Textbook of Maritime Medicine

The public image of the maritime physician is one of a physician practicing on board a ship.  Indeed, it is difficult for a physician to understand and be knowledgeable about maritime medicine without having a working experience on board a ship.  Practicing as a maritime physician on board is, first of all, living the life of a sailor which means sharing long days at sea with the crew and looking forward to enjoying stops at ports.  The position of a maritime physician on board has often been disparaged.  In the past, it was either used as a commercial advertisement (In the XIX century, a British liner company advertised that there were a milk cow and a physician on board) or it was thought of as idleness since it was widely believed that crew members were generally in good health and, consequently, the maritime physician did not have much work to do.  These are, of course, stereotypes from another time.  Being a physician on board means being an all-round physician with a strong knowledge of emergency medicine, surgery, dermatology, and general practice.  The maritime physician on board must be prepared to face any medical or surgical event.  In emergency situations, when an evacuation is required, he must be able to stabilize patients’ health status until the evacuation is possible and prepare the patient for the evacuation most often by helicopter.  Being a medical physician on board seems to be an exciting job but few posts are available.  Indeed, positions for maritime physicians practicing on board are (mostly) found on ships carrying large numbers of passengers such as liners and ferries (they carry thousands of passengers).  Those ships have medical teams with one or several physicians including surgeons, and nurses.  These medical teams operate in medical facilities similar to small hospital wards with outpatient and in-patient facilities, intensive care and surgical wards, and biomedical laboratories.  Given the large number of passengers of all ages and physical conditions on board these ships, the physician must be prepared to take charge of any kind of pathology, in particular cardio-vascular or infectious diseases.  Indeed, the confinement of thousands of tourists in a restricted space like a ship (even a large ship) increases the risk of epidemics (especially gastro-enteritis (for example due to the norovirus).  The maritime physician must be able to deal with these outbreaks.

The medical management of the crew and passengers during the time spent on ports is also an important aspect of maritime medicine.  It requires a good knowledge of tropical diseases such as malaria, dengue fever, as well as tropical maritime diseases (ciguatera, bites or stings from marine animals).

The other types of ships with maritime physicians on board are large military ships (ranging from frigates to aircraft carriers) and civil ships such as oceanography ships and “cabliers”.   On board military (combat) ships, the physician is essential because of the frequency of casualties (traumas, burns and intoxications).  Admiral Nelson once said: « during military operations, health is the most important thing ».  On board civil ships like oceanography ships, the population is made of professionals (scientists, technicians,) whose status differs from the one of sailors.  These professionals are exposed at the same time to the risks associated with navigation and to the risks associated with their specific professional activities (i.e., working in immersion for scientific exploration (small submarine), operating Remote Operated Vehicle or sounding lines, working at a laboratory on board…).

Current international regulations, which determine whether a physician must be on board or not, seems inadequate to us: In 2006, the ILO/IMO, international convention on maritime labour (guideline B4-1) ruled that it is mandatory to have a physician on board when the total number of persons (crew and passengers) is over 100 and that navigation lasts more than 3 days.  According to these regulations, it is not mandatory to have a physician on board a ship like an oceanography ship, which carries 80 to 90 people and navigates for more that 15 days sometimes 30 days far away from a port.  Yet the health risk is greater on board those ships than on board ships navigating for a few days.   We therefore recommend that it is mandatory to have a physician on board when the ship carries over 50 people and navigates longer than 15 days.

The maritime physician on board does not merely wait for medical or surgical emergencies.  He watches over personnel health at all time during the course of the trip.  He has to take charge of all health problems ranging from ear nose throat problems or allergies due to air conditioning to psychological or psychiatric problems – In a restricted environment such as a ship, he becomes everyone’s confident.  In addition to medical care, he is also in charge of carrying out administrative tasks such as medical equipment management.  He is the hygienist on board and is in charge of insect and rodent control, disinfection, ensuring quality of water and food, including nutritional balance of every meal.  Finally, he is the advisor to the commander of the ship who is his (direct) administrative supervisor.

Whether there is a physician on board the ship or not, every sailor must be assessed for medical fitness at sea before boarding.  This assessment is done by maritime physicians qualified in occupational safety.  In accordance with the international convention (Norme A1-2), in each country, the ability to carry out this medical assessment is delivered to physicians by a competent authority.  These physicians generally practice within specialized services such as the “seafarer’s health services” in Spain and France.  Ideally, maritime occupational safety physicians, before practicing “on the ground”, should have a working experience on board.  This would ensure their full understanding of all health constraints associated with navigation.  Most seafarers health services are organized like “on the ground” occupational safety medicine services.  They deal with hygiene, sanitation, safety and working conditions on board.  Today, most controls carried out on board are statutory control.

Occupational safety on board is the other domain of activity of the maritime occupational safety physician.  In this, the maritime physician must study and understand the impact of living and working on board on sailors’ health in order to prevent the occurrence of health problems.  This is a major chapter which includes all questions related to sailors’ medical fitness at sea, the exposure to the physical nuisances on board ships (noise, vibrations), stress and addictions because of the particular psychological environment on board, toxicological problems, postural problems (MSD), work related accidents, hygiene, sanitation and, finally, dealing with national and international regulations.

