Despite preventive measures to reduce the risk of illness, injury, incapacity and death to seafarers, incidents requiring medical attention do occur at sea. The aim of all provisions for the medical care of seafarers, both at sea and ashore, is to mitigate the harm resulting from such incidents. This includes both immediate measures to relieve pain and anxiety and to resuscitate and stabilise the patient, as well as longer-term requirements for evacuation or continued care on board, and for care, rehabilitation and, where possible, rapid return to work ashore.

The challenge faced by all the contributors to this volume is how best to achieve these objectives using the forms of intervention they describe. For each element of the maritime medical care system, risk management is a key component. Current approaches have evolved slowly over the years, often in response to improved treatments for specific conditions or because of improved communications, for example in telemedicine support or helicopter evacuation.

Many elements are legal obligations derived from international conventions. As such, they are rarely amended to take account of developments in care and, when they are, there is often a lack of joined-up thinking to link the different elements of care. This is because each element is part of a different convention and these are the responsibility of three different bodies: ILO, IMO and WHO. Improved international consistency of care arrangements has become increasingly important with global crewing, where the seafarer may be trained in medical care in one country, be on a ship with a medical chest that meets the specifications of another, and have access to telemedicine advice from a third.

The medical facility

The medical facility (or sickbay) on board a ship can have many different functions. A few decades ago the focus was on accommodating the sick or injured, but today the focus is more on the sickbay as a treatment facility. The most obvious function of a sickroom is as a place to examine and treat a sick or injured crew member. This may require the ‘patient’ to lie down or, more commonly, the patient will walk into the sick bay and require somewhere to sit while the examination takes place. The sick bay may also act as a store for medical equipment and as an isolation room for sick seafarers with infectious diseases such as influenza, norovirus or chickenpox. In a worst-case scenario and in the event of a multiple casualty incident, the sick bay may need to be used as a triage area or as an area to receive others from the sea or from less well-equipped ships.

The function and requirements of a hospital room will vary depending on the size and type of ship. On a chemical tanker, emergency showers will need to be available to decontaminate personnel exposed to chemicals, and on lifeboats a shower may be used to provide cooling for burns or to warm people rescued from the sea. Ships used to support diving operations may have a permanent mobile decompression chamber. Purpose-built vessels, such as cruise ships, naval vessels or charity ships, may have more extensive medical facilities, up to and including a full-fledged hospital on board.

Communications

In the past, ships had to look after themselves, including medical care. This was, and to some extent still is, reflected in the education and training of the master and navigators. On older ships, it is also reflected in the design of the medical facilities, sometimes without proper communication with shore.

Today’s reality is that any medical treatment on board that goes beyond ordinary self-care is often a team effort with the officer responsible for medical care or a health professional who is a remote practitioner working with a doctor on shore. Current international and flag state regulations require that care on board should be “as comparable as possible to that generally available to workers ashore, including prompt access to necessary medicines, medical equipment and facilities for diagnosis and treatment, and to medical information and expertise”. Treating serious illness or injury on board without the assistance of a doctor may now be considered malpractice.

To function effectively as a remote practitioner in a medical team with shore-based expertise, the medical facility or workstation must be equipped and designed to work efficiently with the doctor on shore. This may be less of a priority if the ship is sailing close to shore and making short crossings, for example across a fjord or to islands at a short distance from the mainland. Here the need for communication may be limited to a telephone line to call an ambulance to the pier on arrival. However, if the ship is crossing oceans and out of helicopter range, the medical officer may need to carry out advanced medical procedures under the guidance of a TMAS doctor. In such cases, communication cannot be too good. This is reflected in the International Maritime Organisation’s (IMO) Polar Code, which requires ships sailing in Arctic waters to have a telemedicine solution that goes beyond the minimum requirements of the GMDSS. However, it does not specify what this solution should be.

Voice and phone

The most basic communication that needs to be in place is a voice or phone line. Examining a patient and having to leave the medical facility to go to the bridge or somewhere else to talk to the TMAS doctor, then returning to do additional or repeat examinations or ask new questions, and then leaving to talk to the doctor again, simply does not work. On ships without basic communications, the medical facility is simply never used and does not work as intended.

Having a telephone line from the medical facility that can be used with the various communication systems on the ship is the basic solution. In an emergency, reaching a TMAS service by telephone is always the fastest way to get help. The value of this is increased if the officer responsible for medical also has a hands-free solution to talk to the doctor on shore while attending to the patient. The optimum solution is to have freedom of movement so that calls can be made from other areas of the ship, such as a crew cabin, but also from working areas such as engine rooms, the deck or cargo holds. People do not always become ill or injured in the medical facility!

E-mail and the Internet

In many situations, communicating by email is a more effective way to communicate, as is using attachments such as pictures or information from more sophisticated medical equipment such as an ECG, ophthalmoscope or ultrasound. A picture can easily convey detailed information about, for example, a wound, swelling, rash or injured eye that is difficult to describe in words. Pictures are an excellent tool for documenting changes in different conditions and can sometimes help overcome language barriers. 

