Initially boarding or seizure of a ship at sea or in port may require a decisive amount of force, depending on ship’s efforts to escape, deter or even fend off the hostile takeover. A terrorist attack is especially likely to include excessive violence in order to catch public attention. The attack itself may cause a number of casualties, or fatalities among the crew and passengers. The probability of such harm rises with efforts of the crew, or of security personnel to oppose the attack, as was seen in the capturing of Turkish ships by Israeli forces off the coast of Gaza in June 2010.

Even the less severe injuries from such an attack will probably exceed the usual merchant vessel’s ‘medical’ capabilities. After a ‘hit and run’ or suicide terrorist attack outside help - as far as it is available - can be organized immediately. A security and safety force may have to go in first to stabilize the ship and look for explosive devices but then medical rescuers can follow. The medical spectrum during this phase will most probably be dominated by injury to crew and possibly terrorists.

 As contemporary pirates now rely on automatic rifles and rocket-propelled grenades (RPG) to overwhelm even armed crews bullet, shrapnel, blast and burns injuries can be expected during any assault, whether successful or not (10). (In contrast to terrorists and armed robbers Somali pirates so far have rather turned away if met by professional armed resistance.)

Any kind of first aid or emergency care will probably be impossible or at least severely hampered until the assailants break away or take a safe hold of the ship (see next paragraph). In addition distances and therefore timelines at sea are substantially different from those ashore. Also weather conditions may severely inhibit or delay rescue operations and patient transport.

As a consequence equipment and training of first responders (crew) and rescue services for sustained pre-hospital care is needed. Stabilization of patients before and during evacuation is required as deterioration of patients’ conditions can be expected in these circumstances.

 Long lines of communication to a suitable shore facility may mean that stopover platforms have to be considered to refuel helicopters or other craft for the transport of rescue personnel and equipment. For patient evacuation these platforms should ideally have medical facilities for the stabilization of patients in transit or even for an initial ‘clinical’ treatment.

In the Gulf of Aden and along the coast of Somalia medical support is available for merchant vessels from the large naval presence in the area, as warships can usually provide a higher level of medical care. In many cases military medical personnel can be transferred by helicopter to merchant ships to stabilize the wounded and evacuate them to the medical facilities onboard their units for further treatment. (German frigates of the EU Anti-Pirate Maritime Task Force are regularly manned with additional health care professionals, e.g. surgeons, anesthesiologists and dentists!)

 For crewmembers hospitalized at foreign ports it is helpful to have a medical professional available who speaks their language as well as that of the country. This person can liaise with local colleagues to translate and explain as well as to evaluate options for early repatriation. There should be ready access to medical as well as psychological (see chapter 13) assistance for other crewmembers.

 As terrorist attacks as well as the ‘classical’ acts of piracy or organized crime will be limited in duration there is a chance for a relatively rapid rescue operation, although there will be differences in response times depending on the position of the ship and the facilities available from nearby countries, especially in less developed areas of the world. These rescue operations will have to be orchestrated either by local/regional rescue centres or – with a lack of those in many cases – by the crisis response cell of the shipping company or flag state. It is obvious therefore that such cell have to encompass medical expertise!