E.V. Kazakevich1, V.L. Arkhipovsky1, A.P. Sereda2, A.A. Abakumov2
Special features of medical care given to seafarers working
in the Arctic region
1 Federal State Budget Institution of Healthcare "Northern Medical Clinical Centre named after N.A. Semashko of Federal Medical-Biological Agency", Arkhangelsk 2 Federal Medical-Biological Agency, Moscow
Key words: Arctic region, seafarers, ship doctors, medical consultations at sea, medical training of
Abstract
The Arctic region has recently become the top priority in the socio — economic development of Russia. Federal State Budget Institution of Healthcare "Northern Medical Clinical Center named after N.A. Semashko of Federal Medical-Biological Agency ", Arkhangelsk (FSBI NMCC) has gained valuable experience in providing medical care to the crews working in the Arctic region. We have evaluated the peculiarities of sea voyages in this particular
officers in command, Marine medical centre
region as well as the structure of the diseases which affected seamen working in the Arctic conditions. We have analyzed the spectrum problems which marine medical society may encounter including training of medical professionals engaged in maritime health; provision and selection of medical technologies, pharmaceuticals and treatment options as well as medical equipment of medical health centres on board. We have also estimated the appropriateness of setting up Regional marine medical centre.
Introduction
Nowadays the Arctic region is considered to be an important element of the grand strategy in both domestic and Foreign policy of all subarctic countries including Russia, Canada, Denmark, Finland, Iceland, Norway, Sweden and USA.
Russian arctic territory extends from Franz-Josef-Land islands in the north-west to the Wrangel Island and Herald Island in the east, occupying about 1/3 of the entire arctic offshore area. The Arctic territory is under the jurisprudence of Federal legislation and is actively used by Russian Federation. Besides the Northeast Passage and the North Air Passage cross the territory of geographic North Pole, connecting Asia and the Northern America.
Arctic region is rich in numerous mineral resources, first of all — gas and oil. It is estimated that approximately 22% of world undiscovered reserves of hydrocarbons are deposited there (13% of oil, 30% of natural gas; 20% of gas condensate, with 84% of reserves being bedded in the shelf of the Arctic Ocean and 16% of them being found on the land territory of the arctic countries)1.
1 International Arctic Forum. http://forumarctica.ru/about-forum/about-thearctic/
The general length of the Northern Sea Route is 14 thousand kms (57770 sea miles). It is an alternative shipping route for transporting cargo. The Northern Sea Route, being a part of the Northeast Passage, is a shorter route to connect Far East with European part of Russia (Murmansk - Vladivostok) since it cuts time at sea by more than half.
The socio-economic development of the Arctic region is closely associated with the strengthening of maritime potential of our country[3]. We have recently witnessed an appreciable progress in shipbuilding industry. New ice — breakers, ice-classed ships, high — capacity tankers and offshore platforms are being built. The infrastructures of seaports are being improved, commercial development of new oil and gas fields is in progress, the volume of cargo transportation by the Northern Sea Route is constantly increasing2.
In its turn, the implementation of the maritime potential of our country directly
2 The Ordinance of the Government of Russian Federation issued on the 21st of 2014 № 366 The approval (confirmation) of the state program of Russian Federation "Socio -economic development of the Arctic territories of Russian Federation for the period up to 2020".
depends on the health status of workers engaged in the sphere of water transportation.
Analysis of the acquired experience and the investigation of arising problems
Federal State Budget Institution of Healthcare "Northern Medical Clinical Center named after N.A. Semashko of Federal Medical-Biological Agency", Arkhangelsk (FSBI NMCC), located in the port of Arkhangelsk is a medical establishment dedicated to the provision of health care to seamen, fishermen and river transport workers (in Northern basin) for as many as 95 years.
Since 2015 the medical service of seafarers working on board the ships transporting cargo by The Northern Sea Route is implemented within the government plan (target)3. Ship doctors who have undergone professional training in the following specialties: General medicine, Therapy and Surgery, work in FSBI NMCC4.
They have also been trained at special courses at training ships and received certificates according to the International Convention on Standards of training, Certification and Watchkeeping for Seafarers (STCW)5.