For some Telemedical Assistance Services, email is the preferred method of communication. Some private medical assistance or telemedicine providers also have systems that require an online login before it is possible to communicate properly with a doctor onshore. Be aware, however, that this raises issues of patient confidentiality. For more information on ethics and confidentiality, see section 2.9. As a source of information, the internet is also essential for finding information about medicines, procedures, etc. and should be available in a medical facility.

Video and bandwidth

Another useful communication tool is video consultation. The ability for the TMAS to interact with the officer responsible for medical care on board and for the doctor to see the patient’s reaction is invaluable in some situations. For example, many diagnoses are made more or less likely by assessing the patient’s response to pain, vigilance or reflexes. All ocean-going vessels are now required to carry satellite communications with sufficient bandwidth to perform basic video consultations. Video consultation works perfectly well with a bandwidth of 128kb, which is the smallest Inmarsat solution.  Vessels limited to coastal operations do not necessarily have satellite communications.

Video consultations with more advanced TMAS providers work without any additional equipment or software, as long as you have a computer, pad or phone with a camera and an internet connection. This uses the WebRTC protocols embedded in most browsers. A portable webcam, which can be held in the hand or fixed in various positions relative to the patient, adds enormous value to such a system, and pre-planned positions for the camera make this even better.

More and more shipowners are choosing to equip their vessels with compact telemedicine kits, often consisting of a PC or pad connected to a camera and basic electro-medical equipment. Again, the positioning of the equipment and camera should be planned in advance to achieve a desirable solution. The most advanced solutions have multiple cameras pre-installed, giving a choice of different angles and zooms.

When pre-positioning a camera for video, positions should include a view from above with a choice of a frontal or profile view of the patient and surroundings. Additional positions should be available to zoom in on the patient’s upper body and face, abdomen and extremities for procedural guidance. In addition, a portable camera should always allow for close-up views of details such as an eye, nail or wound.

Although all ocean-going vessels are required to have satellite communications with sufficient bandwidth not only for phone calls and email, but also for basic video conferencing, many are unable to implement video consultations. This is often because the bandwidth is used for multiple purposes, there are firewalls to prevent large applications from running, or the crew are not aware of the option. When designing and equipping a sickbay, systems should be put in place to prioritise bandwidth in an emergency and easy-to-use video solutions should be installed. Be aware that some video intercom suppliers offer end-to-end solutions that require the same equipment or protocol to be used at the other end. For a vessel moving between regions and countries, this limits the ability to talk to different TMAS providers and is therefore a poor solution.

Telemedical Maritime Assistance Services (TMAS)

Telemedical maritime assistance services (TMAS) are remote medical advice services designed to provide medical assistance to seafarers and others on board a ship. Quick and easy access to such a service is a key element of on-board medical care and these services are primarily used by seafarers on board ships without a doctor. Ship’s doctors or other health professionals may also seek assistance when needed. The service may be organised and sponsored by member states of the International Maritime Organisation (IMO) or by a private company. Each IMO member state is legally obliged to provide a TMAS at all times, on all ships and free of charge. The master or the officer responsible for medical care on board a ship should request remote medical advice from a TMAS centre as and when they consider it necessary.  It should be noted that the TMAS provides an advisory service and that the final decision and responsibility for the treatment of the patient, including evacuation or diversion, etc., always rests with the Captain on board.

TMAS is an integral part of the Search and Rescue (SAR) capability of many nations. Medical evacuation of the patient may be required, in which case a Maritime Rescue Coordination Centre (MRCC) or Joint Rescue Coordination Centre (JRCC), if available, can assist in organising this evacuation. Good co-operation between the TMAS centres and the MRCC/JRCC is key to this type of operation. 

TMAS is regulated by a convention that is the result of cooperation between the IMO and the International Labour Organisation, Convention 164 of the ILO’s Health Protection and Medical Care (Seafarers) Convention. As TMAS is considered an integral part of SAR, additional requirements are set out in the IAMSAR (International Aviation and Maritime Search and Rescue) manual[2].

The Maritime Labour Convention 2006 (MLC) also refers to TMAS and states that “the competent authority shall ensure, through a pre-established system, that medical advice by radio or satellite communication, including specialist advice, is available to ships at sea 24 hours a day; medical advice, including the transmission of medical messages by radio or satellite communication between a ship and those on shore providing the advice, shall be available to all ships free of charge”.

Despite the regulations, the provision of TMAS varies widely around the world, with significant differences in availability, capability, range of services and quality. In Europe, almost every country provides remote medical assistance through a TMAS centre. In other parts of the world, far fewer countries fulfil the requirement to establish a TMAS centre. For example, India, a country with approximately 13% of all officers at sea, does not provide this service.

TMAS providers differ in some respects, such as whether they are part of a hospital organisation or whether the centre is staffed 24 hours a day by dedicated doctors. Some countries choose to provide the bare minimum, while for others no effort is too great to create a professional organisation. Some services provide advice and guidance only in the event of evacuation from a ship, while others provide ongoing medical advice for all concerns.

