Horneland, Alf Magne

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www.intmarhealth.plInt Marit Health2009; 60, 1–2: 36–39www.intmarhealth.plCopyright © 2009 Via MedicaISSN 1641–9251REV IEW ART ICLE36Alf Magne Horneland, MD, Director, Norwegian Centre for Maritime Medicine Department of Occuaptional  Health, Haukeland University Hospital, 5021 Bergen, Norway,e-mail: alf.magne.horneland@helse-bergen.noMaritime telemedicine— where to go and what to doAlf Magne HornelandNorwegian Centre for Maritime Medicine, Bergen, NorwayINTRODUCTIONTelemedicine in a maritime environment differs fromtelemedicine onshore in several aspects. This fact necessi-tates the need for an independent development of mari-time telemedicine. Some of the aspects of such develop-ment are discussed in this article, dealing with the basis,the need, the possibilities, and the principles for a suitableTelemedical Maritime Assistance Service (TMAS).SHIPPING KEY FACTSThe sea covers 361 million square kilometres of theworld’s surface. Fifty thousand merchant ships are engagedin international trade, transporting every kind of cargo. Onehundred and fifty shipping nations are involved, and overone million seafarers of virtually every nationality are em-ployed in the industry [1].LIMITATIONS FOR MEDICAL CAREON BOARDHuge distances and long periods of time out of reach ofSAR helicopters and without possibilities for MEDEVAC char-acterize the working situation. When someone falls ill underthese conditions, colleagues with little or no medical experi-ence and a minimum of education and training [2] have todeal with illnesses or injuries for days and weeks. Profes-sional medical assistance may be limited to radio medicaladvice from ashore. The equipment and medicines availableon board are rather limited as compared to onshore facilities.INTERNATIONAL FRAMEWORK FOR TMASThe most important international regulating frameworkfor TMAS is the ILO Convention (No. 164) concerning HealthProtection and Medical Care for Seafarers of 1987, pursu-ing the Medical Advice at Sea Recommendation R 106 from1958, and soon to be replaced by the Maritime LabourConvention 2006 (MLC). The Safety of Life at Sea Conven-tion does not deal directly with TMAS, but says somethingabout radio communications and the Global Maritime Dis-tress and Safety System. The WHO has recommendeda list of ship medicines, and the EU regulates some of theservices in the EEC Directive 92/29. The qualifications ofthe seafarers are regulated in the STCW Convention. Hand-books in first aid and medical care are published from manynations, with the International Medical Guide for Ships(IMGS) as the most important one, published by the WHO.The MLC sharpens the requirements as compared tothe ILO Convention 164, in saying that the service shall be“as comparable as possible to that which is generally avail-able to workers ashore” [3], exemplifying this by mentio-ning adequacy of protection of seafarers’ health and med-ical care whilst working on board.Telemedical Maritime Assistance Service shall be avail-able at any hour of the day or night, free of charge, with anoptimum use of facilities available. All ships shall carrya list of radio stations and coast earth stations through whichmedical advice can be obtained. All ships shall carrya medical guide, as well as the international code of signals.All doctors providing medical advice shall receive appropri-ate training and be aware of shipboard conditions.EDUCATION AND TRAININGIN MEDICAL CARE ON BOARDThe beneficial outcome for a sick or injured seafarer onboard depends on a series of conditions. It is not obviouswhich link in this chain should be pointed out as the wea-kest. It might be more fruitful to discuss where the biggestpotential for improvement lies, and hence, where our ef-forts should be concentrated to improve the service. Table1 shows some of the most important factors that deter-mine the outcome of medical care on board. Some of themwww.intmarhealth.pl 37Alf Magne Horneland, Maritime telemedicine — where to go and what to docan be influenced more easily than others can. Educationand training of seafarers is a field where improvementscould be achieved. The IMGS and several other handbooksfor seafarers are designed like textbooks and teaching aidsmore than practical manuals for the handling of situations(illnesses and injuries) on board.CLASSIFICATION OF DISEASESThe International Classification of Diseases (ICD) in itscurrent tenth version is a tool based on a patient’s history,an examination by professionals, usually in a hospital, andlaboratory findings. Often it is not possible to meet ICD-10criteria in a maritime setting.There are no professionals taking the history or