Textbook of Maritime Medicine

9.7.1  General principles

On board of a sea-going vessel the medical care usually rests in the hands of the first deck-officer, although everything remains under the final responsibility of the ship’s captain. Many sorts of ailments and injuries can be handled by the officers on board, possibly after first having sought additional advice of a TMAS. There are evident limits to the capabilities of ship’s officers to diagnose and treat medical conditions, inasmuch as there are limitations to the medical facilities and equipment on board. These limits will differ to some degree, depending on a number of individual factors: the medical training of the crew, the equipment on board as well as the vessel’s position and its distance to the nearest port.

The decision to evacuate a patient from a vessel and secondly, which mode of evacuation is chosen, is sometimes evident but can also be a difficult one. This decision is the result of a number of factors such as probable diagnosis and prognosis as well as the facilities available.

The initiative for a medical evacuation will be taken either by the captain or by the TMAS doctor. Most often the two parties will agree on the decision to take but there may be differences of opinion, each party sometimes having different aspects in view. The nearest RCC (Regional Coordination Centre) and the organisation that is actually going to conduct the evacuation will also have a say in the matter, if not the final one. In cases where differences of opinion arise, these arguments should be clearly brought forward, each respecting each other’s professional (medical versus nautical) arguments and come to an understanding whether an evacuation is necessary and what mode of transport offers the best prospects.

9.7.2         Modes of evacuation

Ship-shore 

If the medical situation of the patient allows and the distance towards a shore-based medical facility is within acceptable reach in distance and time, the safest and most comfortable mode of evacuation is 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. Via the RCC or the vessel’s shipping agent medical transportation on land (usually an  ) will need to be arranged separately to transport the patient to a medical facility ashor

Ship-ship

 If the above is not feasible, the vessel may arrange a rendezvous with another vessel and transfer the patient. This may have two different motives. 

Most often the patient will be transferred onto a vessel serving primarily for the transport to a medical facility ashore, these boats being faster and more manoeuvrable than the vessel itself. These boats, often of the all-weather type, are evidently confined to coastal waters and have a range of a few tens of nautical miles. They mostly have personnel on board with medical training often equaling or surpassing that of the ship’s crew, so they can be of help in stabilizing the patient before transferring him onto the lifeboat. Pilot’s vessels or sometimes shipping agents’ craft may be needed to transport a patient ashore.

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. These different options will be described in more detail further on.

Figure 9.7.1: Ship/ship medevac 

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 hopping 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 (in cargo ships this may be as high as twelve metres, viz. the third storey of a building), to be subsequently landed on the deck of the smaller craft below.

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

Ship-helicopter

Evacuating a patient by helicopter is sometimes the only option given the circumstances. 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 nm outside the coast, this being primarily a question of fuel supply.
SAR helicopters are normally manned with a doctor or medic who are evidently well trained in medical emergency treatment and transportation. This implies that getting help from a helicopter to evacuate the patient, expert medical personnel is also called in. This can be vital to assess the situation, come to a preliminary diagnosis, effectuate advanced first aid treatment and in stabilising the patient. Besides advanced medical know-how, the helicopter crew will also bring in advanced medical equipment such as Propaq (monitoring equipment) and a defibrillator.

Figure 9.7.2: Ship/helicopter medevac

Getting expert medical help on board through a helicopter and transporting the patient need not be an evident sequence. For instance it may well be that the doctor decides, once the patient is sufficiently stabilised, not to transport the patient by helicopter, but to have him transported by the vessel itself to the nearest port. If the patient cannot be stabilised, it may be hazardous to have him undergo the extra physical and emotional stress of a helicopter evacuation. It may also happen that a critically ill or injured patient cannot be saved, and that the body is best to remain on board.

Figure 9.7.3: Hoisting the stretcher and patient

Helicopter evacuations are costly operations and not without dangers in itself. When the weather conditions are adverse, the risks involved increase markedly. The helicopter crew put their own safety at risk in these undertakings, so it is evident that their decision whether or not to fly must be a well-balanced one. This firstly implies that the indication for the “Helivac” to be conducted must be medically sound, and that the benefits for the patient outweigh the risks that will need to be taken.

In ideal cases, the vessel will have a helicopter platform on which the aircraft can land, offload the doctor and possibly a helper, wait until the patient is stabilised and secured on a stretcher, and load everyone back on the craft. In most instances the conditions are not that ideal. If there is no landing platform, the doctor and other crew will need to be lowered by a line for the helicopter, and the aircraft will need to wait in the air, with evident consequences for its fuel reserves. Sometimes the helicopter may choose in the meantime to return to shore or possibly to an offshore oil-rig to refuel and pick up the crew and the patient in second instance.

