Guidance re imgs medical chest.doc

Guidance to the International Medical Guides for Ships 3rd edition: Interim advice on the best use of the medical chest for ocean-going merchant vessels without a doctor onboard Joint Statement of WHO Collaborating Centres for the Health of Seafarers and
the International Maritime Health Association
__________________________________________________________________________________________ Background
Diagnosis and treatment of sick and injured onboard is a challenge to seafaring. This has always been
true despite recent developments in telemedicine. Where no doctor is on board -as it is the case in
most merchant ships- a non-medical person holds the responsibility for medical care. He has to rely
on his medical training, written information, and – if appropriate- shore based radiomedical or
telemedical advise. This information will help him to make best use of the medical chest and
equipment on board. Appropriateness of the information available, adequacy, uniformity and quality of
the medical chest and equipment is a key to the safeguard of the seafarer’s health at his work-place.
The WHO International Medical Guide for Ships (IMGS) was first published in 1967. The IMGS has
widely been used in the maritime world. The second edition1, written in 1988 was recently replaced by
the third edition2 in 2007. Immediately after the publication of the current IMGS a discussion on the
best use of the tool and on further needs developed among experts from the WHO Collaborating
Centres3 for the Health of Seafarers and the International Maritime Health Association4.
During a workshop of the INTERNATIONAL MARITIME HEALTH ASSOCIATION (IMHA) in Athens,
Greece, November 14th-15th 2008 the concerns were summarized as follows: “Flag states that do not
have national requirements for the contents of the medical chest have in the past relied on a list that
has been provided by WHO in the International Medical Guide for Ships (2nd Edition, 1988). This list
provided information on the quantities to be carried on board. It is not a formal international instrument
but the Guide is noted as a source of information in the non-statutory part of the relevant ILO
Convention. Port State Control Inspectors use the IMGS list as the minimum requirement for medical
supplies The medication list is now very out of date and when WHO recently published a new edition
of the Guide it included updated lists of recommended medications that were derived from the WHO
Essential Medications List and of medical equipment taken from The Inter-agency Emergency Health
Kit 2006. While this was a rational approach for the WHO to adopt to ensure that well validated
treatments were available it did not take into account the need for remedies for minor ailments at sea
– the sort that can impair ability to work without being dangerous, nor did it cover all the medical
equipment that was needed in maritime situations. More significantly WHO did not consider that they
could specify quantities of medications to be carried as there was a lack of information on use and
effectiveness of medications at sea. In the absence of such data WHO considered that quantities
should be related to voyage pattern and to political / managerial decisions rather than being stated by
1 International Medical Guide for Ships (2nd Edition). World Health Organization, Geneva.1988. 2 International Medical Guide for Ships (3rd Edition). World Health Organization, Geneva. 2007. 3 The WHO collaborating centres are institutions such as research institutes, parts of universities or academies, which are designated by the Director-General of the World Health Organization to carry out activities in support of the Organization's programmes. 4 IMHA is the sole international association concerned exclusively with Maritime Health. It is an association of professionals from a wide range of disciplines who are committed to improving the health of seafarers by developing better approaches to health protection, health promotion and health treatment. WHO. This lack of specification is not causing immediate problems where the flag state of the ship
has its own national regulations or guidelines but it has led to great difficulties for maritime
pharmacists called on to check and restock medical chests on ships from countries, including many of
those with major open ship registries, that have no national lists. Pharmacists cannot continue to work
to the outdated list and quantities in the old International Medical Guide, while they have no
benchmarks for quantities required from the new one, nor the authority to make consistent decisions
on the quantities to supply”.

WHO Collaborating Centres for the Health of Seafarers and IMHA agreed that there are a number of
topics where improvements are needed. The aim is to produce a knowledge-base to specifying the
contents of medical chests and the medical textbook. While this is a long-term approach requiring
research efforts it was also agreed upon the need to produce an interim guidance on the medical
chest to the current users of the IMGS even in the absence of further evidence. Symptom-oriented
algorithms for diagnosis and treatment as a supplement to the current IMGS 3rd edition will follow
soon.
In this paper the authors, who are experts from the International Medical Health Association and the
WHO Collaborating Centres for the Health of Seafarers publish recommendations to the medical chest
as given in the IMGS 3rd edition. This is an interim advice to be available to ship-owners, -masters and
maritime authorities and pharmacists for use on merchant ships not carrying a medical doctor of those
flags that do not follow the EU Directive 92/295 and do not have national requirements. The readers
and users of the interim advice need to be aware that the expert group does not judge on the content
of the current list as published by the World Health Organization in the 3rd edition of the IMGS.

