Comparative analysis of the medicinal compounds of the ship's "medicine chests" in European Union maritime countries. Need for improvement and harmonization.

BACKGROUND: The contents of the ship pharmacy, namely "medicine chest" and its compliance with therespective regulations concerning the type of drugs to be provided for merchant vessels involved in long distance voyages and without a doctor on board were analysed. The current existing disparity between regulations can make medical assistance more complicated, and more often of low quality, due to frequent off-label use of supplied drugs. This study may represent a starting point leading to a model high-quality medicine chest on board ships. MATERIALS AND METHODS: A comparative analysis between the medicine chest requirements of 12 European countries and the CEE Directive 31 March 1992 n.92/29 was made. Prescriptions of the aforementioned Directive were compared with the WHO Model List of Essential Medicines (third Edition). RESULTS: The investigation showed a lack of homogeneity of contents. It emerged that some medicinechests lack of several pharmaceutical categories required by the reference standards. The subsequentcomparison of the European Directive with the WHO Model List of Essential Medicines has highlightedthe absence of some therapeutic categories that in the ship environment can be of important to ensureadequate therapy in many situations. CONCLUSIONS: There are disparities regarding regulations concerning the ship medicine chests. It is crucial toharmonize these and create a single medicine chest for all the ships without a doctor on board, undergoingperiodic updates and revisions, based on epidemiological analysis that will ensure high-quality healthcareto seafarers around the world.

The changing economic structure of the maritime industry and its adverse effects on seafarers' health care rights.

BACKGROUND: This review seeks to understand whether and how seafarers can exercise their human right to health care and the factors that facilitate or impede that exercise. The general focus is on a critical policy analysis of labour policies from the mid-twentieth century through today, with a specific focus on how Filipino seafarers access their health care rights. MATERIALS AND METHODS: The methodology includes a critical policy analysis of seafaring, focusing on mid-twentieth century political shifts in the recognition and regulation of health care rights. The analysis of international and United States policy provides the backbone for understanding the health care experiences of seafarers by laying the ideological, theoretical, and political foundations of labour rights and precarious employment. RESULTS: Policy analysis shows that there are numerous laws, regulations, and human rights norms that have been established to protect seafarers, but uncertain and limited recourse to lay claim to such laws, regulations, and norms while at sea. Lack of recourse to policies and regulations, taken together with the changed conditions of labour and worker protections through technology and neoliberal policies, create the conditions that may increase the health inequity among seafarers'. CONCLUSIONS: Health policy discussions in the United States and internationally must not solely focus on the health of seafarers as an interruption to travel and trade, but policy makers should consider that their decisions may contribute to how seafarers can exercise their rights to health care. In this context, health is more than disease and access to care - economic and governance structures come to not only matter, but play an integral role in the facilitation or impediment of health care and to the health arrangements/conditions of workers.

La introducción de los rayos X en España. La ciencia médica y la sanidad naval rumbo al siglo XX / The Introduction of X-rays in Spain. Medical Science and Navy Health Heading to the 20th Century

OBJETIVO: Análisis del método de diagnóstico de los rayos X adoptado por el Cuerpo de Sanidad de la Armada en los últimos años del siglo XIX y de los apoyos científicos, legales e institucionales. MATERIAL Y MÉTODO: Memorias clínicas apuntando la necesidad de creación de gabinetes radiológicos en los hospitales de la marina; documentos rescatados de los fondos del Archivo General de la Marina (Viso del Marqués, Ciudad Real). Reglamentos, legislación y apoyos del gobierno. Estudios científicos con los pros y los contras de la técnica diagnóstica de la radiología naciente. RESULTADOS: Demanda y adopción de esta técnica y su aplicación a la asistencia sanitaria en el ámbito castrense y su extensión a la población civil. Primeros pasos de los rayos X en España. CONCLUSIÓN: Implantación de la radiología como método diagnóstico en los hospitales y en los barcos de la Armada, dentro del contexto de la ciencia en España a finales del siglo XIX y comienzos del XX

OBJECTIVE: Analysis of the X-ray diagnose method adopted by the Navy Health Corps in the last few years of the 19th century and its scientific, legal and institutional support. Material and METHOD: Clinic reports referring the need to create X-ray consulting rooms in Navy hospitals; documents retrieved from the General Navy Archive (Viso del Marqués, Ciudad Real), regulations, legislation and government support. Scientific research evaluating the advantages and disadvantages of the newly- born radio diagnosis technique. RESULTS: Demand and adoption of this technique, its medical use in the military realm, and its subsequent extension to civil population. First steps of X-rays in Spain. CONCLUSION: Implementation of radiology as a diagnosis method in Navy hospitals and ships within the context of Spanish science by the end of the 19th century and the beginning of the 20th

Cruise ship's doctors - company employees or independent contractors?

