Proactive Medical Support for the Maritime Industry
[Advertorial by Ray Jarris MD and Ann Jarris MD]
Injuries at sea are often preventable and the maritime industry has made great progress with well-designed safety programs and increasing safety awareness at sea. A similar effort is needed to address the fact that over fifty percent of medical events at sea are the result of medical illness. With medical training for officers, a well-designed medical kit and shore side medical support from maritime-savvy physicians, most mariners who are injured or fall ill at sea can be successfully managed during the voyage.
How can the maritime industry move forward to improve the health of their officers and crew? The vessel owner may ask how the ever-rising costs of Protection and Indemnity insurance and medical care for their officers and crew can be addressed? First and foremost, it is time to move from a "reactive" to a "proactive" stance to address the health and medical care of mariners from hiring to disembarkation at the end of a voyage.
Pre-Boarding Medical Screening and Biometrics
Working at sea most typically means the commercial mariner is isolated from professional medical care until the next port call. Not only are acute injury and illness important to address, mariners with chronic conditions require special attention. As an example, a mariner with diabetes needs careful evaluation, education, and stabilization of their medications and glucose control that is coordinated in conjunction with a medical professional who understands the maritime environment and in particular the operating area of the vessel and length of time at sea. A medical advisor can assist the vessel owner and ship’s medical officer in developing sound and reasonable strategies that allow for the majority for mariners with chronic illness to successfully and work at sea.
For credentialed mariners, it is important to be prepared for national and STCW medical credentialing processes. Mariners are strongly encouraged to anticipate requests for additional information from credentialing authorities such as the USCG/National Maritime Center when they have had a significant medical event or a new medical diagnosis that surfaced since their last document submission. This can be an arduous and challenging process and can lead to delay in re-credentialing. The goal is to gain clearance or possibly a medical waiver that permits the mariner to continue their career at sea. Here again, a medical advisor can work closely with the mariner to help smooth this process.
The value of routine post-offer and annual physical examinations has come under scrutiny. Some maritime firms utilize annual medical screenings both in written and electronic platforms as an alternative, cost-effective strategy. It is highly recommended that a physician with maritime expertise be responsible for reviewing these forms and that the completed forms are available to the consulting medical advisor when a vessel calls for assistance. With boarding crew or new hires screening tests such as a blood pressure check, random finger stick glucose and point-of-care urine testing for glucose are useful to consider. A physician advisor can develop "alert" criteria that should trigger additional testing or follow-up visit to a medical provider for further fitness-for-duty evaluation.
Preparation begins with training for the vessel officers and safety personnel. Basic first aid, CPR and AED training is recommended for all mariners. It is highly recommended and may be required for the medical officer and others to complete the STCW Medical Care Provider or Medical Person in Charge program. The skills taught in these programs prepare the medical officer to work closely and effectively with the vessel’s medical advisor.
As an example of pre-voyage crew engagement, all aboard the vessel should be advised to bring adequate supplies plus 30 days of personal medications, medical supplies such as diabetic glucometer strips, eye glasses and contacts, batteries for hearing aids and if they have sleep apnea and use a CPAP machine, enough distilled water should be available for them to complete their voyage.
The medical chest may be mandated by a vessel's given flag nation, however, as in the United States and other nations, there may be no specific guidance offered to vessel owners. The International Medical Guide for Ships and supplements published by the World Health Organization offer valuable recommendations useful in the initial design of a medical chest. However, not every medication is available in all countries and modifications are typically required. A medical chest is best designed in collaboration with a consulting maritime physician who understands the vessel’s operating area, crew size, length of voyages and at times, the challenges of shipping supplies to other nations where importation restrictions may exist. Special consideration should be given to crewmembers with known chronic medical conditions in anticipation that they may have a complication while at sea that could be managed in consultation with your maritime medical advisor.
Vaccination of crew for preventable infectious disease is very important. Before the influenza season, early vaccination of all joining the vessel is highly encouraged. If that is not possible, vaccination at the time of boarding is encouraged. For vessels operating in malaria endemic areas, both preventive and treatment medications should be available. For control of contagious illness onboard, it is important to stress hand (https://www.cdc.gov/handwashing/pdf/wash-your-hands-steps-8x11.pdf) and cough hygiene (https://www.cdc.gov/flu/protect/covercough.htm) during crew meetings and by posting information on the vessel.
