Medical training of ship officers
The legal basis for the training of nautical officers is given in the STCW Code PART A chapter VI. On the basis of the requirements stated in these chapters IMO has produced a series of model courses:
- · Model course 1:13 “First Aid” 60 hrs
- · Model course 1:14 “Medical First Aid” 80 hrs
- · Model course 1:15 “Medical treatment” 40 hrs
Officers who have the responsibility for medical issues on board must have completed all three courses, the first two deal mainly with safety issues, but also with the treatment of injuries.
The theoretical knowledge of medicine and first aid obtained at these courses is limited. However, it is important to teach the officers to perform some important and potentially lifesaving procedures such as the immediate care of severe injuries and of unconscious persons, and the establishment of venous access. No medical advice or equipment can replace the first aid given in the first minutes after an accident or an acute disease. The efficacy of courses, especially 1:15, will depend heavily on the practical instruction and exercises during the course.
It is questionable whether course 1:15 when limited to 40 hours is sufficient to fully meet the requirements of STCW. There are institutions that have found it necessary to extend the duration of the course to 70, and even 100 hours, something that undoubtedly will improve the skills of the trainees.
Ship hospital or sick bay
The legal basis for the ships’ hospital or sick bay is found in ILO convention 92, article 14, for fishing vessels in ILO convention 126. Further, ILO convention 164 article 11 and EEC directive 92/29 also contain regulations with regard to the ship hospital. A sick bay is mandatory for vessels with a crew above 15 and voyages of longer than 3 days duration, and for fishing boats in excess of 500 tons.
The regulations give directions on positioning of the hospital, size, access, lighting, ventilation, water closet, number of berths etc. Communication arrangements are not mentioned.
If the directives in the conventions were followed by all ship designers, the facilities would be satisfactory. However, ship designers have to deal with a vast number of requirements from the ship owner and others. Unfortunately, the sick bay often ends up as a compromise and a balancing item. In many cases the positioning of the hospital makes the access a problem, and the evacuation of a patient on a stretcher may have to be made through a number of narrow stairs and corridors. In some cases the communication between the sick bay and the bridge is hampered by the absence of a telephone line. Being aware of these problems, the Norwegian Centre of Maritime Medicine elaborated recommendations for ship medical facilities including the ship hospital in 2006. These recommendations can be found here: http://www.ncmm.no/images/NSS%20J23%20001%20006%20amho%20220906%201.%20utgåve%202006-10-16%20nytt%20opptrykk%202010-12-20.pdf
The International medical guide for ships - IMGS
The MLC 2006 stipulates that all ships shall carry a medical guide. The ILO Recommendation105 states that: All medicine chests should contain a medical guide approved by the competent authority, which explains fully how the contents of the medicine chest are to be used. The guide should be sufficiently detailed to enable persons other than a ship's doctor to administer to the needs of sick or injured persons on board both with and without supplementary medical advice by radio.
“The competent authority” is the authority of each country that signs the convention and some seafaring nations have produced their own medical guides. In 1967 - in an attempt to standardize the guide - WHO published “The International Medical Guide for Ships” for the first time. The second edition appeared in 1988 and the third in 2007. The guide also contains an account on the “medical chest” i.e. a list of medical equipment and medicines (see below).
The intention for the guide is that it shall serve both as “standard reference for training courses” and as a practical guide for treating injuries and diseases on board. The book may serve satisfactorally as a textbook used in the courses, even if it appears very comprehensive for a 40 hours course. For use as a practical guide it is less well suited. The organisation of the material in the guide is for the most part based on organ systems or diagnostic entities rather than on symptoms, something that requires a diagnosis before looking up the advice. Hence, the book is not very user friendly to a lay person. The choice of medical conditions included in the guide may also be questioned: fish tape worm infestation and SARS are described, whereas erysipelas and salmonelloses other than typhoid are not. Within the maritime medicine environment, and within ILO and IMO, there is an agreement that a new edition is needed. So far, WHO have not engaged themselves in the discussion. However, it is known that WHO will only publish information that is based on evidence. Since evidence in maritime medicine is rather scanty, this may pose a problem as medical treatment based on good empirical ground will be ignored.
It has been proposed that the new edition of IMGS be divided into several volumes in which the following aspects could be covered:
- · Textbook – for use on courses
- · Practical manual – for daily use on board
- · Addendum with medicines and medical equipment
- · Disease prevention, health promotion and ship sanitation
An approach of this kind has the potetial to make the IMGS a more useful tool both for the education of maritime officers and for the practice of medical care on board.
“The medical chest” – ship medicine and medical equipment
The ILO convention 92 – convention 126 for fishing boats – and convention 164 regulate the obligation for ships to carry medicines and medical equipment. C 164, article 5, states:
Every ship to which this Convention applies shall be required to carry a medicine chest.
The contents of the medicine chest and the medical equipment carried on board shall be prescribed by the competent authority taking into account such factors as the type of ship, the number of persons on board and the nature, destination and duration of voyages. The medicine chest and its contents as well as the medical equipment carried on board shall be properly maintained and inspected at regular intervals, not exceeding 12 months, by responsible persons designated by the competent authority, who shall ensure that the expiry dates and conditions of storage of all medicines are checked. The competent authority shall ensure that the contents of the medicine chest are listed and labeled with generic names in addition to any brand names used, expiry dates and conditions of storage, and that they conform to the medical guide used nationally.
The EEC directive CD 92/29 has presented more detailed and specific requirements with regard to the medical chest for members of the European Economic Community.
Most of the problems related to the medical chest refer to the choice of pharmaceuticals and their quantities. Because most seafaring nations have made their own list, the doctors in telemedical services are faced with the problem of a number of lists with varying content.
In the IMGS from 1988 a a list of medicines was included . The list also contained recommendations for quantities. However, in the IMGS 3rd edition quantities were not specified because WHO considered that quantities should be related to voyage pattern and to political/managerial decisions and could not be based on any evidence available to WHO. This lack of specification of quantitites led to considerable disquiet as the WHO list had been used by many pharmacist as the basis for replenishing stock in medicine chests on ships from those countires that do not have national regulations.
Because the maritime health community had concerns about the design of the next edition of IMGS and its relationship to the medical chest, an IMHA workshop was held in Athens in 2008. It was agreed there to establish a working group to make recommendations for a list of medicine chest contents , to develop and propose a framework for future editions of IMGS, and to initiate an advisory panel of stakeholders to assist.Therefore, it came as a surprise when WHO published in September 2010 a “Quantification Addendum: International Medical Guide for ships”. At present there are, in addition to national and regional lists, two international lists of recommendations for the quantities to be carried in medicine chests. Both are based on the list in the 3rd edition of IMGS and they are broadly similar. Further clarification is needed and the contents list is rather limited in that it does not include remedies for a number of common minor illnesses and symptoms.