Continuity of Care
Work in a port clinic has to be organized in relation to work in the port. Although night and weekend work may have declined in some bigger ports, activities almost never stop. The maritime physician should organize his work in a way that maximal presence is possible. This implies round the clock availability, seven days per week, 24 hours per day. This is in general only possible in an association or in a network of maritime physicians. It is therefore important that the port clinic organizes or participates in a regional watch system for the port area.
Preventative medical care, such as cancer screening or health counselling is not often available to seafarers while on duty. The Maritime Labour Convention 2006 requires that flag states offer preventative services to their national seafarers. In many instances these services are not available to the seafarer, either in their home country or while on duty. Some countries do offer governmental preventative health services to seafarers such as vaccinations or diagnosis and treatment of sexually transmitted diseases to protect the public health. Very rarely the seafarer has access to qualified health counselling which covers a broad scope of known health risks such as stress reduction, smoking cessation, nutrition beside communicable disease control. Ideally, the port clinic may offer information, counselling and anonymous testing of sexually transmitted diseases in cooperation with public health services. Information tailored to the needs of seafarers is available from the International Seafarers Welfare Committee http://www.seafarerswelfare.org/.
Hospitalisation and Repatriation
Whenever a seafarer is hospitalized, the maritime physician should follow-up the case and actively participate in the process of diagnosis and treatment. The maritime physician should make sure that all necessary care is given but also not more than necessary care.
The role of the maritime physician is to bring up elements of interest for the diagnosis and treatment that relate to life on board and the particular history of a patient. He has to make sure that the hospital specialists and their assistants get background information on the patient. The port physician will take an intermediate position between the hospital care and all agencies and individuals that take an interest in the health of the seafarer. The maritime physician gives help to get the seafarer home safely as quick as possible.
A Maritime Medical Unit
Although general medicine is the basis, it is of the utmost importance to have access to other specialties. The selection of the service, department or individual specialist to refer to should be done on the basis of accessibility of their service for seafarers. It is essential that the responsible and treating doctor has the wellbeing of seafarers at heart. Seafarers deserve to be treated to the highest standards[h1] , immediately and without prejudice. A rigid appointment system is not good as it will delay access. Many specialists who provide services for seafarers have a link with seafaring or the maritime world. Some of the specialties that are most important to have at hand are: radiology (ultrasound), orthopaedics (traumatology), ophthalmology, dermatology and cardiology. Dental care is critical for seafarers and although dentists often have their own port service it is most important for the port physician to be familiar with that system and to know how the continuity of care is organized for dental problems.
Port medicine as a multidisciplinary field is rarely connected to university departments. Traditionally port hospitals have been connected to research units in tropical health. Nowadays, some port clinics are connected to research units in occupational health. Port medical practices should actively seek collaboration with research units to perform data analysis or further studies on the health of seafarers and publish their findings. Ideally port maritime physician should join a professional association that of maritime medicine and familiarize themselves with current publications including those for travel and maritime health.
Time is a critical element in medical care for seafarers. Since time is money, money is another critical element in patient care. Therefore it is important to organize efficient care. From process-analysis we know the term “critical path”. For medical practice this is called “Clinical path”. Such clinical path is the result of shared collaborative effort toward deliver the best treatment to the average seafarer. A clinical path patient care strategy is built on a quality-first attitude:
- analyze the different steps in a process of diagnosis and treatment
- try to find time consuming elements
- try to improve efficiency and quality
- select methods that give faster and more accurate information
The introduction of path-based management may be easier if it is first applied to types of care where problems are encountered frequently. A good knowledge of seafarer’s life and medical problems is necessary to start this analysis.
The possible clinical path of a patient
1. Reporting the problem on board
This first step in the process may be problematic. A patient on board may not want to report his problem. A poor social protection, a conflict with a superior, and fear of losing his job may be among the possible explanations.
2. Permission of the captain to send him to the clinic / hospital
Some captains do not want to send their crewmembers ashore. They think the seafarer is using the complaint as an excuse to get off the ship for a few hours. They need all hands on deck for work to be done in the port. They may have limited medical knowledge to judge the situation
3. Transport / Access to the clinic / hospital
In a big port the clinic or hospital may be far from the ship. The taxi that has to pick up the seafarer may be delayed and valuable time is then lost in the treatment and management of the patient. If the transport service has not been instructed properly, they may take the patient to any doctor or hospital without knowing the competencies and facilities needed to treat the patient’s condition.
It is important that a patient is well received in the clinic. This reception must give the patient confidence about the care he is expecting. Language barriers should be handled with patience and assistance. An accompanying person from the ship to help with translation is sometimes necessary. The reception staff have to judge the urgency of the case and inform the doctors.
5. Waiting time
Waiting time should be short in relation to the pathology or the schedule of the vessel.
Always take the cultural background of the seafarer into account. For some it is impolite to give negative answers or denials. Some have different attitudes towards pain. Always give the patient the chance to express his worries or anxiety.
7. Clinical examination
Although this is not usually hindered by language problems it may happen that the response to a test is different because of cultural behaviour. It may also be delicate for some cultures to have a nurse present, while female patients from other backgrounds may expect a chaperone.
8 .Laboratory tests
In the selection of appropriate laboratory tests the choice not only depends on the differential diagnosis but also on what can be done before the ship leaves. Tests need to be relevant to the likely diagnoses but unusual or “tropical” pathology should be remembered.
9. Medical imaging
The selection of the most appropriate test is important. Methods should be sufficiently sensitive and has enough specificity to support the clinical findings and anamnesis.
Sometimes an ultrasound may give a better chance fpr detecting relevant findings than a CT scan or MRI, while on others time is lost by first doing an ultrasound when in the end an MRI / CT is necessary.
10. Communication of results
All results should either be in English or in the native language of the seafarer. If not, an English summary of the reports should be added to the patient’s documents. All results should be typed out; handwritten notes are to be avoided. Services that cannot provide such reports immediately should not be preferred.
It is rather rare in a primary care setting to come to a diagnosis. Most conclusions are working hypotheses. It is essential, and sometimes enough, to advise the patient about his capacities and risks with the safety of the ship as important point of reference.
As in every consultation there is a critical moment to explain the findings and summarise the plans for treatment. This must be clear as information can be misinterpreted; the patient can get lost in technical details or can be frightened by medical language.
Reports to the ship should include essential information about the duty status of the patient and any implications for the safety of the vessel. If the patient has to be repatriated or hospitalized it may also be necessary to involve the agency, the company, the insurance company and the consulate. Medical and other sensitive information should be handed over only to the patient and all results of investigations including x-rays are to be given (with) to the patient to allow follow up and avoid repeated tests in other ports.
Medication has to be given with an explanation in English or the native language of the patient about dosage, length of treatment and possible side effects. Reports and instructions should always mention the generic names. Pharmacies that can deliver on board are preferred and the seafarer should never have to pay the medication and then claim the costs back.
14. Transport back to the ship
Convenient transport back to the ship should assist the patient until he is back on board. The person responsible for transport should, if necessary accompany him to explain about any further arrangements and follow-up consultations. They should wait at the gangway to collect the patient from the ship if transport to the hospital or airport is needed.
This example highlights a number of essential stages and events in a normal consultation that may be critical to the quality of care for a seafarer. A good maritime health service or port clinic is organized so that these elements are taken into account and a maximal effort is made to overcome the barriers for the patient. This can only be done if all those concerned with care have knowledge and insight about their role and tasks. This includes the taxi driver, the receptionist, the nurse and the doctor.