Textbook of Maritime Medicine

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 of the utmost importance to organize an 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 everyone’s collaborative effort toward determining what might be the best way to treat 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
• try to find time consuming elements
• try to improve efficiency and quality
• select methods that give faster and more accurate information

This should be done for the more frequent types of care seafarers need. But the introduction of a 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.

An example

The possible clinical path of a patient

Reporting of the problem on board

This first step in the process is already problematic. A patient on board may be in a position that he does not want to report his problem. A poor social protection, a conflict with a superior, and fear to lose his job may be among the possible explanations.

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

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 arrive with much delay. This may contribute to valuable time lost in the treatment and management of the patient. In case the transport service has not been instructed properly, they may take the patient to any doctor or hospital without knowledge of the possibilities of that place regarding the patient’s condition.

Reception

It is of the utmost importance that a patient is well received in the clinic. The reception must give the patient confidence with regard to 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 has to judge the urgency of the case and inform the doctors.

Waiting time

Waiting time should be short in relation to the pathology or the schedule of the vessel.

Intake

Always take the cultural background of the seafarer into account. For some it is impolite to give negative answers or deny. Some have different attitudes towards pain. Always give the patient the chance to express his worries or anxiety.

Clinical examination

Although this is not usually very 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 around while undressing up to the point of an important aspect of the problem to be omitted.

Laboratory test

In the selection of an appropriate laboratory test the choice does not only depend on the differential diagnosis but also on what can be done before the ship leaves. Relevance of the lab test is important but also more exceptional or “tropical” pathology should be reminded.

Medical imaging

In this respect also the selection of the most appropriate test is important. A method must be sufficiently sensitive and have enough specificity to support the clinical findings and anamnesis.

Sometimes an ultrasound may give a better chance to get relevant findings than a CT scan or MRI, sometimes precious time is lost by first doing an ultrasound if in the end an MRI / CT is necessary.

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 immediate protocols of this kind should not be preferred.

Assessment

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 reference.

Explanation

As in every consultation it is a critical moment to explain the findings and round up the planning and treatment. Information can be misinterpreted; the patient can get lost in technical details or can be frightened by the medical language.

Reporting

Reporting to the ship should hold essential information about the duty status of the patient and 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 to the patient only 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

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 pay the medication in the first place.

Transport back on board

Convenient transport back to the ship should assist the patient until he is back on board and eventually accompany him to explain further arrangements and follow-up consultations or wait at the gangway to get the patient back off the ship to the hospital or airport if appropriate.

This example highlights a number of essential moments and events in a normal consultation that may be decisive for the quality of care a seafarer gets. A real maritime service or port clinic is organized in a way that these elements are taken into account and a maximal effort is done to overcome the barriers for the patient. This can only be done if all partners have knowledge and insight in their role and tasks from the taxi driver to the receptionist, the nurse and the doctor.