ENG1 2010 article by Doctor Kenneth Prudhoe Club de Mar Medical Centre Palma de Mallorca

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"DOCTOR AT SEA" a monthly Column in The Islander Magazine

ENG1 2010 Vintage

Doctors approved by the UK Maritime and Coastguard Agency work within guidelines (Standards of Fitness for Seafarers) issued by the MCA and these guidelines have been under comprehensive revision for the last couple of years. Following a consultation period at the start of 2009, the final drafting will result in a new Medical Guidance Note, MSN 1765(M), effective from 1 January 2010.

I attended the MCA Maritime Health Seminar 2009 in London in November and the new guidelines formed an important part of the programme. In addition to the revised Standards, approved doctors will be supplied with seventeen Guidance Notes covering a wide range of common conditions. These Notes summarise the thinking behind the Standards and also provide decision support aids to help reach a reasonable conclusion when encountering clinical conditions. It is very apparent to me when involved in discussion groups at the Conference that there is usually a range of opinion when confronted with particular problems affecting fitness at sea and the decision tree format is aimed to try to maintain some consistency. The overall aim of this major revision is to provide clear guidance, more flexibility with some conditions, such as hernia or joint replacements, and to optimise safety in other conditions that can produce sudden incapacitation, such as heart disease, seizures, insulin-dependent diabetes.

Approved doctors have relatively limited discretion in the field and sometimes it has only been possible to make progress by advising individuals to appeal against one´s own decision in order to reap the benefit of the referee´s increased scope for discretion. These new guidelines seek to address some of these problem areas and also, as a consequence, reduce the number of appeals. For example, a well-controlled insulin-dependent diabetic will be able to work in near coastal waters or in distant waters with a doctor onboard.

In general, some of the changes should enable more seafarers to continue working safely at sea when they have conditions where treatment has improved. However, there is still some debate going on about the standards for asthma. Prior to the current review, the guidelines supported a case by case assessment of individuals controlled on regular medication. The revised guidelines introduce a quantitative measure of inhaler usage each month which seems quite restrictive but advice to MCA doctors is encouraging discretionary judgements supported by as much documentary evidence as possible. MCA clearly want to develop the best guidelines in the light of field experience and seem to be encouraging discretion, rather than resorting to the appeal mechanism, for asthma candidates in particular and ultimately what works well will become established practice.

Laser refractive surgery is still discouraged and renders a candidate unfit for lookout duties for six months. Also the practical problem of assessing unaided vision in contact lens wearers are covered in the new guidance. Ideally candidates should wear glasses on the day of the examination and can insert the lenses once unaided vision is tested. This avoids temporary distortion of vision immediately after removing contact lenses.

Assessment of hearing is more systematic using a speech recognition test devised by the UK Royal National Institute for the Deaf and which semi-quantifies hearing loss. This test is web based and can be found at www.rnid.org.uk/hearingmatters/

Approved doctors are encouraged to request urine samples produced at the medical and not one brought by the candidate. This is to reduce the chance of fraud. In my experience, it is not crucial to witness every sample as long as the candidate does not carry bags or heavy clothing to the toilet and produces a sample of the right temperature and appearance in the container provided. However, with increasing requests for urinary drug testing by employers, witnessed sampling is becoming correspondingly necessary.

These new guidelines are now with us and look like a big step forward given time for familiarisation with the copious documentation. They will open up career doors for more people and, with some sensible case law experience, should eventually open doors for even more. Put another way, this 2010 vintage has been a long time in the making and it has a good nose but change comes slowly. It definitely has a full body, some will find the after-taste much more to their liking and, once it is in the system, most people should be happier.

Dr Ken Prudhoe, MCA Approved Doctor, can be contacted at Club de Mar Medical Centre, Palma de Mallorca. Tel: (+ 34) 639 949 125.