A key element of medical care on board is quick and efficient provision of medical advice by means of wireless communication.
A number of conventions and regulations, such as ILO recommendation 106 (1958), ILO convention 164, MLC 2006 and EEC directive 92/29, refer to telemedical services to shipping.
The essence is that every signatory nation shall have a prearranged system for wireless medical advice available to ships of all nationalities round the clock and free of charge. Optimum use of radio or satellite communication shall be ensured. Every ship shall carry a complete list of radio stations providing medical advice. The doctors providing medical advice shall receive proper training and be aware of shipboard conditions.
TMAS in different countries
Member countries have solved their TMAS obligations in various ways. Some have dedicated centres with dedicated personnel (e.g. Italy, Spain, Norway, the Netherlands), others have their service connected to a hospital department (e.g. Sweden, Denmark, Germany, UK). The connection to a hospital may cause problems in that the doctor on duty in the department may not be one who is “aware of shipboard conditions”. On the other hand, access to specialists may be easier under such conditions.
There are plans for an international cooperation among TMAS centres. The future may –and should - see TMAS centres more uniform in both design and function.
The TMAS doctor
Although the conventions stipulate that doctors who give telemedical advice to ships shall receive proper training and be aware of shipboard conditions, “proper training” is not defined in any detail. It seems fair to suggest that the advising doctor should have ample knowledge of
- Spoken and written English
- Ship types
- Dangerous cargoes
- Medical facilities along the fairways of the world
- The variations in content of medicine chests
- Ship hospitals
- Joint rescue centres and SAR services
A programme for training of TMAS doctors should be a priority task in future international cooperation between TMAS centres.
The core element in the TMAS activity is communication. The communication is either in writing or by voice and is evidently always wireless. Most physicians will prefer voice communication because of its efficiency and time saving properties. The communication may be supplemented by graphic elements such as still pictures or video and other data.
Communication on the long and medium waves with ships in morse code became possible from 1906. The coverage was mostly near coast areas. After WW II when the short wave was taken into use, the coverage became worldwide. Despite its superior efficacy, morse code faded out in the end of the 21st century making place for a more time efficient system, such as the telex. Now clear text could be transmitted without the need for interpretation. It represented the predecessor of the e-mail of today. However, the advent of the internet in the eighties made the telex obsolete and the telex networks were closed down around 2000. The telefax system by which text and graphics are transmitted via telephone is still (2012) active but is probably also approaching its obsolescence. The satellite era and the advent of the internet opened for the e-mail system which is the predominant mode of written communication ship/shore today.
The advantage of written communication is that the communication is well documented. The disadvantage is the slowness of the process. Documentation of voice communication is possible by means of voice logs.
Radio communication with ships today is rapidly declining except for VHF in coastal regions. Telephone communication via satellite is by far the most used mode for long distance communication in the shipping industry. The signals pass from the land based telephone net, or mobile net, via an earth station and a satellite to the recipient, and back. The audio is usually of a high quality, even if some echo or delay may occur. The ship officers use their own language when they contact the national TMAS, otherwise English is generally used.
The important advantage of the voice communication is the speed of information exchange.
When immediate aid is necessary, written communication is useless. Also, some important elements of medical consultations, such as reassurance, are difficult to mediate in writing. However, voice communication is not without pitfalls, the most important being language problems. Some ship officers do not have the necessary knowledge of English and the problems may delay the advising process. It is reasonable to ask if not proficiency of English should be a prerequisite for acquiring a navigator’s certificate. There is no air pilot who does not speak English well! Some nations have online interpretation services for civil purposes. The establishment of an international service of this kind would be a natural task for the future cooperation among TMAS services.
The TMAS doctor should be careful to use a plain language and refrain from professional jargon.
The International Medical Guide for Ships (WHO 2007) offers forms for standardized communication between TMAS stations and crew in cases of disease or injury. Officers would benefit from consulting these forms before calling the TMAS service.
The most important satellites in maritime communication are Inmarsat, VSAT and Iridium. Inmarsat is geostationary and has been active since 1976, has an almost worldwide coverage and has gradually been upgraded in functionality. The newest satellite Inmarsat 4 offers broadband capability and can transmit video of high quality. VSAT is another geostationary system, but is so far restricted to text and voice. However, the system is being upgraded and will offer broadband capabilities in the future.
Iridium is a system that operates 66 satellites in orbit. The satellites communicate with each other until the signals reach one which has contact with an earth station. The coverage is virtually worldwide and includes the North and South Pole. Communication is restricted to text and voice.
Footprints of Inmarsat 3 and 4 satellites Footprint of VSAT satellites
Data communication. E-mail
Digital data communication via satellite opens for many possibilities. The hitherto most used mode is e-mail. The written message offers – and documents - exact and unequivocal information. However, e-mails can be intercepted and tempered with. Therefore, encrypting of the messages is mandatory to obey the duty of confidentiality. Software that encrypts and decrypts e-mail messages is commercially available. Some software programmes not only take care of the encrypting, but also offer transfer of other information (see below), monitor the consultation, and offer filing systems.
Transfer of still pictures
The use of still pictures in providing medical advice to ships came into use in the nineties. Most vessels now have a high quality digital camera. Still photos represented a major improvement of the diagnostic possibilities. A high resolution colour photography is specially helpful in the diagnosis of dermatological conditions, but also in other diseases and in many types of injuries. Pictures are commonly transferred as attachments to encrypted e-mail.
Transfer of video in real time
In land based medicine, the use of video consultations and video diagnostics has enjoyed great success. It would have been a great advantage if this technology was available also in the maritime setting. So far, the data transmission speed of satellites and the cost of transmission limit the use of video consultations at sea. However, video consultations with a limited resolution and a fairly satisfactory frame rate are possible even today. It is no doubt that development within data compression technology and reduction in prices for transmission will in the near future make high quality video consultations possible also at sea. The employment of video conferencing would satisfy the obligation to “ensure optimum use of facilities made for radio or satellite communication”
Transfer of vital parameters
Vital parameters such as oxygen saturation, pulse, blood pressure and ECG are essential in monitoring seriously ill patients. Easy-to-use devices for registration of such parameters are commercially available. Unlike video, the transmission of these data via satellite does not require a large band with.
The consultation recordEvery medical consultation must be recorded in accordance with the national regulations of each seafaring nation. It is therefore not surprising that records differ among the TMAS services. It would be a great advantage if an agreement could be reached on how records should be organized. The most important elements of a harmonization would be the coding of diagnoses and pharmaceuticals. The choice of a diagnosis coding system is not easy. Some TMAS centres use ICD-10, others ICPC. ICPC should probably be preferred since it has fewer requirements for supplementary diagnostics. Also, ICPC can be supplemented with a set of proprietary codes. For coding of pharmaceuticals, the ATC system is the natural choice. The harmonization of medical records of TMAS centres is the only way to provide a basis for research and comparison. Here is another task for the future cooperation among TMAS centres.