Traditionally, cruise companies have stated that they are in the transport business but not in the business of providing medical services to passengers. They have claimed not to be able to supervise or control the ship's medical personnel and cruise ship's doctors have therefore mostly been signed on as independent contractors, not employees. A United States court decision from 1988, Barbetta versus S/S Bermuda Star, supported this view and ruled that a ship's owner cannot be held vicariously liable for the negligence of the ship's doctor directed at the ship's passengers. Some years ago a cruise passenger fell and hit his head while boarding a trolley ashore. Hours later he was seen aboard by the ship's doctor, who sent him to a local hospital. He died 1 week later, and his daughter filed a complaint alleging the cruise company was vicariously liable for the purported negligence of the ship's doctor and nurse, under actual or apparent agency theories. A United States district court initially dismissed the case, but in November 2014 the United States Court of Appeals for the Eleventh Circuit disagreed and reversed. From then on independently contracted ship's doctors may be considered de facto employees of the cruise line. The author discusses the employment status of physicians working on cruise ships and reviews arguments for and against the Appellate Court's decision.

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.

Legal aspects of cruise medicine - can a non-US ship's doctor be sued for malpractice in Florida?

An English ship's doctor treated a non-US female patient for abdominal discomfort on a foreign-flagged cruise ship off the coast of Haiti. In Mexico the patient underwent abdominal surgery, followed by complications, for which her lawyers wanted to take the ship's doctor to court in Florida, USA. A trial court granted their wish, but this decision was reversed on appeal as the factors discussed were insufficient to establish Florida jurisdiction over the ship's doctor. The decision is not about whether malpractice occurred; it is about limiting the possibility of taking the ship's doctor to a court in a location preferred by the plaintiffs' lawyers. The appeal court ruling is important for non-US doctors working as independent contractors on cruise vessels that visit US ports, and it will hopefully prevent some of the more frivolous law suits from being filed in the future.

[Organisation of scientific and research work of Navy medical service].

The main issues of organization of scientific and research work of medical service in the North Fleet are considered in the present article. Analysis of some paragraphs of documents, regulating this work at army level is given. The authors give an example of successful experience of such work in the North Fleet, table some suggestions which allow to improve the administration of scientific and research work in the navy and also on the district scale.

[Medicine aboard cruise ships--law insurance specifics]. / Versicherungsrechtliche Betrachtungen zur Tätigkeit des Arztes an Bord von Kreuzfahrtschiffen.

The booming cruise industry, associated with ships with more passengers and crew on board, results in growing medical needs for the ship doctor. The ship's doctor insurance policy includes different jurisdictions, namely national law, international law, tort law, insurance law and labor law. In addition, international agreements must be taken into account, which complicates the design of an adequate insurance policy. Equally high are the costs and defense costs for the ship's doctor in case of liability. In order to limit the liability for all parties is to ask for appropriately qualified medical staff, hired on board.

International regulations on labour health and safety applied to fishing and maritime transport sectors. Are maritime workers under-protected.

The work activity developed on board is of great importance in our nearby environment, and it has a series of peculiarities that determine the service rendering of sea workers. On the other hand, work at sea is developed on an international basis. Nowadays such work becomes a completely globalised industrial sector in relation to the elements that make up the ship's operation, including manpower. For that reason several relevant international organisations have paid attention to this industrial sector and have adopted a broad regulation on this matter. In the case of the European Union, the Community procedure emphasises enormous interest in providing specific and comprehensive training to seafarers, as well as in regulating working time on board with the aim of minimising the safety problems caused by fatigue. In the present article a schematic presentation of regulations on workers' health and occupational safety protection derived from the European Union, the International Maritime Organisation, and the International Labour Organisation has been done. Also it shows what parts of these regulations are not applicable to the work on board, and it reveals how the workers of fishing and maritime transport sectors are under-protected with regard to the guarantee of their health and occupational safety compared to workers in other sectors.

[Medical legal issues associated with the evaluation of herniated discs in seafarers to merchant ships]. / Problematiche medico legali associate alla valutazione delle ernie discali nei lavoratori marittimi di navi mercantili.

"Seafarer" means person employed with any job on board a ship offshore, whether publicly or privately, excluding ships of war. Day by day a seafarer is forced to confront a reality in constant motion and live in environments that require awkward movements, and restricting the normal mobility of the person. In order to verify the frequency of herniated discs in this particular category of workers, given the recent introduction of INAIL tabulated diseases, a study was conducted on a sample of seafarers. Data analysis showed that 48.3% of the seafarers of the sample has herniated lumbar disc, and 34.5% of these duties in the deck, and 65.5% of the machine. The study of sample, varied as to age and task being performed, supports the assertion that the individual risk factors, especially age and obesity, are not strongly implicated in the genesis of disk herniation suffered by seafarers while the work factors (vibrations) play a more significant role in the onset of this disease. This consideration is part of a context, that of legal medical evaluation and in particular the causal relationship, which currently seems rather lacking in terms of literature and scientific production.