The aim of the Interim Advice as given below is
to provide an aid for decision making for quantities required for seagoing and coastal vessels to add items named in the textbook of the IMGS 3rd edition but missing in the list of medicines or equipment to add page numbers from the medical textbook to the list of medicines for easier use.
The Interim Advice as given below is not
mandatory for ship-owners, suppliers or port health authorities. It is to the flag states responsibility to specify national requirements in a legally binding way meant to substitute a qualified medical consulting. Owners and operators carry the final responsibility for the content of the medical chests on board of the ship. Owners and operators will need to seek qualified medical consulting for the content and quantities carried on board. The particularities of the voyage will need to be considered by the consultant, like travel to malaria risk areas. The authors of the Interim Advice are solely responsible for the content of all additions made to The List of Recommended Medicines and Equipment of the International Medical Guide for Ships 3rd edition, pages 430-46. We appreciate the comments of the maritime community to this publication which will be continuously revised. All comments and suggestions need to be directed to the 5 Council Directive 92/29/ eec of 31 March 1992 on the minimum safety and health requirements for improved medical treatment on board vessels. How to use the proposed list of recommended
medicines and equipment of the
International Medical Guide for Ships 3rd edition, pages 430-461
The interim advice is only to be used in conjunction with the International Medical Guide
for Ships 3rd edition2 as published by WHO in 2007.
All items suggested from WHO in the original list on pages 430 to 461 are included. Any additions to the original list (items and comments) are made visible by the use of italic letters. Reference pages from the medical textbook to the list of items which justify the additions are given. Running numbers have been given to the list of medicines and equipment including added items. Drugs, forms, books and equipment which are mentioned in the textbook but have not been displayed in the list of medicines are added to the list in alphabetical order. Reference pages to the medical textbook are given for all items to ease the use of the list. If an item may be omitted under special circumstances this is mentioned in italic letters in the last column. Suggestions for quantities have been included. Quantities are calculated on the basis of the following assumptions: Ocean-going merchant vessels without a doctor onboard. Maximum duration of travel of 3 weeks. Crew sizes of 10, 20, 30 or 40 persons. For merchant vessels without a doctor onboard engaged in coastal trade or going to nearby foreign ports, and not more than 24 hours away from a port of call, for fishing boats and private craft: Quantities may be adapted or omitted on the advice of a qualified medical practitioner or pharmacist with regards to the destination, medical facilities ashore, number of crew members and cargo. For dosage, contra-indications, unwanted effects, radiomedical advice and further
remarks the users needs to refer to original text of the IMGS 3rd edition.
Recommended quantities will not always reflect the standard packs in a given country. In this case the recommendation is for the nearest available dispensing sales pack above the minimum required quantity. Owners and operators may substitute exact equivalents on the advice of a qualified medical practitioner or pharmacist, provided they are satisfied that an equivalent level of treatment is assured. Specific items will not be available in certain countries, for example Chlorpyrifos was banned in the European Communion (Directive 98/8 eec of March 16th 1998). The pharmacist will have to supply an analogous drug in corresponding quantities. The same is true for items which have transport restrictions and can not be delivered locally. For ships carrying dangerous goods according to the IMDG Code6: Medicines and
equipment already available in the IMGS list may be counted toward the Medical First Aid
Guide (MFAG) numerical requirement, if appropriate.
______________________________________________________________________________
6 Medical First Aid Guide (MfAG) for use in accidents involving dangerous goods. International Maritime Organization, London, 2004. Ocean-going merchant vessels without a doctor onboard.
Maximum duration of travel of 3 weeks.
Crew sizes of 10, 20, 30 or 40 persons.
