Textbook of Maritime Medicine

In this paragraph the main principles of medical care on board will be dealt with. Principles related to the technique of onboard medical care and organisation templates for this will be discussed.

9.4.1   Principles

Medical care of seafarers is medical care on the watershed of a few different strains of medicine. Medical care to them has elements in it of primary health care, secondary line health care and of occupational medicine. But also diving medicine, hyperbaric medicine and aeronautical medicine care have relevant fields to yield to the medical care of seafarers.

The conclusion is that medical care should take into account a broad set of aspects in order to support the seafarer in the best possible way. Next to a broad basis in medicine there should be evident and thorough knowledge of the aspects, possibilities and limitations that are linked to the shipping industry. There is no single best practice model for medical care as it seems that different approaches will lead to good medical care on board as long as there is attention to all aspects of medical care on board. In this case medical care on board is no primary healthcare in special conditions nor is it secondary line care with elements of primary health care. It is the best of both worlds!

So a broad knowledge into medicine and an eminent insight in working conditions on board are the two basic fundaments that enable the best medical care on board.

Next to this in relation to the principle of the shipping industry, whereas this is a global logistic industry, there needs to be an overall chain thinking- principle that applies on medical care to all seafarers. There are a number of relevant links in this chain

• Pre-employment check-up ( ch 7)
• Medical education (ch 8)
• Medical facilities on board (ch 9.5.5)
• Telemedical options (ch 9.6)
• Medical evacuation (ch 9.7)
• Follow-up care (ch 8)

As you might expect the different links will only have positive influence on medical care when other links are properly taken care of too. Any weak link in this chain might endanger the strength of the chain as a whole.

In this matter, one of the most important things to take into account is the fact that medical care on board is most often provided by a person who is more or less a trained laymen. This person is usually the first officer. It is therefore necessary to take into account the persons experience, knowledge and also his tongue/ nationality to make the right assessment of working with such a person. In most cases it will work out all right but an overestimation of the person’s abilities might endanger the affected seafarer’s health or even the ships safety.

As mentioned, there are aspects of occupational medicine related to medical care on board. But there are also aspects of primary and secondary care in it that give way to discussions on the privacy aspects in the doctor-patient relationship on board. This is difficult for both doctors and for seafarers. The boundaries are easily crossed. The seafarer has a right to privacy in relation to his heath. On the other hand the special circumstances of the shipping industry are posing special demands on seafarers’ attitude towards their health. Special care is needed where their health might endanger the health of their colleagues. This applies also and especially to the accessibility of medical records. Not every item must be accessible to anybody in the chain of medical care on board. The seafarer should be the owner of his medical records. He should give authority to use the records by every person rendering care to him, prior or following an event related to his health. Optimal medical care on board follows from a comprehensive set of directly interlinked activities. Chain thinking is the red line.

 9.4.2.   Technology

Radio medical Services were started in the nineteen-thirties of last century. Amongst the first were the Italian CIRM, Radio Medico Cuxhaven and the Dutch Radio medical Service of the Red Cross. At first there was only the option of   morse code communication with a doctor ashore. Later on came telex and (short wave) radio communication for long distance medical advice. Now we are in the middle of a fast developing satellite communication era. Now even with broadband Inmarsat options to run real time video images. The development of means of communication have greatly improved the quality of the telemedical consultation. If there is money invested in modern techniques of communication, the quality of telemedical consultations can  level that of an on-site consultation.

Medical consultation with ships is either written or by voice.

 Written communication

 This form is carried as a message by fax, telex or email. There are advantages and disadvantages linked to this means of communication.

The major advantage of communicating this way is the fact that everything is in writing. This gives an opportunity to pre-think on the communication. It is generally spoken less quick than spoken communication and the danger of misinterpretation of the message and miscommunications because the spoken tongue (mostly English) is not fully mastered. The latter can be reduced when proper use is being made of images of the patient accompanying the written communication. This usually means sending along (not instead) photographs to illustrate the described clinical picture together with the questions to be answered, This is of great value in dermatological cases and in traumata. But it can also improve care in other cases for instance in cardiological cases where ECG can be attached to the (written) communication.

 Medical Avice

Medical advice from doctors stationed in ports throughout the world is available 24 hours a day to all ships at sea, and should be sought whenever the caregiveris uncertain about the best course of action. The advice is given by direct radio-telephonic contact, satellite communications, fax, or Internet. Advice may,on occasion, be obtained from another ship in the vicinity with a doctor on board.Clearly, it is preferable for the exchange of information to take place in a language common to both parties. If this is not possible, using a translatorfluent in both languages is preferable to one party attempting to convey medical information, or trying to understand advice in an unfamiliar language. Codedmessages are a frequent source of misunderstanding and should be avoided as faras possible.

Voice communication

Voice communication is usually carried by radio communication, or by satellite telephone. It is the quickest way to have contact with medical assistance ashore. The doctor has real-time information and the patient can, if necessary speak to the doctor himself.  The doctor can convince himself that his advice understood. On the other hand the danger of miscommunication and misinterpretation, especially in a conversation of poor technical quality, is a reality.

Technical options for communication improve very fast but as the shipping industry is often a low cost one and these innovations are costly, so implementation of these innovations into the industry may take a long time. Cost-effectiveness studies can convince ship owners and authorities to invest in innovations in communication in order to improve medical care given on board. More detailed descriptions of the technical options are described in paragraph 9.6.

Standardized communication 

The International Guide for Ships (WHO 2007) offers forms for standardized communication between TMAS stations and crew in cases of disease or injury.

9.4.3   Organisation

Radio medical services, the predecessors of TMAS, were mostly organised as a service linked to a hospital, sometimes a military hospital. This also brings up the paradigm question on Maritime Telemedicine: is it primary healthcare under special conditions or is it a medical speciality that needs to been regarded like for instance cardiology.

By far, most TMAS are directly linked to a hospital but as in the Netherlands, there does not need to be a fixed base in a hospital. However, a well organised consultation function for specialist cases needs to be secured. Current technical facilities enable the possibility to have a virtual organisation, i.e., not bound to a specific fixed location

There is a wide range of how TMAS are nationally linked up with Maritime Rescue Coordination Centres (MRCC). Bottom line: the communication lines between the two organisations needs to be well established as to prevent unnecessary delays for a patient.

A rough comparison made in respect to a never executed IMHA-project on Collaboration of TMASses, made it clear that the organisation often differs greatly but quite a few subjects and problems are alike. Because of the organisation of TMAS on national level without sufficient international exchange of experience , too much energy is put into inventing wheels nationally whereas as international collaboration will improve quality of care administered by TMASses.

TMASses are mostly organized on a national level so as to compel to IMO/ EC obligations. Sometimes tele-medical advice is organized on the level of the shipping company. One should be aware that the shipping company’s choice of a telecom provider might influence the accessibility of a TMAS.