Medical treatment ashore. Local care, evacuation or

repatriation. The eternal dilemma……..

Dr Sue Stannard

Dr Sue Stannard

• Clinical background in Emergency Medicine, Anaesthetics, Paediatrics

• Evacuation and repatriation medicine – Medical Director of International SOS (London)

• Cruise medicine – time at sea and later Medical Director of Carnival UK Cruise Lines

• Medical adviser, Norwegian Centre for Maritime Medicine

Size of the problem (2013)

• 20 seafarers landed with illnesses

o 1 fatalities o 1 evacuation o 10 repatriated for ongoing care

• 58 injuries o 2 fatalities o 1 evacuation o 15 repatriations for ongoing care

Safety training programme has shown a 40% reduction in injuries for

the first 6 months of 2014.

Treatment options for the disembarked seafarer

• Local care in the port where the seafarer is landed from the ship

• Evacuation to the nearest centre with medical facilities where appropriate care can be received

• Repatriation home for ongoing care

Different option may be appropriate at different times – need to constantly review the situation

Local care

• May be excellent

• May be appropriate or adequate to at least provide initial emergency care

• May be very limited in resources, personnel, facilities and only appropriate for life or limb saving care

• May be nothing but a hut with a visiting Doctor on different days

Evacuation or Repatriation

• Evacuation: transfer to the nearest centre that can provide the care required at that time

• Repatriation: transfer to the home country or region

• How to get there? o Ground transport: car, ambulance, train

o Train

o Boat

o Flight – commercial or air ambulance

Can/should the seafarer be moved?

• What is the current medical condition? • What is the urgency of intervention? • What are the physical and physiological

considerations that affect fitness to travel and fitness to fly?

• How can the seafarer be moved? • Where should they be moved to?

Is the risk of moving the patient ultimately better

than leaving the patient in the existing facility?

Fitness to fly

• Pressure – volume effects – Boyle’s Law

• Relative hypoxia – Dalton’s Law

• Medical care required in flight

• Commercial carrier considerations

o Infectious disease

o Harm or upset to other passengers

o Can appropriate care can be delivered in flight

oWill medical clearance be granted

Who is making the decisions?

• Medically trained or access to personnel with medical knowledge

• Objective assessment of needs and local capabilities

• Informed decision with regards to fitness to fly and logistical considerations

• Aware of the financial aspects but not governed by such

• Aware of the legislation, contracts etc

MLC 2006

Guideline B4.1.3 – Medical care ashore 1. Shore-based medical facilities for treating seafarers should be adequate for the purposes. The doctors, dentists and other medical personnel should be properly qualified.

2. Measures should be taken to ensure that seafarers have access when in port to:

(a) outpatient treatment for sickness and injury; (b) hospitalization when necessary; and (c) facilities for dental treatment, especially in cases of emergency.

3. Suitable measures should be taken to facilitate the treatment of seafarers suffering from disease. In particular, seafarers should be promptly admitted to clinics and hospitals ashore, without difficulty and irrespective of nationality or religious belief, and, whenever possible, arrangements should be made to ensure, when necessary, continuation of treatment to supplement the medical facilities available to them.

Medical considerations

• What treatment is required and in what time line?

• Who is making the decision?

• Are the medical and nursing staff properly qualified and up to date with their training?

• What is ‘adequate for the purposes?’

• What standards are you using?

Ethical considerations

• Are you comparing care in the seafarer’s home country, flag state, ship owner’s country? Should it make a difference?

• Should all officers and crew be treated the same?

• Is it acceptable for a seafarer to be treated for a prolonged time away from home and family?

• Financial aspects

Seafarer’s perspective

• Are they comfortable with the care they are receiving?

• Nursing and holistic care

• Social and welfare support

• Access to telephones and other modes of communication

• Costs – medical care and lost earnings

• Ongoing plans – return home or rejoin ship

Ship owner’s perspective

• Are they providing the seafarer with an adequate and appropriate level of care?

• What systems are in place to monitor the medical care that is being given, the plans made and the costs incurred?

• Costs

• Staffing of the vessel and ability to continue it’s schedule

• Ongoing plans for seafarer and vessel staffing

Summary

• More questions than answers, an eternal dilemma

• Each case is unique, there can’t be a ‘one size fits all’ policy

• Does the decision meet all of the medical, logistical and ethical aspects of the case?

Better to prevent these events where possible with appropriate examination and selection

Thank you! Takk!