Lowering and hoisting persons from a vessel can be hampered markedly by cranes, masts, antennas and objects on deck. The procedures for lowering and hoisting persons from a helicopter may differ. It is essential that the ship’s crew are fully aware and acquainted with the procedure. There are examples of dramatic accidents caused by differences in protocols involving these procedures. The US Coast Guard has issued a concise list of recommendations for the ship’s crew to keep in mind when requesting and conducting a helivac. See the table at the end of the chapter.

(See separate caption) (Rights of reproduction? shouldn’t be an issue)

One should also realise that, once aboard the helicopter, in spite of a doctor being nearby, the possibilities for further stabilisation and / or treatment are minimal due to noise, lighting, movement and restrained space.

It is important to realise that transport of a patient from a vessel either by the vessel itself, via another vessel or by helicopter sometimes needs to be followed by yet another transport by road ambulance to reach an on-shore medical facility.

Medical Indications  for evacuation 

In general, the reason to initiate the evacuation of a patient from a sea-going vessel is when it concerns:

• Medical conditions which are of such nature that lasting invalidity or death may result and for which treatment on board is not feasible.
• Medical conditions in which the diagnosis is not yet certain, but the symptoms of which can be characterised as being potentially dangerous, with a risk of invalidity or death.  The risk of potential invalidity is sometimes one which 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 if it concerns the patient’s dominant hand or not.

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. Even in the confined surroundings of a hospital such transfers with an immobilised patient are known to be associated with such complications. These may range in severity from the pulling out of intravenous lines or dislocation of immobilisation splints to life-threatening ones such as the pulling out of endotracheal tubes or accidents involving the entire stretcher-with-patient during the inadvertible transfer, hanging in the air by lines, from one craft onto another.

If the patient is suspected of having a disease which may possibly resort under the International Health Regulation (WHO) for communicable diseases (implemented July 2007), it is essential for the TMAS doctor to notify all parties concerned, namely the respective RCC and the evacuation organisation.  The captain, under these circumstances, is under legal obligation to notify the Port Authorities of the port he is heading to.

Medical contraindications to evacuation (withe helicopter)

There are no absolute medical contraindications to medical evacuation. Of paramount concern are the urgency of treatment, the uncertainty of diagnosis, and an estimate of the effects of treatment delay or deferral on the patient's prognosis. Stabilization of the patient prior to evacuation cannot be overemphasized. These principles more than any other influence the final therapeutic outcome. On occasion, it may be prudent to delay evacuation in order to stabilize the patient.

An evacuation by helicopter is associated with a number of physical conditions that may have an adverse effect on the medical condition of the patient to be evacuated. These factors comprise:

Reduced Atmospheric Pressure

Rescue helicopters that are involved in Medevac operations normally do not have pressurised cabins. The maximum altitude at which they fly, especially on short hauls, is usually less than 2000 metres above sea level. The atmospheric pressure on board during the flight is, however, reduced to some degree. The result of this is that the gases present within the body tend to expand in accordance with Boyle's law. If unable to escape, this pressure may rupture the containing walls of the cavity or impair the circulation inside the wall, causing local hypoxia and possibly subsequent necrosis. It is good custom to inflate the cuff of an endotracheal tube with saline rather than air to prevent rupture due to relative over-pressure, the same goes for the balloon of a urinary catheter.

The use of inflatable splints poses similar problems. The relative over-pressure inside the splint will increase, resulting in a tourniquet-effect. There is a well-documented incident in which MAST trousers were used to stabilize a wounded patient. After the flight, the patient's feet were pulseless which ultimately lead to bilateral lower extremity amputations.

Special consideration to this must be taken in cases of suspected (tension) pneumothorax. If the condition can be diagnosed by the helicopter doctor, it is evidently wise to relieve the pressure beforehand by a thoracic drain.

 Large unreduced hernias, volvulus, intussusception, and ileus are particularly susceptible to trapped gas phenomena. The circulation of the involved bowel loop may be severely compromised from trapped gas expansion. Insertion of a nasogastric tube may be good precaution.

In cases involving trauma in the oro-facialregion, oedema of the nasopharynx may trap the air confined to the sinuses causing pain during the flight. Administration of nasal decongestants may be a sensible precaution to take.