Within the space of 2015 — 2016 our ship doctors made 7 voyages with overall duration 479 days on board the vessels belonging to "The Northern Shipping Company" (motor-vessels "Inzhener Trubin", "Ivan Ryabov", "S. Kuznetshov", "Kapitan Mironov") as well as on board an ice — breaker "Dikson" belonging to the Federal State Budget Institution
3 The Ordinance of the Government of R.F. issued on the 26th of December, 2014 №1540 "The peculiarities in the organization and financial support of medical care provision, including the access to extra medical services stipulated by the legislation of Russian Federation 1) to the population living in closed administrative and territorial units, on the territories exposed to hazardous physical, chemical and biological factors, included into the pertinent list; 2) to the employees of companies included into the list of selected branches of industry with extremely hazardous working conditions".
4 The order of Ministry of Public Health issued on the 8th of October, 2015 № 707H "The approval of the requirements to the qualification of medical care providers and pharmacists with higher education having qualification "Health care system and medical sciences".
5 The International Convention on Standards of Training,
Certification and Watchkeeping for Seafarers (STCW)
(1978)
"Rosmorport", Arkhangelsk)6. FSBI NMCC has signed a treaty with the above-mentioned organizations. According to the contract FSBI NMCC commits itself to pay salary to the employed medical personnel working as ship doctors while the ship owners are obliged to provide meals and the scale of medicines and medical equipment commensurate with the vessel's usual voyage category.
The most frequent voyages were Arkhangelsk — Sabetta — Arkhangelsk. Sabetta is a settlement located on the penincular Yamal. It is the place where a new seaport and a shipping canal in Culf of Ob are being built7. The vast hydrocarbon resources were discovered on the Yamal peninsula: Sorthern — Tambey's gas condensate and Newport oil deposits. A new plant producing liquefied gas was constructed. The first ship carrying liquefied gases left the port of Sabetta at the end of April, 2017. In the near future they plan to perform oil transfer reloading on board tankers using the oil terminal that has been built in Gulf of Ob.
According to the ship doctors' reports there were 213 primary visits, 1153 recurrent visits and 468 preventive medical check-ups. The doctors revealed 49 cases of respiratory diseases, 23 cases of gastro-intestinal diseases and 18 cases of cardio-vascular diseases.
We present some cases of rendering emergency medical aid at sea.
A 28-year old engineer of motor-vessel "Kapitan Mironov" sustained a lacerated wound of the upper part of his left calf ( 10 cm in length) and the contusion to his left femur. The incident occurred on the 21st of December, 2015 during the storm at Barenz Sea. In the doctor's office on board the ship the wound was sutured, the ship doctor having put 8 stitches.
A 49-year old boatswain of the motor-vessel "Inzhener Trubin" had fallen ill on the
6 The Order of the Government of Russian Federation issued on the 21st of August, 2006 № 1156-p "The approval of the list of organizations and territories serviced by Federal Medical-Biological Agency of Russia".
7 The Ordinance of the Government of Russian Federation issued on the 21st of 2014 № 366 The approval (confirmation) of the state program of Russian Federation "Socio -economic development of the Arctic territories of Russian Federation for the period up to 2020".
23rd of March, 2016. The diagnosis of gastrointestinal bleeding was made and the patient was transferred to the ice-breaker "Kapitan Dranitshin", and then evacuated by helicopter of the Search and Rescue Coast Service to FSBI NMCC (at the distance of 200 kms). The patient had the history of resected stomach due to duodenal ulcer in 2009. In the clinic bleeding from the ulcer was arrested by clipping vessels of gastro-duodenal anastomosis.
The peculiarities of sea voyages in the Arctic region comprise hard climatic conditions including low temperatures and the polar nigh, extreme physical and emotion exertion that crew members may experience while following the icebreaker in the convoy, complicated and costly evacuation of the sick and casualties to the coast medical institutions.
