Medical assistance at the sea: legal and medico-legal problems.

BACKGROUND: In case of pathologies or accidents on board which require medical intervention but lacking on-board medical or paramedical personnel, the ship's captain, or his delegate can contact a Telemedical Maritime Assistance Service (TMAS). International Maritime Organisation considers telemedicine at sea as an integral part of rescue procedures. Five key elements contribute to the delivery of good medical assistance at sea: one or more coordination and rescue centres; the TMAS; the possibility of intervention at sea; an organisation of appropriate institutions on ground and common operating procedures. This paper analyses the responsibility of the ship's captain and of the TMAS doctor in case of diseases or injuries on board in the frame of the main important international regulations. RESPONSIBILITY OF THE SHIP CAPTAIN: In case of a disease or injury on board a ship, the captain must contact the TMAS as soon as possible. A captain not acting promptly and not doing whatever it is possible for the ill/injured person by consulting the TMAS or a physician and/or not following prescriptions received, could be charged for omission of responsibility. A captain underestimating a medical problem and knowing that the patient's condition could worsen, but still not consulting a medical centre for assistance, should be ready to accept the consequences of his choices. RESPONSIBILITY OF THE PHYSICIAN: The doctor of TMAS has full responsibility for the diagnosis, prescription and treatment, while the ship's captain is responsible for the final decision. Regarding the medical treatment and assistance on board a ship, the TMAS doctor should pay attention not only for the diagnosis, but also for the prognosis. Telemedicine implies that the doctor should make decisions without a clinical examination, often without some additional medical examinations and by maintaining a contact with other people who are in direct contact with the patient. The physician usually has to rely on the account of colleagues of the sick seafarer as far as medical history is concerned. This may make harder to take a decision. CONCLUSIONS: The ship's captain is guilty if he fails to contact a TMAS in case of diseases or accidents on board. Similar to a traditional relationship between a patient and a physician, the doctor consulted via telecommunication systems is also responsible for his diagnosis and treatment. However, in telemedicine the contrasts with the most basic principles of the traditional medicine are obvious. This makes the delivery of medical care of seafarers on board ships quite complicated.

[Occupational lung diseases caused by exposure to chrysotile asbestos dust and the preventive measures].

To reveal major principles in system of occupational lung diseases prevention among workers engaged into extraction and usage of chrysotile asbestos, the authors specified main criteria for diagnosis of asbestos-related pulmonary diseases and signs of exposure to chrysotile dust, with identification of risk groups for occupational diseases development. The authors formulated main principles of prevention and rehabilitation for workers with asbestos-related pulmonary diseases. Special attention was paid to harmonization of all medical and technical measures aimed at prevention and liquidation of occupational asbestos-related diseases.

Offshore industry: medical emergency response in the offshore oil and gas industry.

BACKGROUND: The hunt for oil and gas has taken workers into new more distant locations including those offshore. The remoteness of the offshore platforms and vessels coupled with the potential risk of being cut off by bad weather presents particular challenges for medical emergency response (MER). AIMS: Firstly to define the challenges for MER in terms of locations, population and epidemiology of injuries and illnesses in the offshore environment. Secondly to give examples of legal requirements and industry standards to manage MER. Thirdly to look at existing and emerging practice to manage these challenges. METHODS: A review of published literature was supplemented with a summary of current practice in the industry. RESULTS AND DISCUSSION: Medical professionals (medics) working offshore on installations and vessels are primarily responsible for the medical care of the workers. The medics have clinics with suitable medical equipment for managing emergencies as well as providing limited primary care. Some countries have legislation that stipulate minimum requirements. Where there is no national legislation, industry and company guidance is used to define the MER standards. Supervision of the offshore medics is often provided by doctors on shore via radio and phone links. These methods of communication are now being augmented with more sophisticated telemedicine solutions such as the Internet and live video links. These newer solutions allow for prompt high-quality care and provide the scope for a variety of new treatment options to be available for the offshore workforce.

[Educational and training issues in occupational first aid: the requisites for the teachers of the workers responsible for first aid]. / I requisiti per i formatori dei lavoratori designati al primo soccorso aziendale.

BACKGROUND: The inter-ministerial decree (D.I.) 388/03 (the Italian law on first aid in the workplace) attaches particular importance to the organization of first aid and to the content of the teaching and training of designated workers, specifying teaching objectives, programme and duration of courses. However it provides less details on the requirements and qualifications of the teachers and trainers. OBJECTIVES: To discuss this topic in the light of the guidelines contained in the literature and the existing legislation. METHODS: We used the specific references of literature and legislation concerning first aid training of designated workers. RESULTS: The objectives and the content of the training courses call for a high level of professional competence and approach. Therefore, training of designated workers should be planned and carried out in accordance with the training standards used for the teaching and training of the so-called "lay rescuers". CONCLUSIONS: The need to achieve high training standards for workers responsible for first aid at the workplace is to a large extent justified by the difficulty of the role of employees. This need follows the current tendency in regulations to guarantee adequate and up-dated training also for other agents operating within the system of workplace prevention. In this context the occupational physician plays a significant role in the training programmes for designated workers.

