing vessel. Some of these options will also provide an additional level of medical care that can be used to stabilise and continue care for the patient during transfer.
Improved level of care. Sometimes the patient may be transported to a vessel offering more advanced medical care. Naval vessels, passenger cruise vessels and hospital ships are some examples of ships that will offer help in case of medical emergencies, sometimes far out at sea.

The risks of transferring a patient from one vessel onto another at sea must not be underestimated. Even if the sea is calm, walking down the gangway for a sick or injured person, and stepping onto a smaller vessel always has its potential hazards, regardless of the willing help offered from all sides. If the patient needs to be transported on a stretcher, this stretcher will need to be lowered by ropes down the side of the vessel, or via side doors if they are available, to be landed on the deck of the smaller craft below. In cargo ships the deck may be as high as 12 metres above the level of the sea.

Two large vessels adjoining at sea may sometimes be unfeasible. Transfers at sea onto larger ships as mentioned earlier may require an intermediate transfer in one of the vessel’s dinghies, thus implying two transfers ship-to-ship.

Ship-helicopter

Helicopters are a swift and efficient means of transporting the patient towards more advanced medical help. A helicopter’s range, however, is limited to an average of 150-200 nautical miles outside the coast, this being primarily a question of fuel supply. Newer craft are capable of increasing distances but there availability may well be restricted.

Helicopters involved in the evacuation of a seafarer from a ship maybe part of the national SAR capability, eg the Norwegian Coast Guard and the United States Coast Guard. These helicopters are manned with a doctor, intensive care nurse or medic who are well trained in medical emergency treatment and transportation. This implies that in getting help from a helicopter to evacuate the patient, expert medical personnel are also available offering a higher level of medical care, all be it in the relatively confined space of a helicopter. The helicopter and its crew will also bring in advanced medical equipment such as life-support and monitoring equipment and a defibrillator. However, in other areas of the world the helicopter and crew used may be a private provider with little or no experience of or training in maritime operations, no medical crew on board to offer care to the patient in transfer and no additional equipment. They are simply a means of transportation. In other areas there may be no helicopter evacuation capability at all, or a very limited number of craft serving a large geographical area.

D.9.4 Decision to evacuate

The Master, the officer responsible for medical care or the TMAS doctor, may identify the potential need for evacuation. However, many others may become involved in the discussion including

staff from the nearest MRCC/JRCC, medical or other,
helicopter and other vessel crew assessing weather and sea conditions
doctors or others at the receiving facility
doctors or others from the port health authority
the ship owner or operator and/or their insurer

Ideally, the parties will agree on the decision to take but there may be differences of opinion with each party having a different point of view and differing priorities. In cases where differences of opinion arise, these arguments should be clearly brought forward, each respecting each other’s professional arguments and come to a common understanding whether an evacuation is necessary and according to a thorough risk assessment. It is important to ensure that medical confidentiality is maintained as far as possible in all discussions, particularly those involving non medical staff. Further information on ethics and confidentiality is available in Ch 2.9.

D.9.5 Preparing the patient for evacuation

It is important that all relevant information should be collected and accompany the patient, preferably in a plastic sealing or envelope. It is essential that these comprise:

the patient’s passport, seaman’s book, vaccination book
medical reports from the time on board that include as a minimum:
- details of onset of illness or injury
- description of medical findings and a log of the development of these in the course of lapsed time, especially concerning the vital signs such as heart rate, blood pressure, breathing frequency, temperature, conscious level etc.
- therapeutic measures taken, especially which medication was administered, how and when
- a copy of all correspondence with TMAS or with doctors in previous ports concerning the patient.
personal belongings, as the patient is unlikely to immediately return to the vessel. These should at least include some cash, bank cards and a mobile phone and charger. If practicable and time permitting, his suitcase and personal effects should be packed and sent along with him.

It may also be necessary to prepare accompanying family members in the case of a passenger and to contact the seafarer’s or passenger’s next of kin. Shore side personnel may do this but it is important to ensure that it is not forgotten. In addition, if they are not already involved, relevant personnel and organisations ashore, for example the receiving medical facility, should be contacted and updated with the plans, contact details for the seafarer and relevant company contacts. An agreement should be reached about follow up of the seafarer once ashore. More information on management of a landed seafarer ashore is available in Ch. 5.10 and 5.11.

D.9.6 Medical care around the world

Variation

Medical facilities vary hugely in different areas of the world. Variation can be seen in

The availability of specialty services such as neurosurgery, tertiary level intensive care and support services such as interventional radiology, range of laboratory investigations
The practice of medicine, protocols followed, procedures performed, medication used etc
The level of nursing care and what assistance is given by the nursing staff eg feeding, provision of food etc
The input and role of the patient’s family in providing basic care such as washing
The buildings and their state of repair
The availability of medicines and other equipment e.g. ventilators

What is available where?

To keep an accurate, up to date and comprehensive list of all the medical facilities around the world, even limited to the coastline is almost impossible. The amount of information gathering and the speed at which things change make this a huge challenge although some of the cruise companies have attempted it in the past. Information may be available:

TMAS or MRCC/JRCC services may have a good oversight of what is available in their own and surrounding nations.
Assistance companies have a documented list of providers in different areas of the world but this is limited to their operating area.
Shipping companies may have built up their own list of medical facilities in ports that they visit often,
Local port agents will be aware of some of the facilities locally. However, they are usually non-medical and may not be aware of what medical care is required as opposed to what can be provided. In addition, there is often a degree of local politics involved in making referrals.

The provision of medical care within a country may be variable depending on location and population. Not all ports, towns or even cities may have a full range of medical services depending on the level of health care nationally and how it is organised in country. Whilst MLC 2006 and other international regulations clearly state that a nation ‘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’, health care that is not available for the local population cannot suddenly be available for a seafarer.

Care of the landed seafarer

Managing ongoing medical care may involve 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.
Liaison with the seafarer, 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 seafarer in terms of basic needs and to ensure communication etc to family and friends. He will also appreciate the provision of books, magazines etc, ideally in his native language, snacks and time to talk with another person that understands his position.
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.

Further information on this area is available in Ch 5.10 (Port Health care) and Ch.5.12 (Repatriation and Rehabilitation – may need to cross reference different sections).

^[1] https://www.dailymail.co.uk/news/article-1379884/Janet-Richardson-dies-dropped-sea-botched-rescue-attempt-cruise-ship.html

^[2] https://www.ilo.org/wcmsp5/groups/public/---ed_norm/---normes/documents/normativeinstrument/wcms_763684.pdf

^[3] https://www.ics-shipping.org/publication/guide-to-helicopter-ship-operations-fifth-edition/