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Optimizing at Sea Medical Support by Implementation of Advanced Medical Techniques in Ship Integration

PmSm (Profesional Medical Solutions Management), est la filiale spécialisée en assistance médicale d’Adecco Medical. PmSm prend en charge l’Assistance Médicale de très nombreux sites d’accueil du public (aéroports,  parc de loisirs, gare, etc) , des sites industriels ou de recherche et des navires ou plateformes de recherche pétrolière.

Bruno Sicard est un médecin expert indépendant, consultant de PmSm et il est intervenu lors du troisième International Symposium de Maritime Disaster Management d’Al-Khobar en Arabie Saoudite.

Cette intervention en anglais nous a semblé fort intéressante et nous vous la livrons en version originale.

Abstract :
Adapted medical support for casualties and crew members is critical to conduct maritime disaster rescue missions. Current and future ships tend to have a reduced crew, which is more specialized and which manages complex integrated systems (navigation, combat, detection, helicopter and landing craft manning) and the crew needs to stay fit for work for the duration of the mission. At sea medical support, which include an onboard dedicated facility, medical equipment, medical providers, medical communication and ashore medical support (telemedicine), must be tailored to match the needs expected for the mission, these are extremely broad in Maritime Disasters .

Capitalizing on a large experience on aircraft carriers, helicopter carriers, hospital ships, specialized ships, remote medicine and emergency services, the author, former head of the Human Factor and Medicine Department in the French Navy Program Division, discusses the new trends in at-sea medical support. Current and future medical imaging and diagnostic equipment, telemedicine, dual designated facilities, medical providers’ qualifications, all must be integrated in the complex design of the ship and the multidimensional mission environment. Eventually, early integration and anticipation are key factors in keeping medical support effective for the life span of the ship at a reasonable cost.


Managing disasters means dealing with overwhelming challenges that are beyond usual tasks and cannot be addressed through standards procedures. In this context the concept of triage was developed: one must decide not to treat some severe casualties inorder to dedicate the limited means to save more people. In ships damage control, in firefighting, in any disaster, triage is often implemented to compensate for insufficient resources.
When adding the maritime dimension to a disaster situation, the task is even more challenging due to the sea environment where onboard human and technical resources are scarce and reinforcement can be delayed by distance, sea conditions and availability of these reinforcements.
However, ships present unique advantages compare to inland projected disaster teams. They provide a totally autonomous unit, which initially do not require logistical support,
even the most basic ones(shelter, water, security, safety, food, energy),from the disaster area. Shipscarry an “équipage”-a crew –a very structured, disciplined, highly trained and socially organized human group, whose members are used to work and live together in hostile environment, and therefore are better fit to address the disaster chaos.
With a wide experience in Human Factors (former head of Human Factor and Medicine Department in the French Navy Program Division, head of Telemedicine Department, Panel Member in Human Factor and Medicine Research and Technology Agency, NATO) and Medicine in Extreme Environment (Medical Doctor certified in Disaster Medicine, PhD in Physiology Integrated in Extreme Environment, certified in Chemical-Bacteriological-Radiological-Nuclear-Explosive Casualties Management, Aerospace Medicine, Diving Medicine) the author will cover the various factorsthat will affect performance in the medical component of  Maritime Disaster Management. After reviewing the numerous medical challenges, various solutions through medical and human factor engineering will be discussed.

2. Medical Challenges in Maritime Disaster Management

Maritime Disaster management cover a very wide range of situations, each one bringing its own set of specific medical challenges that must be addressed, many being overwhelming and beyond usual medical practice standards.
The area where the disaster occurs is a major influencing factor. Type of areas concerned includes: open sea, far away from the nearest land or close to shore, or inland in coastal areas where maritime response can be the most appropriate. Either in coastal areas or at sea, degree of remoteness from nearest adequate support is actually what matter most to manage the rescue. Also as a consequence to the actual disaster, support may suddenly be much more remote than expected, i.e. local medical facilities could be wiped out by a tornado, hurricane, tsunami or contaminated by a bacterial or viral epidemic, chemical or nuclear waste. At sea disaster may involve commercial ships, offshore platform with dangerous load (chemicals, oil products, liquid gas or other explosive material), and vulnerable population (large number of passengers on a cruise ship, refugees on an overloaded boat drifting for days, stranded employees on an offshore oil platform on fire).
In many cases multiple factors will intricate: a natural disaster may set off a chemical, explosive and/or nuclear disaster then an epidemic outbreak may occur due to the collapse of food and water supply and local logistic unable to dispose properly of the deceased and to treat victims.
From this review of potential maritime disasters, the associated medical challenges include the whole spectrum of medical needs since population may concern both genders, from new born to elderly, with medical or trauma casualties, and possible biological, chemical or nuclear contamination.
To summarize, response to maritime disaster will bring multiple, technical, human and medical challenges. To address these complex situations, at sea versatility and adaptability, and ability to cooperate with naval partners and ashore allies, are critical.From a maritime prospective, what are the solutions to provide adequate medical support?