Only to be used in conjunction with the International Medical Guide for
Ships 3rd edition
Comments in italic letters refer to added items recommended minimum which are mentioned in the textbook but have number of items for ocean- not been displayed in the list of medicines. Remarks on items which may be omitted under alphabetical order and are written in on an estimated 3 weeks special circumstance are given. For dosage, contra-indications, doctor consulting, unwanted complement of 10 to 40 effects and remarks refer to IMGS 3 rd ed. p. MEDICINES, p. 431 – 450
Item Recommended Item
per per per per Indications (on board ships)
No. Dosage form, Strength
10 20 30 40 Added comments
100 200 300 400 - high dose (600-900mg): to reduce pain, - low dose (100-150mg) to inhibit formation of blood clots in angina pectoris, myocardial See pages 17-25 and 113-116, 133-135, 137, - treatment of primary or recurrent herpes simplex - may be useful for severe varicel a and herpes zoster infection (doctor should be consulted) - to raise blood pressure in anaphylaxis - to dilate airways in severe asthma or anaphylaxis - to treat infections responsive to this antibiotic See pages 7-776, 140-144, 181-183, 204, 216-217, Prophylaxis and treatment of Malaria as Treatment of severe malaria. See pages 265-269 required only for voyages to areas where malaria Treatment of malaria. See pages 265-269 required only for voyages to areas where malaria - to treat slow heart rate in myocardial infarction - to treat organophosphate insecticide poisoning See pages 141-144, 195-207, 260, 274, 277, 281 - to treat infections responsive to this antibiotic See pages 16, 141-144, 153, 160-161, 172, 175, - to treat al ergy symptoms in hay fever, hives, allergic dermatitis, etc. See page 145 to absorb ingested poisons. See pages 93-96 - to treat infections responsive to this antibiotic See pages 77, 156-157, 181-183, 195-207, 221-223, - to treat life-threatening and severe asthma 100 100 to treat alcohol withdrawal. See pages 235-239. - to avoid straining in patients with anal fissure and - to prevent constipation caused by opioid use as recommended in IMGS3 for the specific See pages 195-207, 209-210, 221-223, 271-272. an alternative to hand-washing when hands are to detect damage to cornea: damaged area stains to treat severe fluid retention in lungs (pulmonary oedema) due to cardiac failure, see pages 15, 136 to treat low blood sugar (hypoglycaemia) due to insulin when oral intake is impossible and intravenous glucose cannot be given. See pages It is recommended to carry a glucose measuring - to treat psychotic hal ucinations and delusions - to treat severe agitation and aggressiveness to treat allergy and some other inflammatory skin conditions. See pages 169, 212-213, 219-221 - to reduce mild-to-moderate pain, especial y if Consider diseases transmitted by mosquitoes as areas of risk of acquiring Dengue Fever p 258-259, Malaria p. 265-269, a disease transmitted by Yellow fever p 284 See also pages 363-364 for mosquito control in for local anaesthesia when suturing wounds or 120 to treat symptoms of diarrhoea not effective for tapeworm infection or hydatid - to treat hypertension (high blood pressure) - to treat atrial fibrillation (irregular or rapid - to treat angina pectoris (chest pain) - to prevent migraine See pages 133-137 to treat infections responsive to antibiotics If women on board, supply also Miconazole vaginal to terminate epileptic fits. See pages 121, 128-130 to prevent post-partum haemorrhage. Page 192 - to reduce pain not relieved by other analgesics to reduce severe pain likely to last several days in to reverse effects of opioids, especial y in case of Caution: Scopolamine treatment causes sedation, to prevent or treat dehydration, especial y due to diarrhoea, see pages 257-258 and 347 - to treat nasal obstruction due to al ergies or viral - to improve sinus drainage in sinusitis 300 400 to reduce pain and fever (but not inflammation) - to treat other inflammatory conditions (on -to treat chapped skin. See page 212, 261 for lubricating rectal thermometer To make inhaling salbutamol more effective For sterile eye irrigation, see page 38 to treat minor eye infections; to prevent infections Part of wound care if state of vaccination is Part of wound care if state of vaccination is Against moderate pain; See pages 22-23 In severe pain use morphine; See pages 17-25 to reverse excessive or unwanted effects of warfarin or related drugs. See pages 96, 173 reconstitution of injectable drugs provided as Carry at least 60 tablet. Prophylaxis against HIV infections after needle- stick injury. One tablet daily twice daily for four Qualified medical advise In case of exposure immediately seek radio-medical using other antiviral substance needed for general risk advice for risk assessment in individual person. prophylaxis/pep_guidelines/en exposure on board . EQUIPMENT p. 451 -461