exam-ining the patient and usually there are no additional labo-ratory results.The International Classification of Primary Care (ICPC)in its current second version is a tool based on the patient’shistory, and an examination by professionals in primarycare, with few or no laboratory results. The ICPC-2 is de-signed to describe conditions that have certain aspects incommon, without verifying the condition at the level of theICD-10.THE ACTUAL TMAS WORKThe reports from different TMASs throughout the worldshow the same pattern. Illness is more usual than inju-ries. Minor cases occur more often than major cases. Sta-tistics are sparse, possibly due to small TMAS units witha poorly developed cooperation network. The pre-sea andperiodic medical examination contributes to the selectionof seafarers, and is a helpful tool to avoid individuals witha high risk of causing medical emergencies being em-ployed on board.TELEMEDICINE ON SHORE AND AT SEAOne of the most important differences between onshoreand at-sea telemedicine is that the communication onshoretakes place between health professionals, while at sea thecommunication is between lay seafarers and health pro-fessionals. Onshore there is a short delay until a sufficientlevel of medical assistance can be achieved, while this isnot easily achieved at sea, where professional medical as-sistance may be delayed by days or even weeks.The lack of sufficient bandwidth at sea makes datatransfer difficult between ships and onshore facilities.COMMERCIALISMVERSUS PROFESSIONALISMThe commercial urge to sell and to convince ship ow-ners and masters about the feasibility of installing advancedequipment may sometimes result in non-beneficial effects.Study-designs, which include installation of equipment fortesting purposes and asking the crew about the feeling ofsafety before and after the installation, may give false re-sults and in some cases may be suspected of being cam-ouflaged marketing.The professional attitude is to base the developmenton the need to have and the need to help. This implies thedistribution of useful equipment only, and the conductionof studies aimed at the evaluation of benefits and cost-benefits of new equipment. The result will be safety basedon reality rather than feelings.TWO CONTROVERSIAL EXAMPLESECGECG is an important tool in shore-based health care,mainly in hospitals, but also in primary health care. It isnot difficult to convince lay people that such an instrumentwould increase the safety on board by improving process-es of medical diagnosis and treatment. However, a normalECG does not prove a normal heart in a patient with acutechest pain. In the early stages of myocardial infarction (MI),decisions must be based on the patient’s history and theresults of a clinical examination. In as many as 85–90 % ofpatients with suspected myocardial infarction, the absenceof significant ST elevation on arrival in hospital necessi-tates cardiac marker measuring in blood samples duringthe first 24 hours to diagnose the condition [4]. In anotherstudy, the ECG taken on admission to the emergency roomwas shown to detect only 65% of patients with subsequentlyverified myocardial infarction [5]. It is demonstrated thatTable 1. The chain is no stronger than its weakest linkThe SHIP CREW TMAS service Trading areaShip hospital Fitness standards Availability RisksMedicine chest Education Equipment DistancesCommunication equipment Training-skills Doctors Medevac possibilitiesExperience Experience HarboursJRCCsInt Marit Health 2009; 60, 1–2: 1–82www.intmarhealth.pl38typical ECG-changes that show few false positive findingsare true positive in fewer than 50% of patients on admit-tance to hospital, who later demonstrated to have MI [6,7]. Other studies have shown that the ECG may be normalin as many as 80% of MI cases after four hours, and in asmany as 50% after 24 hours.Some ship-owners have equipped their ships with ECGsin order to rule out MI in seafarers with chest pain withoutabnormal ECGs, relying on medical advice from doctors whoare not very experienced in primary care in remote areasor in a maritime setting, or doctors who are not very experi-enced in interpreting ECGs. The result can be that a personsuffering from MI will be kept on board without treatment,without getting proper treatment on shore.Thrombolysis is not yet an alternative at sea, and it isdifficult to see how it could be used in the future withouthaving access to medical professionals and an intensivecare unit on board. It is also difficult to see how the exis-ting requirements of a 12-lead diagnostic ECG could be sa-tisfactorily met at sea.The benefits of an ECG on board must be balanced tothe difficulties in constructing ECG equipment which