3. Medical Answers to Maritime Disaster Management

As stated in the introduction, a ship, either commercial or military, provides an autonomous unit with its crew and living “shell”, the boat, which provides safety, security, housing, food, communications… In a disaster situation, this autonomy is extremely valuable, since most of the time there is no other support, obviously in open sea, but also inland in coastal areas when disaster affects local logistic. Therefore maritime management is often involved in these coastal disasters since it is the most appropriate solution in the early stage of the rescue. Benefitting from this logistical ship autonomy, the medical component of this early maritime response to coastal disaster is often the only medical support for the first hours or days, until land based medical rescue teams can be organized.

Maritime medical response in a disaster situation must focus on providing medical support for up to one week, with the equivalent of NATO Role 1, 2 and at the most Role 3 (1). Role 1 will provide first aid, life saving measures and triage, Role 2 will include triage and treatment until evacuation which includes resuscitation and emergency surgery to stabilize patients, Role 3 will add medical diagnostic with significant medical imaging and specialized surgical and medical treatment, while Role 4 includes definitive care and does not belong to the early phase of disaster medical management.
Newly designed ships are extremely automated and are run by reduced crew who besides being less numerous are also more specialized. Therefore if technical redundancy increases, crew redundancy decreases. To keep the crew and the rescue team membersfully operational, high level medical care is necessary to protect the scarce human resource on board.

Medical techniques and procedures are subject to constant progress, and if for medical providers constant updating in education is routinely done, medical facility must also continuously adapt to the latest standard in medical practice which increases efficiency and safety. This continuous upgrading of medical equipment is mandatory for medical facilities like hospitals, in order to be certified to provide medical care. The cost of upgrading is high ashore but is usually higher for medical facility on board since it may require special at-sea certification for safetyand significant changes in berthing. The following example will illustrate these specific maritime medical constrains, and how they can be addressed.

  • Medical imagingis making extremely rapid progress with a trend toward faster, better, smaller X-Ray, ultra sound, CT scanner or MRI systems. With the help of computed imaging, one must consider also the type of operator, training level, but also the channels and bandwidth necessary to process these images which are routinely used.The required imaging system will dependon targeted level of care. X ray and portable ultra sound are standard for a Role 1 and 2 facilities, while it would be counter-productive to run a Role 3 facility without a CT scanner and in a near future an MRI. These sophisticated imaging equipment are life savers systems but also allow better managing in a disaster situation. How many unnecessary surgical procedures or medical evacuations will you avoid thanks to these equipment’s? A 15000 Euros portable ultrasound may rule out abdominal internal bleeding while a 200,000 Euros mobile CT scan may avoid craniotomy or exploratory surgery in severe trauma patients.
  • Likewiseminilabs which fit in a closet may diagnostic infectious, contagious diseases which are critical to manage casualties and protect the crew and rescue team. But with dozens of different systems on the market, selecting the right equipment for the mission is a complex task, since it must fit on board, be sea proofed (some equipment can’t work properly with platform motion), be user friendly, easy to fix and whose components life span must be long enough to avoid constant replacement.
  • Telemedicine will enhance any onboard medical capability by many ways. A ship medical provider will have his expertise enhanced by “tele-compagnonage” or ”remote buddy-help”, by receiving advices from ashore (by audio, still images, animated images, video or even tele-operating medical device like an ultrasound probe or surgical robot).For example :
    • an orthopedic surgeon may conduct lifesaving neurosurgery guided from ashore by a fellow neurosurgeon who will monitor the procedure through a video-cam integrated in the surgical lamp
    • an X-Ray technician will be able to run an onboard CT-scanner or MRI system whose images will be interpreted by a radiologist sitting in its inland hospital
    • an isolated registered nurse will receive video advices for diagnostic
    • a trained technician will be able to maintain or trouble shoot sophisticated medical equipment through tele-maintenance, therefore saving the necessity to embark

Telemedicine will optimize onboard resources (medical providers and equipment) and therefore save much more money than the actual cost of integrating in the ship the communication equipment and deploying the satellite devices for data transmission between ships and ashore support facilities.