The main problems that we have encountered providing medical help to crew members are the lack of qualified medical personnel as well as necessary equipment for the ship medical centres. Nowadays FSBI of NMCC is stuffed with 8 ship doctors (mean age being 61). The majority of doctors began their life of work in the period of the Soviet Union and have gained extensive experience in treating patients. We believe that in order to recruit newly qualified medical specialists it is imperative to elaborate the criteria according to which wage increases could be available for those working in the stern conditions of the Arctic region. We also propose to make amendments in the nomenclature and introduce a new subspecialty "marine medicine"8 [ 1;3]. It enables medical professionals to improve their qualification at refresher courses dedicated to the promotion, protection and maintenance of maritime health, and be certified for this job.
At present time there no regulatory acts of Ministry of Public Health that substantiate the provision of ships with necessary medicines, medical stores and medical equipment. The Order of Ministry of Public Health of the USSR issued on the 6th of September, 1989
8 The Order of Ministry of Public Health issued on the 7th of October, 2015 № 700H "The nomenclature of specialties for the professionals with higher medical and pharmaceutical education"
#511 "The improvements in the provision of medico-sanitary service of workers engaged in merchant marine, inland water transport, fishing fleet and fishing industry" was revoked in November 20 1 29.
The Order of Ministry of Public health of Russian Federation issued on the 5th of May 2012 #499H "Approval of the requirements to the medical chest to be provided to the seagoing merchant vessels, domestic commercial vessels and vessels of a mixed type (river-sea) not staffed with medical professionals" was annulled by the Instruction of the Government of Russian Federation issued on the 30th of September, 2014 #1935-P.
To replenish a medicine chest that contains the medicines and medical equipment that would allow an appropriately trained person to treat injuries and illnesses on board the vessel, ship owners use the list of medicaments (Quantification Addendum) provided by the "International Medical Guide for Ships"10. The given list is only destined to be used on board the ship not staffed with a ship doctor. The list comprises 57 drug preparations the number of which is obviously insufficient for the proper functioning in the Arctic conditions. We think that it is necessary to work out not only updated list of obligatory medicaments but the list of medical stores and medical equipment including defibrillators as well.
In addition we propose to develop the requirements to the use of controlled drugs and psychotropic preparations for medical purposes on board a ship since these are efficient analgesics in case of grave traumas, acute coronary syndrome, etc.
Nowadays it is known that the majority of ships transporting cargo in the Arctic region are not staffed with ship doctors except nuclear-powered ice-breakers. A lot of companies working in the Arctic region are not included
9 The countermand of Ministry of Public Health issued on the 7th of November, 2012 № 587 "To consider the order of Ministry of Public Health of the USSR issued on the 6th of September 1989 № 511"The improvements in the provision of medico-sanitary service of workers engaged in merchant marine, inland water transport, fishing fleet and fishing industry not valid".
10 International Medical Guide for Ships (IMGS), 3rd Edi-
tion 2007, World Health Organization (WHO)
into the Instruction of the Government issued on 21st of August, 2006. As a result, ship owners don't assume responsibilities for upkeep of ship medical personnel.
According to the Convention there must be one of the officers (the Master or other persons) who is designated with responsibilities for rendering medical care or the first aid on board a vessel11.
Medical training is an integral part of professional training of seamen. More than 100 officers undergo special training courses "Medical help to the sick and casualties" arranged by FSBI NMCC. This work is carried out on the contractual basis together with the Arkhangelsk branch of Federal Budget Institution "Morspassluzhba Rosmorrechflot" (the training vessel "Kotlas") and "Arkhangelsk Trawler Fleet" (the training, vessel "Belokamenka"), both having obtained accreditation by Ministry of Transport.
To our opinion there are still some outstanding questions dealing with medical training of crew members. They are the following:
• there is no approved list of medical institutions authorized to arrange medical training courses for crew members; the list should be passed by the executive branch of power.
• there is no National Marine Medical Training Centre specially designated to provide facilities for doctor-instructors to improve their qualification. We suppose that such a centre should plan and coordinate the overall teaching process; publish manuals, create teaching and visual aids, work out test systems, monitor the quality of training.