Maritime occupational safety medicine concerns all categories of professional seafarers: commercial navy, fishing, offshore activities, and professional divers.  The maritime occupational safety physician must therefore be knowledgeable about all aspects of occupational safety.  He must understand (in great depth) physical nuisances (noise, vibrations, temperature and lighting), psychological issues (such as stress related to work and to the environment) and organizational issues.  Like occupational safety physicians in charge of companies on the ground, his goal is to improve sailors’ living and working conditions on board, and to study health problems that are specific to working at sea or interfering with them.

In addition, the maritime occupational safety physician is in charge of assessing sailor’s medical fitness to the post (on board).  The maritime environment gives a real specificity to maritime occupational safety.  Assessing sailor’s medical fitness at sea is mandatory. This obligation was first established at the Convention on Maritime Labour in 2006 – previously (called) Conventions ILO/IMO n°73 and 113 -. Because of the hostility of the maritime environment and the great distance to any health facility at sea, in addition to assessing the sailor’s ability to the post (mechanic, cook, helmsman…), the maritime occupational physician must assess the risk caused by the sailor’s health status and decide if the risk is acceptable or not.  It is a huge responsibility.

The maritime physician will assess carefully the risks associated with exposure to noise, vibrations, and air conditioning on sailors’ health.  On board, sailors are exposed to these nuisances 24 hours / 24, several months per year.  The physician will also pay great attention to the stress attributable to the psychological environment on a ship.

Maritime occupational safety also includes activities carried out when the ship is in ports – as developed by Professor X. Baur in Hamburg.  Many accidents occur when the ship has berthed, during maintenance and repair work.  Maintenance interventions on cooling systems (cold store/ refrigeration, air conditioning, fire prevention systems) are particularly dangerous especially in the case of leaks of cooling fluids such as Freon or Ammoniac.  Numerous deaths are attributable to intoxications by these fluids at sea as well as on port.  During loading and unloading operations workers are also exposed to great traumatic or toxicological risks.  During cleaning operations of hydrocarbons tanks, drastic measures must be taken to prevent intoxications with dangerous gas, especially carbon monoxide. Because these toxic risks are frequent, the maritime occupational physician must have an in-depth knowledge about toxicology.

Occupational safety medicine is also concerned with “littoral environmental medicine” an entity which is becoming increasingly important.  This includes the control of pollutions caused by ships on the littoral environment.  Pollution agents include hydrocarbons (black tides), agro-industries products (soya dust), fishes and shellfish pollutants, or microorganisms (algae, bacteria and viruses) transported by the water from ballast tanks.  There are many examples of such pollutions. For example, in Barcelona Spain, asthma epidemics due to soya dust released during ship unloading, in Japan, intoxication of the population through the consumption of fish contaminated by mercury (Minamata disease), or, in Brazil, a cholera epidemic following the dispersion of contaminated water from the ballast tank.

Toxicological (bromomethane) or infectious (malaria, virus) agents can be transported in containers.  This is a real challenge given the huge increase worldwide of maritime transportation.

The third type of maritime physician is the maritime emergency specialist.   During the last decades, most developed countries have implemented maritime centres for radio-medical consultation.  These centres are opened 24 hours a day to assist commandants with the management of crew members’ health problems.  During the last 15 years, two developments occurred simultaneously: On the one hand medical knowledge has improved among crew members since the obligation, for commercial navy officers, to be able to carry out simple medical acts such as intra muscular injections.  These regulations were implemented within the framework of the STCW 95 regulations.  On the other hand, communication means between ships and ground have increased tremendously via satellite and Internet.  This allowed for the development of telemedicine systems (which are still at their beginning).  With telemedicine systems, physicians in radio-medical centres receive patients’ data such as EKG and photographs directly and almost in real time.  This provides them with better diagnosis and patient management means.  Conversely, the commandant or the officer in charge of health care on board is able to implement treatments prescribed under the physician’s guidance.  With telemedicine, medical maritime physicians are able to practice general medicine (from a distance) as opposed to merely being in charge of emergency situations.

When there is a physician on board, telemedicine remains very useful.  While caring for a patient, the physician on board is able to discuss with colleagues from the radio-medical centre about diagnosis and treatment issues.  This greatly reduces the sense of isolation that many physicians at sea experience.

When a medical or traumatic situation requires a medical evacuation and the ship is near rapid and adequate means of evacuation, the maritime emergency physicians takes charge.  Emergency physicians are lifted on board the ship, most of the time by helicopter, to prepare the wounded or sick patient for the evacuation.  These interventions are difficult, both physically and technically, because the conditions at sea are often acrobatic.  Emergency physicians must have, aside from a strong knowledge in emergency medicine, an in depth knowledge about treatment under special conditions in thee air (altitude, pressure) and living conditions on board.   The emergency physician is also in charge of diving accidents and leisure water sports accidents.

One could think that the three types of maritime medical practice, aptitude medicine, emergency medicine, and medicine on board and in port, have little in common.  Yet, the specificity of maritime medicine is such that, no matter what type of practice, maritime physicians must have an in depth understanding of the maritime environment, its laws and regulations.  Whether he is emergency physician, physician on board or occupational safety physician, the maritime physician must understand sailors’ living and working conditions on board, the special psychological conditions sailors are exposed to, as well as all the other risks at sea (fall in the water, hypothermia).   Maritime medicine is not merely a medical specialty. It is a medical field with several specialties, all of which are concerned with the sea, a very hostile environment.