In cases involving a skull fracture, air trapping may also be a factor to take into account. If air has entered the cranial cavity, aeromedical evacuation must be accomplished at cabin altitudes maintained at as near sea level as possible. This is also the case in capital trauma cases where an intracerebral haemorrhage or cerebral oedema may present.

This pressure factor is also of marked importance in patients with caisson disease/decompression sickness after diving accidents: if the relative under-pressure the patient has been confronted with is already a problem at sea level it is even more so with the reduced atmospheric pressure inside a helicopter.

Decreased Oxygen Tension

The decreased oxygen tension associated with reduced atmospheric pressure may also have significant adverse effects. Oxygen saturation is decreased only slightly in unpressurized aircraft flying below 2000m. However, this reduction can be relevant in patients with whom tissue oxygenation at sea level was already critical. Patients at risk include those with anaemia, often because of recent acute blood loss, impaired pulmonary function, cardiac failure and instable angina pectoris. This factor can normally be compensated by administering extra low-flow oxygen from a pressurised tank; the readings form a portable oxygen saturation meter serving as guideline.

Motion sickness

 Especially in bad weather, motion sickness can affect anyone, but the implications in a critically ill patient can be important. The incidence of this is frequent in helicopter flights but also in evacuations by smaller vessels. The vagal effect on a critical circulation is not in the best interests of the patient. In many conditions where the upper gastrointestinal tract is involved, the extra strain of vomiting can have adverse consequences on the patient’s condition. Examples of these are suspected or overtly bleeding gastric or duodenal ulcers, injuries involving the abdominal or thoracic wall or of the orofacial area such as a mandibular fracture. In the latter, the risk of aspiration must be taken into account, especially if the mandibular fracture has been immobilised by a bandage or a wire.  

Administration of antihistamines (25 to 50 mg of meclizine, 50 mg of cyclizine or 50 mg of dimenhydrinate) or "scopoderm" (0.6 mg of scopolamine mg of d-amphetamine) prior to the flight may reduce these symptoms if not medically contraindicated. Because these medications need time to take its effect, administration may be advised by the TMAS doctor before the arrival of the evacuation crew.

Dehydration

The relative humidity at altitude is also reduced. Dehydration may represent a risk to the unconscious, marginally hydrated patient. Patients with tracheostomies or those who must breathe through their mouths may require humidified air or oxygen to prevent drying of respiratory secretions. Corneal drying in comatose patients may be averted by holding their eyelids closed by adhesive tape.

Limited space

 Special care must be taken when evacuating psychiatric patients who risk becoming uncooperative or even violent during the evacuation process. It may in some instances
 be a safe precaution to have them strapped in a litter and/or sedated during the flight.     

 Costs involved in an evacuation.

Although not of prime importance assuming the indication of an evacuation is sound, it is still wise to keep in mind that a medical evacuation can involve costs in the order of tens of thousands of dollars. Very often the costs of the evacuation and patient transport are considered running costs of the respective navy or other state-run organization conducting the evacuation.

A captain requesting a medical evacuation will primarily have the patient’s benefits in view. But one must keep in mind that other interests may also influence his request; not in the least can commercial or financial motives play a role in the matter. For a fishing vessel, having to bring the patient to a port even nearby, implies that they will have to suspend their fishing activities for a while and will also make them encounter other costs such as fuel, harbour dues etc... A passenger ferry, if needed to return to port to offload a patient, will cause all the passengers, trucks with merchandise etc. to sustain a delay of hours, this having important consequences for many parties involved and not in the least the reputation of the shipping line. Some shipping companies may have chosen to insure themselves against these costs; many consider these as part of the overall running costs of the company, similar to a delay due to bad weather.

In making the decision as to which mode of evacuation is chosen, one must therefore keep in mind that there may, therefore, exist financial motives for the captain to urge for medical evacuation by a third party instead of delivering the patient by the vessel itself although the latter may, medically speaking, be the safest and preferable option. It can sometimes imply that the severity of the case such as reported by the officers may to some extent be over-estimated or reported as such, so as to force the decision toward evacuation by a third party.

Preparing for transport

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:

• passport, seaman’s book, vaccination book
• Medical reports. This should include minimally: 

                       -   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
                           as temperature, blood pressure, breathing frequency, Glasgow Coma Scale etc.-  therapeutic measures taken, especially which   
                           medication was administered? (morphine!)

                       -   all correspondence with a TMAS or with doctors in previous ports concerning the patient should be printed and included. 