[Expert assessment of commands of naval medical service, incorporated in Service for Disaster Medicine].

Expert assessment of possibilities of naval medical service for delivery of assistance in emergency situations in deployment areas is performed. It is noted that the main menaces are radiation, chemical accidents, and explosiveness of objects. Inconsistency between supposed losses and possibilities of naval medical service is probable in case of emergency. This inconsistency requires improvement of interaction with medical services of other ministries, drill of coordinative actions of naval medical commands with other commands of other ministries in organizational frames of united Service for Disaster Medicine.

Lessons from managing an injured suspected pirate onboard a Role 1 medical facility.

The embarkation of detainees is complex and medical requirements and ethical considerations can collide with operational requirements. Morally and ethically the correct route of action is always to disembark the patient at the earliest opportunity to a first rate medical facility; however this is not always possible for a variety of geographical, operational, financial and political reasons. It is ultimately a command decision utilising the best advice that the Medical Officer can provide. It is important that Commanding Officers and Medical Officers have a strong working relationship and understand each other's responsibilities and constraints.

Seafarer with hyperactivity disorder on amphetamine.

A general practitioner decided that a first-time Scandinavian seafarer with hyperactivity disorder, reasonably well-regulated on dextroamphetamine, was fit for unrestricted work at sea. Carrying amphetamine across US borders is drug smuggling, and when the cruise ship could not supply his medication from local ports, his behaviour became so erratic that he had to be signed off. Doctors providing medical fitness certificates for work at sea must understand the special requirements of seafaring life, know details about medicine use restrictions aboard, and be familiar with international import bans and national prescription regulations for controlled substances.

[The influence of infectious diseases on ancient maritime navigation and the earliest attempts to control them through codes]. / Utjecaj zaraznih bolesti na starovjekovnu plovidbu i pokusaji zastite preko odredaba najstarijih zakonika.

This article describes the influence of infectious diseases on ancient maritime navigation and the early attempts to prevent their spread with legal regulations. In ancient times, the greatest health hazard for sailors were poor hygienic conditions, water supply, nutrition, accommodation, air, and lighting on board. These conditions favoured the development and transmission of infectious diseases. The oldest legal attempts to regulate maritime navigation and indirectly improve health conditions on board are found in the Code of Bilalama from the beginning of the 20th century BC and in the Babylonian Code of Hammurabi from the 18th century BC. The first regulations dealing with infectious diseases are found in the Book of Leviticus, 59 altogether, which are later also found in the Bible. The rhodian maritime law from the 7th to 9th century AD also contains health regulations on accommodation on board and defines minimum water requirements. Greek and Roman vessels were the first to take physicians on board.

Legal gaps relating to labour safety and health in the maritime transport sector in Spain.

Nowadays the labour sector is experiencing an important increase in the application of risk prevention policies. Although these policies are very significant due to their repercussions in the health of workers, we noticed important legal gaps in maritime sector regulations. Frequently sea workers are legally abandoned, by exclusion or omission, at the moment of claiming for the improvement of their working environment and the reduction of the negative consequences derived from this negligence over their safety and health. In the present paper we try to shed some light on this topic by analysing and examining minutely the Spanish applicable risk prevention legislation for this sector. Moreover, the recommendations of the International Maritime Organization are compared with the current application of the law. At the same time, we present some possible solutions to such problems from an objective point of view.

Seafarer with solitary, well-functioning kidney - fit for service at sea without restrictions?

A 20-year-old, healthy man, who four years earlier had lost a kidney in a skiing accident, applied for a medical fitness certificate for service on board German flag vessels. Under reference to national and international regulations he was initially turned down, but attained permission to sail on appeal. We discuss the justification of denying persons with a single, well-functioning kidney the opportunity to work at sea, conclude that there is no good reason to refuse a fitness certificate, and propose to change national and international regulations accordingly.

[The health of sailors--at sea and in port towns]. / Helse til sjøs og i fremmed havn.

Initiatives to promote better health among Norwegian sailors in the period 1890 - 1940 should be seen in the context of contemporary Norwegian health care policies. Preventive measures were most important, and special attention was given to hygiene and tuberculosis. Public health officials, shipping companies and non-governmental organizations, such as the Norwegian Red Cross, cooperated to do this work. Health care work among mariners had some special aspects. Sailors were the first group in the country to be subject to obligatory health checks. The sailors were exposed to other diseases in ports abroad than at home; and during the period examined in this article, Norwegian tropical medicine and ships medicine were interwoven. In addition, the prevention and treatment of venereal diseases among sailors were subject to great interest, especially after the First World War. The article is based on the author's research for her doctoral dissertation, i.e. literature and historical sources, such as articles from journals and newspapers and archival resources (from the Ministry of Social Affairs and the Shipping Office at the Ministry of Trade).