per per per per
Category
No. Recommended item
10 20 30 40
Added comments
1. RESUSCITATION EQUIPMENT
1.1
appliance for the administration of oxygen See pages 4-5. If no additional equipment from the MFAG on board consider to increase amount of Oropharyngeal airway, see pages 4-5, 315 Oropharyngeal airway, see pages 4-5, 315 Mechanical aspirator, see pages 4-5 Mechanical aspirator, different sizes; see pages 4-5 Bag and mask resuscitator including oxygen reservoir bag and oxygen tubing, see pages 4-5 Cannula for mouth-to-mouth resuscitation, 2. DRESSING MATERIAL AND SUTURING EQUIPMENT
2.1
200 200 200 200 adhesive dressings 100 100 Sterile gauze compresses 100 100 Sterile gauze compresses 60 cm / 90 cm my be substituted by gauze rol of Gauze dressing with non-adherent surface Elastic fixation bandage, 4 m x 3 Triangular sling. See pages 43-58 and 77 Sterile sheet for burn victims. Different sizes Only if honey for medical purposes available Otherwise use a hydrogel-burnkit. See pages 79-83 Safety pins (stainless steel), 12 1 Butterfly sutures. See pages 69-74 Skin adhesive for closing smal wounds. See pages Suturing equipment. See pages 71-74. Replace with non-absorbable sutures for easier use Suturing equipment. See pages 71-74. Replace with non-absorbable sutures for easier Suturing equipment. See pages 71-74. Replace with non-absorbable sutures for easier 2.19c Surgical gloves size 6.5, sterile 3 2.19d Surgical gloves size 7.5, sterile, 3 2.19e Surgical gloves size 8.5, sterile, 3 3. INSTRUMENTS
3.1
Disposable scalpels See pages 71-74, 216-219. Forceps. See pages 71-74, 216-219. 4. EXAMINATION AND MONITORING EQUIPMENT
4.1
Tongue depressors, disposable 100 100 100 100 Disposable tongue depressors 100 100 Reactive strips for urine analysis, see pages 311- Microscope slides, See pages 265-269 Aneroid sphygmomanometer, see pages 305-307 Standard thermometer, see pages 302-304 Rectal thermometer, see pages 302-304 Thermometer 32˚-34˚C, digital 1 Hypothermic thermometer, preferable range 26°C to 42°C to differentiate between severe-moderate- mild hypothermia; see pages 343-344. Penlight (blue light) to detect damage to cornea. FORMS AND BOOKS
4.11
Use ass master copy. Should be filled in before Use as master copy (see pages 455 - 461) Use as master copy (see pages 455 – 461) Use as master copy (see pages 455 – 461) Use as master copy (see pages 455 - 461) International travel and Health, current edition 5. EQUIPMENT FOR INJECTION, INFUSION, AND CATHETERIZATION
5.1
Equipment for injection, see pages 324-329 Equipment for injection, see pages 324-329 Equipment for injection, see pages 324-329 Equipment for subcutaneous injection, see pages Equipment for intramuscular injection, see pages Equipment for drawing the medicine into the syringe, see pages 324-329 Equipment for intravenous fluid infusion, see page Equipment for intravenous fluid infusion, see page Equipment for intravenous infusion, see pages Equipment for infusion, see pages 324-329 5.10a Penile sheath set with condom 1 Bladder drainage equipment, see page 308-309 5.10b Indwel ing urine catheter 14 Bladder drainage equipment, see pages 319- 321 Bladder drainage equipment, see pages 319-321 Bladder drainage equipment, see pages 319-321 Bladder drainage equipment, see pages 319-321 Bladder drainage equipment, see pages 319-321 6. GENERAL MEDICAL AND NURSING EQUIPMENT
6.1
100 200 300 400 Condoms, assorted sizes Plaster-of-Paris bandages, may be omitted if splints Plaster-of-Paris bandages, may be omitted if splints 6.21a Stockinet sizes for arm splints 1 100 100 100 100 70% alcohol swabs for skin cleansing prior to If Tetanus vaccine and Immunoglobin are on board DISINFACTANTS, DISINSECTANTS
6.27
To disinfect potable water tanks with chlorine For disinfection of used instruments* and *Caution: Al items entering the skin or are in direct contact with mucous membranes should be single use (i.e. injection needles, urinary catheters. For disinfection of contaminated surfaces, hard- surface objects and floors (non-food-handling For disinfection of food-handling area: cutlery, dishes, plates, glasses), see page 331 To use against cockroaches in food storage and preparation area, see pages 362-365 To use against cockroaches in other areas than food storage and preparation area 7. IMMOBILIZATION AND TRANSPORTATION EQUIPMENT
7.1
Mal eable splints (small). See pages 43-58. Mal eable splints (medium). See pages 43-58. Mal eable splints (large). See pages 43-58. Stretcher equipment (a system for trauma management, i.e. immobilization and stretcher equipment most suited for treatment in the vessel concerned. Preferably al owing crane/helicopter for neck immobilisation. See pages 7, 45

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