  • Dealing with medical waste is a complex technical challenge. Most hospitals subcontract the disposal of medical waste to specialized service companies. There are currently different techniques, based on incinerating, crushing, autoclaving, shredding, microwaves…. Cost and reliability between these techniques vary tremendously at sea when considering cost of acquisition, berthing, maintenance and running cost. Then one must anticipate future international rules that may ban some of these current techniques because they are either not efficient enough with some unconventional biological hazard (prions) or may be unfriendly for the environment. For example French and US Navy conducted sea trials of such equipment that allow to select devices that are not affected by the ship rolling movement, easy to  integrate (plug and play system), user friendly, remote maintenance capable.
  • Forensic techniques are often a major component in disaster management in order to identify the victims. The first step is to be able to store the human remains in refrigerating rooms. By experience the best answer in a maritime environment is to fit one or more dedicated refrigerated ISO containers on the ship’s deck. This integration must be anticipated in the design of the ship to make sure the container will be able to be secured and plugged to the deck with easy access by stretchers to carry the corpses.

To berth heavy medical equipment onboard, anticipation is the key point. When a hospital upgrade with a new surgical room or MRI, if it is necessary to take down a couple of walls to make room for the new equipment, it is usually not very costly. Onboard a ship, access from the pier to the dedicated room is critical, and since most ships are designed for a 20 to 40 life span, one must anticipate in the ship design what will be the future needs for medical equipment and what these equipment will require (room volume, electric input, climate control, maximum degree of roll, floor weight resistance, X-Ray insulation, electromagnetic environment, disposal of contaminated water, fumes management, oxygen management, air flow management, sterilization needs).

4. Implementing Medical Solutions in Maritime Disaster Management

4.1  Human Factor Integration

To optimize medical response in a maritime disaster management one must integrate as early as possible this component. Starting in the design of the ship, even before the first blue prints, a thorough analysis of the medical needs and dedicated capabilities must be done with the future user/owner of the ship. Due to the long life span of ships and the cost of retrofitting, anticipation of future needs, equipment, and regulation is necessary. By usingHuman Factor Integrationprocess to implement medical support in a maritime environment, significant time and money can be saved.

What is Human Factor process applied to medical and maritime engineering? Engineers are designing technical systems which are used by operator(s). An engineer anticipates what will be the task of this (these) operator(s), who as a person (or group) will conduct activities which are the human translation of tasks. While the machines are standardized by engineers, human are different, therefore a specific task will be declined as a unique activity conducted by a unique individual with his(her) own characteristics (gender, biometric, training, fatigue, stress) or a unique group of individuals (group dynamic, morale, crew resource management…). If the activity is too different from the specified task (for example because of individual cognitive or physical strength decrement or at the collective level a crew miscommunication or lack of coordination) then failure of the system will occur. There are many examples of such failure, the aerospace environment is known for thoroughly investigating accidents and most of the time underlined Human Factors cause as the most contributing factor to the accident. Selection, training, follow up of procedures tend to limit the differences between the way the different individuals and group of individuals will conduct the same task. Human Factor Integration, by looking at all the physiological, psychological, sociological factors, will reduce the gap between specified task and observed activity. To integrate a complex activity like medical support that involves multiple operators using sophisticated equipment to conduct complex coordinated task at sea, one must master both medical and maritime fields to obtain the best compromise between efficiency and costs. One of the most challenging Human Factor components will be to coordinate harmoniously medical providers who are not used to work together in a maritime environment. For example, in Maritime Disaster management, one may observe side by side with naval medical personnel, medical team from allies’ air forces, armies or non-governmental organizations. The legaland psycho-sociological issues must be addressed before the teams embarked to avoid organizational, technical, certification, language, culture and ethical conflicts.

4.2  Dual Designated Spaces

Dual designated space must be implemented as much as possible; combat ships, but also commercial ship builders, emphasized dual designated space design to optimized surface and money. Many tasks do not need to be done simultaneously at sea, and the same spaces when designed properly may accommodate multiple functions. For example on the three French Navy Mistral type 21000 tons LPDs (Landing Platform Decks) some passengers quarters (to accommodate embarked troops) close to the 900 square meter hospital or with easy access to it, were designed for wounded patients (with specific sanitary, medical fluids, monitoring, access for rolling stretchers) but routinely used by the embarked troops (2). That way when there are few casualties, they are treated in the hospital beds, and when the number of casualties increases greatly, like in a disaster situation, the dual designated beds (patients and troops) will be used for the wounded and the troops will be temporary housed in less comfortable quarters.
Dual designated space can be declined in many other ways: an onboard gym or a theater can be designed to accommodate with minimum change refugees or contaminated/contagious casualties (with sealed doors, specific ventilation and waste water system) that can be isolated from the rest of the ship to protect the crew. An onboard restaurant or a muster station can be design as a triage area with preinstalled adequate lighting, communication, closets with medical equipment and oxygen. A passenger elevator can be upgraded to accommodate a stretcher and the accompanying medical team; this must be done in the early definition of the ship since cost of changing an already built in ship elevator is prohibitive and may not be technically possible.