• the Federal Law "Education in Russian Federation" issued on the 29 th of December 2012 № 273-FZ makes no provision for medical training of navigating officers. Since such training of navigators which is aimed at providing an officer with at least working knowledge so that he can deal swiftly and effectively with most medical emergencies at sea, is not specified in Federal law "Education
11 The International Convention on Standards of Training, Certification and Watchkeeping for Seafarers (STCW) (1978)
in Russian Federation", we consider the legislative approval of paramedical training of navigators to be of importance [1].
Medical consultation is a vital method of maintaining health and safety of life at sea especially during a long voyage [2], especially in the Arctic conditions. According to international regulations12 the competent authority should provide expert medical advice over the air (by radio), including consultations of specialist doctors. These free consultations are to be given 24 hours irrespective of type of a ship and flying the flag.
FSBI NMCC has long standing experience of medical consultations at sea. Special call-centre of our medical institution always turns to the doctors on duty working in the inpatient department when consultation of a surgeon, a therapeutist, a neurologist or other specialist is required. Telephone number to contact the reception ward of FSBI NMCC is available for all vessels for 24 hours and is included into the system of International Regulations for Preventing Collisions at Sea.
All consultations are logged in a special medical registry. There were 286 medical consultations between 2009 and 2016.
In its circular letter issued on the 25 th of May, 2000 № 96013, the Committee on Safety of Life at Sea of International Marine Organization recommends all the countries — members of International Maritime Organization and companies engaged in sea shipping to set up Marine Medical Consultative Centres. The existence of such an organization as a subdivision in the system of medical aid at sea):
• enables us to avoid isolation of both the casualty (sick or wounded) and the captain who is responsible for his (her) health and life from the point of view of obtaining pertinent information;
• prevents unnecessary evacuation of the casualty, that being vital is often hazardous and costly.
12 The Maritime Labour Convention (MLC). Marine Order 11 (Living and working conditions on vessels).
13 Circular letter of the Committee on "Safety of Life at Sea" of International Marine Organization issued on the 25th of May, 2000 № 960 "Medical Help at sea". Saint Petersburg.: Central Scientific Research Institute of Merchant Marine, 2000.
• Besides this centre may help rescue services, that are the first to contact the captain of a ship in a difficult situation, make a correct decision.
We propose Marine Medical Consultative Centre to be officially assigned by the competent authority of a given state. Up to now no centre of this type has ever been established.
Medical Consultations given by means of telecommunication are thought to be promising for the Arctic region. Telemedicine allows to make medical consultations more sophisticated and avoid possible mistakes while taking decision concerning evacuation of casualties. In spite of indisputable advantages of telemedical consultations their practical application is hindered by heavy expenses.
Our suggestions
Lately we have observed increasing navigation along the Arctic coasts of Norway and Russia. It results from the fulfillment of some infrastructural projects in the Arctic region, intensive development of gas — and — oil extraction on the shelf of northern seas14 as well as redistribution of troops for the protection of state frontier in the North. Taking into consideration climatic and geographical peculiarities of the Arctic region, vast territory and long distance, remoteness, scarceness of health care institutions located along the sea coast, we presume that the need of qualified medical help will be increasing.
In 2012 Russian Federation ratified the Convention of International Labour Organization "Maritime Labour Convention"15. According to this document it is reasonable to set up special healthcare centres to protect the health of seafarers. Similar centres can be found in those countries that participate in sea shipping.
We are sure that there are sufficient reasons to set up Regional Arctic Marine
14 The Ordinance of the Government of Russian Federation issued on the 21st of 2014 № 366 "The approval of the state program of Russian Federation "Socio - economic development of the Arctic territories of Russian Federation for the period up to 2020".
15 The Maritime Labour Convention (MLC). Marine Order 11(Living and working conditions on vessels).
Medical Centre affiliated to the Federal State Budget Institution of Healthcare "Northern Medical Clinical Center named after N.A. Semashko of Federal Medical-Biological Agency", Arkhangelsk.
For many years FSBI NMCC has been occupied with medical treatment of workers of water transport. A lot of organizations have got registered to FSBI NMCC for their employees to receive expert medical advice and specialized health care. FSBI NMCC has managed to preserve skilled human resources and scientific research workers. In addition to that, FSBI NMCC has gained extensive experience in health care of seafarers.
