MEDICINA MARITIMA

* Necesitatea excelentei * ‡ Protection and Indemnity insurance (commonly referred to as ³P&I´) provides cover to shipowners and charterers against third-party liabilities encountered in their commercial operations. Responsibility for damage to cargo, for pollution, for the death, injury or illness of passengers or crew and for damage to docks and other installations are examples of typical exposures. (http://www.american-club.com/go.cfm/about_us) * ‡ Datorita conditiilor de munca si pentru prevenirea accidentelor de munca, armatorii au solicitat examinari din ce in ce mai complexe ale personalului navigant. ‡ Standardele de examinare au devenit din ce in ce mai dure. ‡ S-a impus necesitatea existentei unor clinici si a unor medici recunoscuti international ± pe baza calitatii actului medical prestat de acestia. ‡ S-au pus bazele unor fise de examinare comun acceptate si recunoscute * ‡ Actual autoritatile maritime desemneaza clinici si medici ± dupa auditari riguroase ± care sa presteze examinarile medicale ale personalului navigant conform standardelor fiecarei autoritati in parte ‡ Medicii si clinicile acreditate au obligatia de a se conforma unor standarde in ceea ce priveste locatia, circuitele, echipamentele , abilitatile si capabilitatile medicale cerute de autoritatile internationale ‡ Lipsa specialitatii in Romania de sine statatoare ± ca medicina maritima ± impune obtinerea de acreditari si aprobari internationale ‡ Autoritatile internationale urmaresc constant si riguros calitatea serviciilor prestate de medicii si clinicile acreditate prin audituri regulate si prin cererea de rapoarte de activitate. * ‡Scaderea standardelor de calitate a examinarilor , feed backul oferit de personalul navigant precum si un numar mare de repatrieri medicale duce invariabil la pierderea acreditarii de catre clinica/medicul implicat ‡Armatorii solicita diferite tipuri de fise maritime ± de fond sau de pavilion, ceea ce implica eforturi sustinute ale personalului medical pentru intrunirea tuturor cerintelor armatorilor. * *Repatrierea medicala a unui navigator declanseaza o serie de actiuni cu implicatii serioase: necesitatea gasirii de urgenta a unui inlocuitor, care sa fie examinat si trimis, achitarea costurilor de spitalizare si repatriere a navigatorului, achitarea unui compensatii materiale pe durata concediului medical, achitarea de compensatii materiale familiei in cazul decesului navigatorului la bordul navei ( in cuantum de aprox 100 000 eur) * ‡ Lipsa unui membru al echipajului implica retinerea navei la cheu (nu este permisa plecarea cu echipaj incomplet) ± cu costuri imense pentru armator : intarzierea in livrarea marfurilor , neonorarea comenzilor, posibilitatea declansarii unei situatii mult mai grave cum ar fi dezinhibarea unei substante chimice periculoase prin prelungirea timpului pana la descarcare (datorita depasirii timpului de viata al substantei inhibitoare) ‡ In general costurile intarzierilor si a nerespectarii programului unei nave costa armatorul intre 200 000 si 250 000 eur /zi. ‡ Armatorul isi rezerva dreptul de a da in judecata clinica prestatoare a examinarii in conditiile in care cauza intarzierilor a fost generata de o stare medicala precunoscuta sau ignorata de catre medicii examinatori * ‡ Din aceste considerente, s-au facut eforturi considerente si constante in privinta prevenirii imbolnavirilor la bordul navei, a repatrierilor medicale si a deceselor pe mare ± de aici ± elaborarea de standarde si ghiduri medicale foarte concise si clare , acreditarea si aprobarea medicilor familiarizati cu conditiile speciale de munca pe mare, verificarea acestora si a calitatii actului medical prestat de acestia. ‡ Unul din programele derivat din toate aceste constatari este programul PEME ± Pre-Employment Medical Examination * ‡ To ensure that crew are fit and to reduce the potential for unnecessary claims, Steamship Mutual offers a rigorous and enhanced PEME. Using only recommended clinics, the scheme aims to ensure that seafarers who are medically unfit are not given clearance to serve at sea. ‡ As part of the Club¶s ongoing loss prevention programme, a PEME scheme was introduced in January 2009 for crewmembers recruited in the Philippines, in an effort to reduce the risk of unnecessary crew claims arising from pre-existing medical conditions. Further details are given in the PEME brochure and also in Club circular B.479 of December 2008. ‡ The scheme is based upon enhanced examinations designed to screen for conditions likely to be encountered for personnel in three age bands ± under 30, 31 to 45, and 46 and over. These examination standards have been compiled with the assistance of independent UK based consultants ± Medical Rescue International (MRI). The Medical Examination Records for the three age bands can also be downloaded below. (http://www.simsl.com/Loss-Prevention-and-Safety-Training/PEME.html) ‡ Datorita conditiilor specifice ale acestei activitati ± examinarea medicala