4.3  Mobile and Sea-Proofed Heavy Equipment

When considering investing in heavy medical equipment one must consider to privilege sea-proofed, off the shelf and mobile systems.
The French Navy decided to use mobile light CT-scan instead of integrating a fixed one on each of its three new LPDs Mistral type. This choice saved money because these multipurpose ships are not always using their Role 3 medical capabilities, and therefore a mobile CT scan can be dispatched on one of these ships as needed since the ships were designed to easily and rapidly embark and plug-in this mobile imaging system. This compromise does not only save money in acquisition cost (one CT scan instead of three) but also in running cost: a CT scan when not used frequently tend to have more trouble, and in case of major break down is easier to replace by rolling a new one instead of disconnecting a fixed fully embedded one.  Finally, future updating to a newer mobile system will be easier than changing an obsolete fixed machine.
Portable ultrasounds machines become standard in emergency care, and should be privileged instead of more sophisticated heavy ones.

Oxygen needs in a disaster situation could be covered mostly by mobile oxygen concentrators instead of logistically difficult to manage stored oxygen.
For heavy equipment very few companies tested medical equipment at sea. Therefore it is wise to conduct sea trials before committing to specific equipment when they are not sea proofed. For example some large autoclaves for sterilization of surgical instruments cannot work properly if there are exposed to a few degrees of roll, because water which is drained by gravity cannot be fully evacuated. Exchange of data and experience between allies Navy should be promoted.

Mobile medical waste treatment plants are also more maritime friendly than industrial fixed ones. As stated above, the system selected by French Navy and also tested by the US Navy, based on autoclaving and compressing waste into a neutral cake, after sea trials was adapted and hardened for onboard service.
The ultimate mobile system is illustrated by medical specialized containers like the one developed and use by the French army that can be embarked, set, and connected to the onboard hospital on the French LPDs. This system offer versatility and adaptability to the medical needs. On the Mistral 21000 tons LPDs up to 8 medical containers can be easily embarked from the pier, rolled and secured in the helicopter hangar and connected to the adjacent hospital, increasing the medical capability in just a few hours. There are different types of containers available that can be mixed at will: digital X-ray, CT scan, surgical room, resuscitation ward, and laboratory. But to set these containers early integration in the ship design was done to address access, safety, electric input, waste water and stretcher circulation issues. The German Meko 200, a 3900 tons multi role vessel, can carry on its deck a flexible mobile hospital composed of connecting medical containers. In a disaster situation, on some commercial ships like a RORO, or on combat ships with a helicopter hangar, loading these types of containers or other mobile medical facility could be done after adaptation of the receiving platform.

4.4  Circulation and Communication

Finally, when designing medical response for disasters, planners must take great attention to circulation. Having number of casualties, contaminated persons, refugees, with potential physical limitations due to illness, trauma, age, embark, be taking care of and disembark after hours or days on board requires careful planning. Stretcher circulation will probably be the most challenging, especially if no compatible elevator is available. On French LPDs, circulation was designed in order for a patient to be rolled in a wheeled stretcher manned by a single operator, from and to the pier, the flight deck (for medieval by helicopter), or the wet deck for at-sea embarking through the landing crafts. Even a backup circulation plan is set in case of elevator malfunction that will still allow stretchers to be rolled in and out. On passenger cruise ships circulation is usually stretcher compatible, but on cargo ships and most combat ships, loading in and out a patient on a stretcher is usually time and man consuming and therefore increases the work load in disaster conditions.

Communications, internal and external to the ship, will be critical to medically manage a disaster. Dedicated medical intercom between the different rooms of the inboard medical facility, including the dual designated space will optimize the use of the medical providers. Patient monitoring when possible for a Role 2 or Role 3 equivalent will be necessary with centralization of the vital signs information to the medical central watch post. We already stated the importance of telemedicine. The required bandwidth might be extremely high. Close monitoring of the external medical data transmission must be done in order to prioritize the different data exchange, and set a “communication triage” procedure at the ship communication center.

5. Conclusion

Ship, either commercial or military, provides an autonomous unit with its crew that will be the first and sometime unique responder to maritime disaster. Implementing at sea current and future medical standards in procedures and equipment is a challenge that requires an extensive knowledge of both medical and maritime engineering. This medical implementation is not an option: in disaster situations, victims (offshore employees, cruise ship passengers and crew, coastal area refugees) deserve a quality of medical care close to usual standards, within reason in regard to the circumstances.

Bruno Sicard
Independent Medical and Human Factor Consultant, France

NATO Logistics Handbook [1997].Chapter 16 Medical Support. Sicard B., Tymen R., Perrichot C., [2003].Mistral: A New Concept of Medical Platform for Tri-Service Long Lasting Deployment. International Review of the Armed Forces Medical Services and NATO Research and Technology Organization, RTO-MP-109; 18-1, 18-6.