In Denmark there is an exception to the rule that the master remains responsible for the ongoing care of the seafarer. When the Danish TMAS centre is called and it is agreed that a sick or injured seafarer should be evacuated, medical responsibility is transferred to the attending physician.

The TMAS may be a government-funded service or a private service. Private providers are often, but not always, a general practitioner providing a consultation at a distance from shore. Large assistance companies with 24/7 manned operating platforms can also provide telemedical assistance to ships around the world.

There are two main differences between private and public providers of TMAS:

• Public providers, organized by the state, work within the legal frame set by the IMO for TMAS centres. Private providers do not have to follow any rules or guidelines set by the IMO.
• State run providers are financially supported by the flag state, whereas the state does not support private providers in any way.

To survive, a private organisation needs to be consulted and the shipping company usually has to pay for access to the service. Payments can be annual or per consultation. It is vital for a private organisation to provide a quality service, otherwise companies will take their business elsewhere. A government organised and funded TMAS service does not have this need for a minimum number of consultations as the income is guaranteed by the government. Therefore, both systems have a different way of guaranteeing the quality of the service provided; government facilities because they follow a minimum set of requirements set by the IMO, and private providers simply because they still exist and retain clients.

There is a growing desire to improve co-operation between TMAS services to ensure quality and consistency of service. Closer co-operation would also provide better information on the diagnoses etc. of cases handled on board.

Communication with TMAS

Communication is the key to quality and effective TMAS. It can be spoken or written and pictures and videos can be sent to clarify certain symptoms. This communication can be established by a variety of available means including VHF, HF, MF (satellite) telephone, e-mail and INMARSAT.

The List of Radio determination and Special Service Stations contains contact details for the government-organised TMAS services. This list is on board and available in the ALRS Vol. I. For most TMAS centres, communication channels include all possible modern means of communication: (satellite) telephone, INMARSAT, e-mail, VHF, HF and MF. A TMAS service can also be reached by contacting an MRCC/JRCC.

Some TMAS services operate in a different way. For example, only one or a limited number of communication methods can be used. For example, in Portugal, the only way to contact a TMAS service is to use VHF channel 16. Another possibility is that a TMAS service can only be contacted by first contacting an MRCC/JRCC or another organisation such as the coastguard.

Ship’s officers generally use their own language when contacting their national TMAS. For all other communications and with other centres, English is generally used. Each medical consultation should be recorded in accordance with the national regulations of each TMAS centre.

Written communication

Communication with ships in Morse code on long and medium waves became possible from 1906. Coverage was mainly limited to coastal areas until after the Second World War, when short waves were also used and coverage became global. Despite its superior efficiency, the use of Morse code declined during the late 20th century. It was finally replaced by the Global Maritime Distress and Safety System (GMDSS) on 1 February 1999. This allowed clear text to be transmitted without the need for interpretation, the forerunner of today’s email. However, the advent of the internet in the 1980s made telex obsolete and the telex networks were closed down around 2000. The satellite era and the advent of the internet allowed the development of the email system, which is now the predominant form of written communication between ship and shore.

The advantage of written communication is that it is well documented and any language problems or misunderstandings can be reduced. The disadvantage is the slowness of the process. Pictures, video and vital data can also be transmitted and can add great value where appropriate.

Voice communication

With the exception of VHF in coastal areas, radio communication on ships is rapidly declining. Telephone communication via satellite is by far the most widely used form of long-distance communication in the shipping industry. Signals pass from the land-based telephone network or mobile network via an earth station and a satellite to the receiver and back. The sound is usually of high quality, although there may be some echo or delay.

The main advantage of voice communication is the speed of information exchange. When immediate help is needed, written communication can be far too slow. Voice communication can be supplemented by written communication if necessary. Documentation of voice communication is possible through voice logs. In addition, other important aspects of medical consultations, such as reassurance, are easier to provide by voice. However, voice communication is not without its pitfalls, the most important of which are language problems. Some ship’s officers do not have the necessary knowledge of English and this can cause major problems in identifying the medical problem, its severity and advising on appropriate care and action. Some countries have online interpretation services for civil purposes. The establishment of such an international service would be a natural task for future cooperation between TMAS services.

Both the TMAS doctor and the ship’s officer should have an appropriate level of English and the TMAS doctor should take care to use plain language and avoid technical jargon.

The use of standard forms can also improve communication and these can be found in the International Medical Guide for Ships 2007. Officers would benefit from consulting these forms before calling the TMAS service and TMAS doctors should be familiar with them.

In practice, the English vocabulary of many seafarers is not good enough to communicate about medical problems. In addition:

• Medicine is not practised the same around the world. Trust between the officer responsible for medical care and the TMAS doctor is a critical factor.
• Different cultures have different ways of communicating. Non-explicit links can be even more easily lost in communication. There are already many barriers to communication between doctor and patient.

Note: This text is excerpt from the Textbook of Maritime Health by Norwegian Centre for Maritime and Diving Medicine, available at: https://textbook.maritimemedicine.com/