trebuie facuta cu putin timp inainte de plecarea in voiaj ( putin inainte pentru a asigura deplasarea in stare de sanatate a marinarului la nava, dar suficient timp pentru a permite reevaluari ale analizelor sau de specialitate daca starea medicala a marinarului o impune ‡ Este necesara o evaluare cat mai amanuntita si o stadializare a problemelor medicale existente pentru a putea stabili aptitudinea marinarului de a naviga si riscul de agravare al unor stari preexistente. * Examination (PEME) program in the two largest labor supplying countries providing seafarers to Member¶s vessels: Ukraine and the Philippines. On 20 February 2006, the Board of Directors of the American Club made it mandatory for all Members to use the Club approved clinics in these countries or be subject to a double-retention deductible for illness claims. The program was further extended in 2006 and 2008 to include seafarers from India, Indonesia, Latvia, Poland, Romania and Russian Federation. The PEME program continues to be successful in reducing the frequency of illness claims arising in respect of seafarers employed on American Club entered vessels which would otherwise have arisen. In this document, the American Club presents the set of medical tests, examinations and associated standards that have been used for the mandatory PEME program, and a new medical history questionnaire that should form an integral part of the PEME. Your Managers recommend that Members review the list of examinations carefully with their crewing departments and manning agents for each country from where seafarers are employed. In addition, Members should remain vigilant vis-à-vis their manning agents to ensure PEMEs are carried out objectively, and without influence from the manning agent or the seafarer. * The examination forms are fully comprehensive. However, certain tests and procedures may be subject to limitations in accordance with local or national laws and regulations (e.g. HIV testing) and Members should ensure that they have a clear understanding of any such limitations. As with the mandatory PEME program, it is recommended that this be an annual examination at a minimum. We hope this guidance will help Members in providing a framework for PEMEs and a consistent set of standards which will assist Members in controlling claims arising from pre-existing conditions. Finally, these Guidelines are a living document and will be periodically updated and upgraded to further refine the PEME program. Dr. William Moore Senior Vice President Shipowners Claims Bureau, Inc., Managers American Club New York * AMERICAN CLUB PRE-EMPLOYMENT MEDICAL EXAMINATION ACCEPTANCE GUIDELINES INTRODUCTION The following parameters should be used as guidance for considering a seafarer or other shipboard personnel as being medically fit for duty. There are variations in acceptability standards depending upon many different factors but these are the standards that the American Club deems a seafarer as being fit for duty. 1. Medical History Questionnaire Ensure that the medical history questionnaire is completed and in particular the Declaration at the completion of filling out this form. The Declaration is important should their be a future claim that may have been related to a pre-existing condition that may have not been reported. 2. Physical Examination A basic physical examination should include at a minimum measurements of height, weight and blood pressure. In addition, medical discretion should be used to consider if there are any abnormalities through a simple visual and physical examination of the seafarer. a. Body Mass Index (BMI) ‡ Kilograms and meters (or centimeters) Formula: weight (kg) / [height (m)]2 ‡ Pounds and inches Formula: weight (lb) / [height (in)]2 x 703 With the metric system, the formula for BMI is weight in kilograms divided by height in meters squared. Since height is commonly measured in centimeters, divide height in centimeters by 100 to obtain height in meters. Example: Weight = 68 kg, Height = 165 cm (1.65 m) Calculation: 68 ÷ (1.65)2 = 24.98 Calculate BMI by dividing weight in pounds (lbs) by height in inches (in) squared and multiplying by a conversion factor of 703. Example: Weight = 150 lbs, Height = 5¶5´ (65") Calculation: [150 ÷ (65)2] x 703 = 24.96 * The standard weight status categories associated with BMI ranges for adults are shown in the following table. BMI Weight Status Below 18.5 Underweight 18.5 ± 24.9 Normal 25.0 ± 29.9 Overweight 30.0 and Above Obese b. Blood pressure Blood pressure measured between 110/60 to the upper limit of 140/90. 3. Dental Examination Visual test to identify teeth with problems (crooked, cavity, removed, etc.) and properly document those abnormalities²a dental chart with this information will be sufficient. If there are any teeth or oral conditions that could possibly worsen and need for a dentist¶s attention during the duration of the Seafarer¶s contract at sea, these should be rectified before being considered fit for duty. 4. Psychological Standard tests if available. In some jurisdictions, a seafarer could also provide Military ticket or certificate that proves that they were not committed to a mental hospital or facility. 