In the greater part of the history of seafaring the seafarers have – with the exception of the navy – been left without any kind of medical advice when at sea.. Even if personalities such as Vasco da Gama, Lord Anson and not at least James Lind have shown a certain interest in the health and well-being of seafarers, this area has for a great deal been ignored
The reason for the unavailability of medical aid at sea was obviously the lack of communication. A solution to this did not emerge until Tesla and Marconi detected that electromagnetic waves could transfer information without wires.
Norway established radio communication with ships in 1908. Even if the communication with the morse code was bothersome, it was a huge step forward. Radio telephony in the middle and long waves was not developed until the nineteen twenties, and then only in coastal areas.
Radiotelephony with a wide coverage became possible after the 2nd world war with the development of the short wave. Today, satellites offer almost unlimited possibilities for communication with sound, text and pictures.
Even if the technology was available, there was no system for medical advice to ships until professor Guido in Rome offered a service of this kind in 1935. His one-man service later developed into an institution – C:I:R:M: - which today is the largest provider of medical advice to ships in Europe.
Some time passed before other seafaring nations followed, but in 1958 the ILO passed a convention that instructed all seafaring nations to have a service for medical advice to ships (TMAS) and a medical chest. In 1992, the EEC passed a similar “council directive” with the same imperative (Council Directive 29, 1992). Norway has ratified these directives and is consequently obliged to establish and run a service in accordance with the regulation.
Professor Guido in consultation with a ship
The start of the Norwegian service is connected to an anecdote. A Norwegian ship in the middle of the Atlantic in 1949 returned to harbour with a sick sailor at a very high extra expenditure. It turned out to be only a nettle rash. Two physicians at Haukeland hospital (now Haukeland University Hospital) dr. Myhre and dr. Boe found the absence of medical advice to ships as unacceptable and offered to be available for such service. Dr. Boe went abroad after some time, but dr. Myhre rendered the service singlehanded for 35 years!
In the beginning dr. Myhre gave advice for free, but after some time he received a moderate fee from The Seamens’ Office (Sjømannskontoret) at the Ministry of Commerce. Later, the National Social Security covered the expenses.
After dr. Myhre retired in 1984 the service taken over by professor. Aksel Schreiner in cooperation with professor Alfred Halsteinsen, professor Erik Florvåg and specialist in internal medicine Kjell Gisholt. The service has become known under the name “Radio Medico Norway”
Because all the physicians who participated in the service had positions at Haukeland hospital, it has been a common misconception that the service has been rendered by the hospital. This is not the case. The service has been provided on a private initiative in understanding with the social security system for seafarers. However, from 1st of January 2011 the service will – as we shall see later – be allocated to the Norwegian Centre for Maritime Medicine at the Department of Occupational Medicine at Haukeland University Hospital.
Dr. Jon R. Myhre Professor Johs. Boe
From left: Alfred Halstensen, Aksel Schreiner, Erik Florvåg, Kjell Gisholt (fra 1st of January 2009 Schreiner was replaced by Arne Ulven –picture to the right)
The organisation of TMAS varies considerably from country to country. Italy and Spain have dedicated institutions with equipment and resources. In some countries such as Sweden, Germany and Denmark the service provided by a department in a hospital, while in Norway the service is “private” and voluntary. The participating physicians have organised themselves each with one week duty round the clock at a time. The group had no obligation to deliver reports, and no budget. Hence, continuing education and training, courses and recruiting were not possible. Purchase of equipment and repairs had to be indorsed by NAV and paid on invoice.
This unfortunate situation started to change when from January 1st 2011 the Norwegian TMAS service was incorporated in the Norwegian Centre for Maritime Medicine at Department of Occupational Medicine, Haukeland University Hospital. Read more below.
Contact and cooperation
Radio Medico Norway may be contacted directly and they will respond to any call. However, most of the calls are routed through Rogaland radio. The staff of this institution are familiar with all kinds of wireless communication and have good insight in the conditions at sea.
It is therefore strongly desirable that calls for medical assistance go through them. The satellite Inmarsat has the short number 32 that brings the call directly to the communication board at the radio station. The cooperation with Rogaland radio has been - and still is- a prerequisite for high quality service.
Other very important cooperation partners are The Joint Rescue Coordination Centres
in Northern and Southern Norway, especially the southern one which has the competence and resources to administer rescue operations in all waters.
Rogaland radio Joint Rescue Centre Southern Norway
The hitherto most important steps were the introduction of the mobile telephone in the seventies, and the digital photography in the nineties. Even if our first mobile phones weighed 7 kg, they provided a liberty and a mobility during hours of duty that was quite novel. How the mobile phone has developed since, is common knowledge.