• Personal belongings. More often than not, the patient is unlikely to return to the vessel shortly. If practicable and time permitting, his suitcase and personal effects should be packed and sent along with him. 

9.7.3    Medical facilities along the coastlines of the world

An accurate and comprehensive list of all medical facilities along the world’s coasts, however seemingly practical, is not feasible and will be out-dated as soon as this document is released. The local RCC conducting the operation is the most reliable source of information as to what the options are in view of conducting the medical evacuation and as to where the patient is to be transported. They may also be consulted in cases where no evacuation by a third party is necessary, but where the vessel is advised to seek medical help in an “emergency” port.

It is evident that along many of the world’s coastlines, medical facilities are far apart. This may be either because the coast is un- or scantly inhabited, or because the local population have very limited resources as is often the case in the tropics.

In an attempt to alleviate this shortcoming, the following entities have been devised to provide in the best possible medical help to sea-going vessels with limited medical facilities.

 9.7.4    AMVER

Mission statement: “ AMVER is a worldwide voluntary ship reporting system operated by the United States Coast Guard (USCG) to promote safety of life and property at sea. Amver’s mission is to quickly provide SAR authorities, on demand, accurate information on the positions and characteristics of vessels near a reported distress. Any merchant vessel anywhere on the globe, on a voyage of greater than 24 hours duration, is welcome in the Amver system and family. International participation is voluntary regardless of the vessel’s flag of registry, the nationality of the owner or company, or ports of call.  ”

Amver information is protected as "commercial proprietary" information and is released only to recognized national search and rescue authorities, and only in an emergency.

AMVER was primarily devised to provide help to ships in distress. In a medical emergency, the RCC may also consult AMVER to obtain a “SURPIC” (surface picture); indicating if a vessel with more extensive medical facilities is in the vicinity of the vessel to provide help to the patient. These may be naval vessels under various flags, passenger cruise liners, floating hospitals etc.

http://www.a0.com/

 Floating Hospitals

The concept of a floating hospital is to bring secondary or even third level medical care to where these facilities are needed but not available. Examples of this are the floating hospitals that many of the world’s navies have in operation, although these ships are normally in service only in times of political tension. Other larger Navy vessels normally have their medical staff on board willing to give medical help to civilians at sea, but these are still limited as to what level of medical help they can offer.

For example: the US Navy is the only one operating two nearly 1000 bed hospital ships, the “Comfort” and the “Mercy”. The help of these ships is seldom practicable for medical cases in the merchant fleet. They are only in full operation when they are appointed specific missions, the last time being the Gulf War, and one was moored in New York after the 9/11 attack, moored nearby to offer medical help and support to the rescue workers. Otherwise the two are moored in the ports of Baltimore and San Diego respectively, strategically one on either coast of the USA.

“Mercyships” are an NGO that operate floating hospitals, mainly along the coast of Western Africa. These ships provide medical and surgical care for inhabitants along the coast, like for instance complications after childbirth and deformities after war injuries (Liberia and Sierra Leone).

http://www.mercyships.org.uk/what-we-do/surgeries-and-health-care 

Figure 9.7.4: Mercy ship

m/v “Esperanza del Mar“ This vessel is, from the point of medical help, of great practical value to the international shipping, and especially the international fishing fleet   This vessel is operated through the Spanish Institute of Marine Welfare and has extensive medical facilities for up to 60 patients. They are primarily focussed on medical help to the extensive international fishing fleet operating in the waters near the Mauritanian coast. They are also equipped to provide help in case of naval emergencies and salvage operations.

m/v "Juan de la Cosa" is a similar support vessel of the same Spanish organization, operating in the waters along the North-Western corner of Spain/Gulf of Biscay. It's home port is Santander.*

 ___________________________________________________________________________________________________________________

* Juan de la Cosa  (ca. 1460-1509) was a Spanish cartographer, conquistador and explorer. He made the earliest existant European world map to incorporate the territories of the Americas that were discovered in the 15th century, sailed first three voyages with Cristopher Columbus and was the owner/captain of the "Santa Maria".