We expect the main tasks of Arctic Marine Medical Centre to be the following:
• the fulfillment of international commitments associated with health and safety of sailors
• medical examination of seafarers
• medical assistance to crew members during a voyage
• medical training of officers in command
• provision of medical advice at sea including the use of telemedical communication means
• routing evacuation of the sick and casualties for medical purposes, and interaction with coast rescue coordinating services in the Arctic zone.
• introduction of high-tech methods and techniques to the treatment and rehabilitation of seafarers
• medical support of diving, underwater and accident-related work
• elaboration of programs in the field of marine and submarine medicine
• scientific investigations in the field of prophylaxis, diagnostics, and treatment of the diseases, as well as medical rehabilitation of employees working in the marine, submarine and diving spheres.
We are of the opinion that it is essential to empower this centre to function efficiently on the basis of economically sound financing.
We believe that the emergence of the Arctic Marine Medical Centre would meet both national and international requirements.
Reference
1. Bumay O.K., Ivanchenko A.B., Abaku-mov A.A. Preparation of regulatory — legal foundation for the system of medico-sanitary service of seafarers when they are employed or engaged on board sea or river vessel: problem investigation, suggestions and prospects// "Medicine of extreme situations". 2017. No. 1. P. 65-77
2. Kazakevich E.V., Arkhipovsky V.L., Bumay O.K. Marine Medical Consultative Centres as an element of overall system providing medical care to seafarers.// Marine bulletin. 2016. No. 1 (57). P. 112-113
3. Mosyagin I.A. The current state of maritime medicine and conceptual approach to its development in Russian Federation // Marine medicine. 2016. No. 4. Vol. 2. P. 7-19.
Contacts:
Arkhipovcky Vadim Leonardovich M.D., PhD, the head of the polyclinic of the Federal State Budget Institution of Healthcare "Northern Medical Clinical Centre named after N.A. Semashko of Federal Medical-Biological Agency", Arkhangelsk. Tel.: +7 (8182) 28-80-39. E-mail: arhvadim@nmcs.ru
информация_
Расширенное совместное заседание профильных комиссий ФМБА России по психиатрии
и наркологии
Клиническая больница №85 ФМБА России стала площадкой, где прошло расширенное совместное заседание профильных комиссий Федерального медико-биологического агентства по психиатрии и наркологии. Сюда прибыли 23 специалиста из 16 медучреждений ФМБА России: руководители, заместители руководителей, психиатры, психиатры-наркологи, психотерапевты, а также сотрудники кафедр промышленного здравоохранения, наркологии и психотерапии Института повышения квалификации ФМБА России.
Профильную комиссию по наркологии ФМБА России возглавляет главный внештатный специалист психиатр-нарколог, главный врач ФГБУЗ ЦПБ ФМБА России В.А. Приятель, а профильную комиссию по психиатрии ФМБА России - главный внештатный специалист психиатр ФМБА России, руководитель Центра психического здоровья Клинической больницы № 85 ФМБА России Д.Д.Федотов.
В ходе совместного заседания состоялось обсуждение наиболее важных аспектов медицинского обеспечения безопасности производства и охраны психического здоровья работников. Особое внимание было уделено вопросам периодических медосмотров, обязательного психиатрического освидетельствования работников и координации работы психофизиологических лабораторий (кабинетов) с заводским здравоохранением медицинских организаций ФМБА России.
В перерыве заседания его участники ознакомились с работой Центра медицинской реабилитации и спортивной медицины, возможности которого успешно используются в работе Центром психического здоровья и реабилитации для профилактики, лечения и восстановления пациентов психиатрического профиля. Участники заседания также посетили отделение функциональной диагностики и кабинет психофизиологических исследований и реабилитации, соматопсихиатрическое отделение.
В ходе расширенного совместного заседания профильных комиссий при главном внештатном специалисте психиатре и главном внештатном специалисте психиатре-наркологе ФМБА России были подняты наиболее острые и актуальные проблемы функционирования психиатрических и наркологических служб медицинских организаций ФМБА России.