Mobile telephone 1985 Mobile telephone 2011
In the nineties most commercial ships were equipped with a digital camera. With this the basis for medical diagnoses was taken to a new level. Transfer of pictures via e-mail is perhaps somewhat dubious from a safety point of view, but is very efficient. The pictures below are evidence for diagnostic improvement
Pictures taken on board and sent by e-mail
There is a great interest in introducing two-way video between shore and ships. This kind of telemedicine has enjoyed great success on shore, but experience from seafaring is scanty. The prerequisites are there: Inmarsat BGAN offers streaming of video with a binary speed of 385 kb/s which is sufficient for high quality live pictures. Also, some companies offer software that can organise a consultation with filing of case record, pictures, ECG and vital parameters such as oxygen saturation, pulse and blood pressure. These systems require dedicated installations on board and ashore, and are so far very expensive. However, systems of this kind will find their way into maritime medicine in the near future.
The number of calls to the Norwegian Radio Medico varies from 0 to 6-7 consultations per day with an average of 3. The service responds to any call, independent of nationality.
The medical service resembles general practice to a high degree. More than 95% of calls are banal ailments or injuries that can easily be dealt with. The close relation to Haukeland University Hospital with rapid access to special competence has increased the quality of the service. Less than 5% of the calls come from more serious diseases, accidents and injuries. However, it is these cases that are responsible for the morbidity and lethality in seafaring. It has been discussed to direct emergency calls in serious cases with a potency for a medical evacuation to an AMK ( Commanding centre for acute medicine), but so far Radio Medico have continued to administer these cases in cooperation with the JRCC.
The nature of activity
Even if the medical problems arising on board a ship are for the most part banal and take the character of general practice, the medical advisor must have a solid insight in the special conditions prevailing in seafaring. A few examples may illustrate this fact:
A seafarer was found unconscious in his cabin. Insulin was found in his baggage. The medical responsible on board thought he had taken toolkittle insulin and gave him “a suitable dosage”. However, the sailor had taken too much insulin and now he fell into a deep hypoglycaemic shock. Nobody on board was capable of establishing a venous access. The solution was to introduce a catheter to the oesophagus, apply a funnel and pour sugar containing soda into the stomach during the whole night. The man survived.
A seaman on a ship in the middle of the Pacific got his abdomen ripped open by a swaddling cable and the intestines hang all out. With the help of Rogaland radio we broadcasted an emergency signal which was received by an American naval vessel with a surgeon and a helicopter on board. The victim was sent to hospital in Sri Lanka and survived.
These examples show that a physician who gives medical advice to ships must obtain knowledge of the special conditions at sea. He must know the possibilities and the limitation of therapeutic options, the medicines and equipment present on board, the possibilities for evacuation of personnel in all waters, and must be well trained in communication technique. They also show that the cooperation with experts in maritime communication is essential.
Radio Medico Norway continues to be completely mobile because three of the doctors still have a full time position at the hospital. Even if this has functioned quite well for 50 years, the development will in the future demand a stationary unit on shore. Also, it cannot be expected that from doctors today that they will agree to a schedule which includes weeks of service with round the clock coverage. Consequently, the number of doctors employed in the service must be raised, and the payment must be competitive. A stationary unit with specially trained doctors will also better meet the demands that will follow from the technological development.
In 2004 the Norwegian Government decided that a centre for maritime medicine be established and gave the assignment to The Western Norway Regional Health Authority. The Health Authority – together with Bergen Health Trust found it suitable to place the centre in Bergen because Radio Medico was situated there, and medical advice was the single part of maritime medicine practised at the time. Bergen Health Trust placed the centre at the Department for Occupational Diseases under the name Norwegian Centre for Maritime Medicine (NCMM)
The mandate for the centre as stated in the government proposition (St.prp.1 2004-2005) was as follows:
· Collect and mediate knowledge of maritime medicine to authorities, organisations and other interested parties
· Initiate and perform research
· Register the prevalence of diseases and injuries at sea
· Give educational support to seafarers
· Be a hub for international cooperation
· Radio Medico should be a part of the centres activities
As evident from the above, the Ministry states that the medical advice service should be assigned to the NCMM, but without giving it a high priority. This is one of the reasons why it has taken time to incorporate Radio Medico in the centre. However, in 2010 Bergen Health Trust decided that the Norwegian TMAS shall be operated by Haukeland University Hospital represented by NCMM.. This makes considerable demands to the centre. A service with high quality will require:
· A stationary centre office with advanced communication equipment
· A dedicated, digital filing system
· Development of procedures
· Training of doctors for the service
· Employment of a leader
The process of establishing a high quality TMAS at the centre is initiated and is expected to be finished by the end of 2011. The Norwegian TMAS will then enter an entirely new phase by being a part of a hospital administration. Records, communication and data handling will be subject to systems that will meet all administrative and professional requirements. The new systems will enable the centre to do research on collected data, and to test and assess novel communication and examination methods. A leader of the service will be employed whose main task will be to optimize the service and to administer the process of coordinating the TMAS centres worldwide.