Figure 9.7.5: "Esperanza del mar"

• Bangla Desh and India operate a number of floating hospitals in the estuaries of the Ganges and the Brahmaputra. Because these vessels operate in shallow coastal waters and up river mouths, the better alternative of a hospital ashore may be relatively near.
• United States Coast Guard.  The USCG have an extensive network of not only support vessels around the entire coast of the USA but also of numerous hospitals to which patients can be referred. The USCG involves 60,000 men and reserves and is part of the US Home Security Dept and has close ties with the US Navy. Apart from tasks involving Home Security, environmental protection, drug and illegal immigrant interdiction etc, they have an important task in SAR operations and operate an extensive network of support vessels an airplanes

9.7.5         Repatriation

After a medical evacuation the patient will have a good chance of finding himself in a foreign hospital in an unknown port.  It is therefore essential that the shipping company is informed by the organisations involved in the medical evacuation as to where/in which hospital the patient is delivered. The employer may or may not have a regular shipping agent in that particular port but may otherwise appoint one ad hoc to serve the interests of the seafarer. A number of issues may need to be taken care of such as:

• Warranty or pre-payment of the hospital costs
• Liaison with the patient’s shipping company and next-of-kin while is in hospital
• Arranging for the transportation back home once the treatment in hospital is terminated. This may again imply a “medical transport”.

Medical decisions taken in hospital must take into account the possibilities of follow-up treatment in the seaman’s country of residence. This is often a developing nation in which the medical facilities may sometimes be less than is realised by the treating doctors in hospital. Revalidation after extensive surgical procedures, medical treatment (such as HIV medication) which will need to be taken for a longer time), to name a few examples, are issues that must be taken in view when planning the return home. 

The use of the U.S. Coast Guard instructions for MEDEVAC is recommended

U. S. COAST GUARD - HELICOPTER EVACUATION / MEDICAL EVACUATION

Requesting Helicopter Assistance:

•  give accurate position, time, speed, course, and weather (ceiling, visibility, wind direction /speed, and sea state).
•  give complete medical emergency description (date/time of injury, severity, can they walk?)
•  be prepared to change course toward the approaching helicopter if directed.

Before helicopter arrival

• Provide continuous radio guard on 2182 or 4125 kHz, 156.8 MHz (CH 16 VHF-FM) or a voice frequency specified by the SAR mission coordinator.
• Select and clear the hoist area, preferably aft in the stern. Secure loose gear, awnings, rigging and booms. Lower antennas if possible.
• At night, illuminate the hoist area as well as possible. Do not shine lights toward the helicopter (may blind pilot). Light any obstructions to warn the helo.
• Point searchlights vertically to help helo locate the ship. Extinguish when helo is on scene. Advise SAR mission coordinator of location of hoist area on vessel before helo arrives so the pilot can make his approach aft amidships or forward as necessary.
•  Advise SAR mission coordinator how many people you have on board the vessel.

There will be a high noise level under the helicopter, making voice communications almost impossible. Arrange a set of hand signals among the vessel crew who

will assist.

 Prepare patient medical/injury information to accompany them

Tag patient with medication information: type if any, were administered and when.

FOLLOW THE DIRECTIONS OF THE HELICOPTER CREW

Hoisting operation

• Have patient's medical record and necessary papers packaged ready to transfer with them. Move patient to position as close to the hoist area as their condition permits. Time is important.
• Helo may lower a rescue swimmer to evaluate patient and assist hoist. Assist them and follow instructions.
• Be prepared to load patient in a Coast Guard rescue device, which will be lowered by the helicopter. Do this as quickly as possible. Be sure the patient is strapped in, face up, with a life jacket if their condition permits.
• Change course so the ship rides as easily as possible with the wind on the bow, preferably the port bow. Reduce speed if necessary to ease ship's movement, but maintain steerageway. Once the hoist begins, maintain course and speed.
• If you do not have radio contact with the helicopter –– when you are in all respects ready for the hoist –– signal the helicopter in with a "come on" by hand, or at night by flashlight.
• Allow the rescue device to touch the deck before handling it to avoid static discharge.
• If helo drops a trail line, use it to guide rescue device to the deck.
•  If necessary to take rescue device away from hoist point, unhook the hoist cable and keep free for helicopter to haul in. Do not attempt to move rescue device without unhooking it. DO NOT secure the cable to the vessel.
• Place patient in rescue device, sitting with hands clear of sides or strapped in face up. Signal hoist operator when ready for hoist. Patient signals by nodding head if he is able. Deck personnel give "thumbs up" to hoist operator. Steady the rescue device to prevent turning or swinging.
• If a trail line is attached to the rescue device use it to steady rescue device during hoist. Keep feet clear of line.

PROVIDED BY THE USCG PASSENGER VESSEL SAFETY / MASS RESCUE PROGRAM - REV. 10/9/03