[Integrated prophylactic care of employees--is it a future model?]. / Zintegrowana opieka profilaktyczna nad pracujacymi--czy jest modelem przyszlosiowym?

The author presents his own experience in the area of prophylaxis and cooperation with safety and health services as well as with occupational hygienists. The attention is turned to an essential difference between two terms "employees" and "workers". The proposed model of integrated prophylactic care is described and the need for cooperation between Trade Unions, National Insurance Company (ZUS) and Agricultural Insurance Company (KRUS) is highlighted. In the author's opinion the integrated occupational health services, safety and health services and occupational hygiene should be a future model of workers' health protection in Poland. Integrated units should cover with their activities all employees throughout the country.

Occupational health services in PR China.

In China, the origin of occupational health started in the mid 1950s soon after the founding of the People's Republic of China. However, more complete concept and practice of occupational health was defined after the early 1980s, when China started her full-scale drive for economic reform and policy of openness. The integrity intends to cover occupational health, occupational medicine, industrial toxicology, industrial hygiene, occupational ergonomics, and occupational psychology as theoretical and practical components of occupational health. As a result, occupational health in China has undergone many changes and has improved over the past decades. These changes and improvements came about, most likely due to a new scheme, where a holistic approach of the recognition, regulation, and provision of occupational health services in a wider coverage is gradually formed and brought into effect. This presentation provides the current status of occupational health and safety problems, the latest legislative to occupational health and safety, and a general scenario of the organizational structure and function of occupational health services in China. It attempts to share with participants both our experience and lessons learned towards creating a more open and effective channel of ideas and information sharing.

[Different lists of occupational diseases within European Union countries--is it a problem for legal harmonisation?]. / Orzecznictwo w chorobach zawodowych w panstwach czlonkowskich Unii Eeuropejskiej.

Author describes a need for establishing binding common list of occupational diseases in the European Union. Introducing common European list will enable to collect reliable epidemiological data concerning occupational diseases (what can be useful in designing prophylaxis programmes) and will allow avoiding insurance problems arising from work-connected migration (according to the principle of free movement of workers).

How I help managers understand and value an occupational health department.

A professional occupational health department is more valuable to businesses than an old-style medical department. Occupational health professionals need to rise to the challenge of promoting the contribution they can make. This article discusses some of the key points which need to be addressed when helping managers understand occupational health's important role.

[Occupational health care as a basis of occupational medicine monitoring in small companies. Common occupational medicine/ergonomic approach to prevention]. / Arbeits- und Gesundheitsschutz als Grundlage arbeitsmedizinischer Betreuung kleiner Betriebe. Gemeinsamer arbeitsmedizinisch/ergonomischer Ansatz zur Prävention, Rehabilitation und Gesundheitsförderung.

Set out from various specific angles, the concept concerning a modern common industrial medicine/safety/ergonomics approach can be fitted into the present legal framework. Adapted according to specific needs, this approach can equally be applied in all areas--health promotion, prevention, cure, rehabilitation. Those involved in the current debate about industrial health policies start out from the premise that industrial medicine could contribute strongly in this respect. While the workmen's compensation scheme, together with the industrial medical profession, is to a considerable extent involved in the subject as a whole on the basis of the industrial safety Act, its competencies are however limited, being in actual fact confined to the field of health maintenance in the occupational context. The examinations they effect in this framework cannot be based on a holistic medical orientation, because our constitution has expressly excluded the private sphere of the individual (self-management domain). Hence, there are very little chances of success for any attempt of changing current health care practice solely via the workmen's compensation administrations. It currently is, rather, the health and pension insurance schemes who hold the potential for influence. The common approach of industrial medicine, safety and ergonomics outlined may be of considerable use also in view of their goals, and holds sufficient justification for their intervening favourably in the ongoing debate about quality and quantity of industrial medical service provision with the ministries in charge.

Biomedical surveillance: rights conflict with rights.

Medical screening and biomedical monitoring violate individual rights. Such conflicts of right with right are acted upon synergistically by uncertainty which, in some important respects, increases rather than decreases as a result of research. Issues of rightness and wrongness, ethical issues, arise because the human beings who are subjects of medical screening and biological monitoring often have little or no option whether to be subjected to them. We identify issues of rightness and wrongness of biomedical surveillance for various purposes of occupational health and safety. We distinguish between social validity and scientific validity. We observe that principles are well established for scientific validity, but not for social validity. We support guidelines as a way forward.