istechnically suitable for sea conditions, the training of per-sonnel to ensure correct ECG registrations, and the pro-cess of calibration and technical maintenance of theequipment.REAL TIME MOTION PICTURESThe use of real time motion pictures in onshore tele-medicine is well established as a useful tool. On the sea,the lack of sufficient bandwidth has thus far restricted theuse of such technology.Still pictures have been used for a long time, and areregarded as a valuable tool in injuries and dermatologicalconditions. There are some situations where real time mo-tion pictures would probably add valuable information tothe assessment of the situation, but the benefits have notbeen demonstrated in studies so far. It could be useful inguiding the seafarer in certain procedures, e.g. in the re-placement of a joint dislocation.DISCUSSIONThe limitations in medical care on board are obvious.Experiences from medical care services onshore should notbe transferred directly to the maritime environment with-out a thorough review.The aims of the TMAS, as described in the MLC 2006,are rather challenging, and will probably be difficult to reachin the near future. This should encourage us to strive for abetter service.The weakest link in the chain is probably the seafarers’educational and training level in medical care. This couldbe improved, but will need an international consensus toensure defined minimum requirements on a higher level.The STCW revision is such a process. Medical handbooksfor seafarers must be designed more like manuals for thehandling of situations on board, rather than textbooks sui-ted for teaching purposes.The small TMAS units and the sparse statistics from thisfield clearly demonstrate the need for the development ofa stronger network and a closer cooperation between them.The process of achieving common TMAS proceduresmust include a description of today’s service and agree-ment on the wanted service. We need to develop standardsand generic protocols. We also need to enhance the com-petence of the existing TMAS units and assist more na-tions to start up centres. We must share information andharmonize policies, activities, systems, education, and re-search as cornerstones of our collaboration.Neither ICD-10 nor ICPC-2 is well suited for TMAS di-sease classification. None of them complies with a situa-tion in which lay people can register the patient’s historyand carry out the practical medical examination, even ifguided from a doctor onshore.The development of a special diagnostic tool for themaritime setting might be better, but could compromisecomparisons with other services, like hospitals and prima-ry care.It is of utmost importance that development in the TMASfield is driven by professionalism, not by commercialism.The “nice to have” principle and studies that are camou-flaged marketing are not what we need.CONCLUSIONSThe conditions for medical care are quite different atsea as compared to medical care onshore, and will be so inthe future. This makes the transfer value of onshore expe-riences to the maritime environment low.A cooperation network is important to harmonize andcoordinate development of the TMAS services.Cost benefit analysis should be carried out prior to in-stallation of sophisticated equipment on board.The weakest chain in medical service on board is theeducation and training level of seafarers in medical care.Suitable manuals have to be developed as supplements tothe textbooks on the market.REFERENCES1. www.marisec.org.2. STCW Code A-VI/4-2.3. Maritime Labour Convention 2006, Regulation 4.1.www.intmarhealth.pl 39Alf Magne Horneland, Maritime telemedicine — where to go and what to do4. Lindahl B. Therapeutic implications of the use of cardiac markersin acute coronary syndromes. Scand J Clin Lab Invest 1999; (sup-pl 230): 43–49.5. Behar S, Schor S, Kariv I, Barell V, Modan B. Evaluation of electro-cardiogram in emergency room as a decision-making tool. Chest1977; 71: 486–491.6. Gibler WB, Young GP, Hedges JR et al. Acute myocardial infarc-tion in chest pain patients with nondiagnostic ECGs: serial CK-MB sampling in the emergency department. The EmergencyMedicine Cardiac Research Group. Ann Emerg Med 1992; 21:504–512.7. Panteghini M, Apple FS, Christenson RH, Dati F, Mair J, Wu AH.Proposal from IFCC Committee on standardization of markers ofcardiac damage (C-SMCD): recommendation on use of biochemi-cal markers of cardiac damage in acute coronary syndromes. ScandJ Clin Lab Invest 1999; 59 (suppl 230): 103–112.

Maritime telemedicine - where to go and what to do

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Maritime telemedicine - where to go and what to do

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