Be sure to check the medical reference books carried aboard the vessel. Outdated references are likely more a liability than a benefit. For vessels with satellite internet, many good online resources are available such as MedlinePlus (www.medlineplus.gov) or Medscape (www.medscape.com). Additionally, there are excellent downloadable medical references available. Check with your medical advisor to see which they recommend.
Shipboard Awareness: "If you don't look for trouble, trouble will find you"
Rather than waiting for those onboard to present to the medical officer complaining of an illness, pain or injury, the medical officer and others are encouraged to monitor their staff for signs of illness or altered movement that suggests an early injury may be developing. The medical officer might best engage early when an illness or "overuse" injury is suspected. Once an illness or injury is recognized it should be addressed and documented in the ship's medical log at a minimum although complete medical notes are highly recommended. Whenever the medical chest is accessed for a medication that is a prescription on land, it is a very appropriate time to obtain guidance from the vessel's shoreside medical advisor. Early and appropriate care on board may go a long way to avoid progression to a condition that necessitates a vessel diversion or call for a medevac helicopter!
For those aboard known to have a chronic medical condition, this is where a proactive mode is the most important. Examples would be monitoring blood pressure for a crew member with known high blood pressure who is taking medication or inspecting the glucose log and daily medication log for a mariner with diabetes. Parameters for when to consult with your medical advisor are best worked out in advance rather than to encounter a severe consequence of uncontrolled high blood pressure or sustained high blood sugar that can become life-threatening.
It is advisable that the vessel medical advisor regularly review the ship medical log. This creates the opportunity of identifying patterns of illness and injury and is an excellent opportunity to work with the medical officer to enhance their understanding of medical care at sea.
Contact your vessel medical advisor provider early and often. Email is excellent for non-emergency questions or for on-going care recommendations. However, use the telephone when rapid attention is needed. Digital photographs forwarded to your shoreside medical advisor by email are often very useful. The addition of live telemedical consults via satellite internet is available but in our experience adds only slight value to other modalities of communication especially if digital images can be forwarded to the medical consultant.
Entry to Medical Care
For crew that need medical consults on shore or when reaching home, your medical advisor can be a great resource. A physician-to-physician conversation can help the provider who will see the mariner better understand what occurred at sea, the care that was delivered by the medical officer and what options might exist to return the mariner to the vessel to complete their voyage. By working together, both the treating physician on shore and the vessel medical advisor are more likely to reach the safest and most reasonable understanding for a crewmember's ability to return to the ship or disembarkation for additional care.
When a serious medical event occurs at sea it may become necessary to initiate a vessel diversion, transfer to another vessel headed to port or helicopter evacuation. These events are demanding and stressful for all involved not least of whom is the mariner in need of medical assistance. Careful coordination with your medical advisor and the appropriate Rescue Coordination Center is critical. Vessel officers should anticipate changes in weather and sea conditions and have contingency plans always at the ready. On-going coordination with both air and ground ambulance should not be overlooked. The medical advisor should regularly update all parties in collaboration with the vessel master and very importantly, should have an accepting physician identified at the receiving hospital or their respective emergency department.
There are many more medical topics for both mariners and vessel owners to consider. The goals are the same: board safely, work safely, and return home in good health. Time spent examining how the medical processes work for your vessel will prove worthwhile and more likely than not be very cost effective.
Ann Jarris MD, MBA, FACEP, CEO of Discovery Health, LLC
Dr. Ann Jarris is a board-certified emergency medicine physician. A former emergency medical technician with extensive experience in wilderness, remote and rural medicine, she has a passion for delivering medical advice to remote sites.
Dr. Ann received her undergraduate degree at Dartmouth College. She attended medical school at the Mayo Clinic in Rochester, Minnesota, completed her emergency medicine residency at the University of Arizona, and received her MBA from Seattle University. She has practiced as an emergency medicine physician for over a decade in Washington and Oregon.
Ray Jarris MD, MA FAAFP, Chief Medical Officer of Discovery Health, LLC
Dr. Ray Jarris has 33 years experience in the emergency, occupational and family medicine settings. He has founded several maritime-oriented medical services companies including Maritime Health Services, Global Medical Systems and MD Solutions International.
He has extensive experience in remote site medical support and maritime medicine and has sailed as expedition team physician to Antarctica and the Arctic. Dr. Ray completed undergraduate and graduate study as well as earned a medical degree at Boston University. He completed his residency in Family Medicine at the University of Washington.
For more information on Discovery Health, please visit https://www.discoveryhealthmd.com/.
The opinions expressed herein are the author's and not necessarily those of The Maritime Executive.