5. Visual Tests Standard tests (Snellen²standard letter µtests¶). Deck watch keeping personnel should have, at a minimum, 20/20 vision. For personnel without watchkeeping duties, consideration should be made on a case-by case basis if outside this guideline * 6. Color Vision Ishihara/Rapkin test ±Seafarers with watchkeeping duties should be given to ensuring no color differentiation problems with red and green. For personnel with non-watchkeeping duties, consider on a case-by-case basis. 7. Audiometry Standard hearing test and a µWhisper Test¶. The Whisper Test is performed 3-6 meters (10 to 20 feet) away from the applicant to determine if they can hear from a distance. ‡ For deck personnel, the minimum distance for the Whisper Test is 3 meters (10 feet). ‡ For engine room personnel, the minimum distance for the Whisper Test is 3.5 meters (11.5 feet). 8. Chest X-Ray Annual chest x-ray (i.e. once every year) to check for any recognizable abnormalities. X-rays should be properly labeled as ³Anterior/Posterior´ or ³Posterior/Anterior.´ 9. EKG Standard testing to determine if there are abnormalities. 10. Urinalysis ‡ If heamaturia (blood in urine) is observed, then an ultrasound should be conducted and if it shows further small abnormalities, then crewman has option of an Intravenous Pyelogram (IVP). ‡ If it is found that there is protein and/or glucose in the urine, assess further because it can show a potential problem (e.g. hypertension, kidney problems or diabetes). * 11. Fecalysis (food service or food handling personnel only) Non-obligatory for standard ship crew but obligatory for food service personnel. Page 8 12. Complete Blood Count (normally checking for anemia) Check for anemia, platelet count, white-blood cell count. 13. Ultrasound examination An ultrasound examination should be conducted to detect the presence of gall and/or kidney stones. 14. Fasting Blood Sugar (Checks blood sugar the following day after not eating after midnight) The following group of tests should be considered under the Fasting Blood Sugar examination: ‡ Glucose ‡ Cholesterol ‡ Creatinine ‡ Blood Urea Nitrogen (BUN) ‡ Uric Acid ‡ Erythrocyte sediment test ‡ Thrombocytes 15. Hep B Antigen If screening is positive then further profile should be considered depending upon seafarer¶s exposure. If positive, and the virus is active and the seafarer should be automatically disqualified from active duty. Otherwise no problem (but see SGPT SGOT²will pick up all forms of Hep) * 16. VDRL If VDRL test is found positive, a T. Pallidum Hemagglutination Assay can be considered as an additional test at the Member¶s discretion. 17. HIV Test The American Club has required testing for Human Immunodeficiency Virus (HIV) for seafarers however there are countries where such testing is either illegal or must be conducted with the seafarers consent. Consideration should be given 18. Stress Test Stress tests should be performed under two conditions if: ‡ indicated by abnormalities during resting EKG, stress test should be performed to determine if there are any other abnormalities; or ‡ If the seafarer is 40 years of age or older. 19. Diabetes Diabetes can normally be detected through various series of tests reflected through Fasting Blood Sugar testing. A seafarer can be acceptable on a case-by-case basis for oral medication only±at owners / doctors discretion provided that proper oral medication is provided for duration of time at sea or at least 3 months with a provision to replenish oral medication before subscription is finished. Otherwise, non-oral medication is not acceptable for seafarers. Page 9 20. Liver Function Test (SGPT & SGOT) SGOT between 8-38 and an SGPT level between 9-52 are considered normal. 21. Alcohol/Drug Test At a minimum, tests for the following should be considered: ‡ alcohol abuse (various tests above can possibly detect alcohol abuse such as SGOT and SGPT testing); ‡ THC/cannabis; ‡ cocaine; ‡ barbiturates; and ‡ amphetamines. * ‡ Cerintele unei fise de tip American P&I: Examinare fizica +istoric+ dentara +Ishihara (PE) Testare psihologica (Psychologica test) Radiografie pulmonara (lung X-ray) EKG (EKG) Audiometrie (Audiometry) Spirometrie (Spirometry) Test de effort (Stress test) Ecografie abdominala ( Abdominal ultrasound) Hemoleucograma (CBC) VSH (ESR) Glicemie (Seric glucose) Ex sumar de urina (Urinalysis) VDRL (VDRL) TGO (SGOT) TGP (SGTP) Colesterol seric (Seric Cholesterol ) Creatinina serica (Seric Creatinine) Uree (BUN) Ac uric (Uric Acid) * Cerintele unei fise de tip American P&I: * AgHBs (HbsAg) Ac anti HCV ( HCV Ab) HIV (HIV Test 1+2) Grup sanguin (Blood type) Test drog alcool (drug and alcohol test ) Coproparazitologic ( Parasitological stool exam) * Ex coprobacteriologic ( Stool culture )* * ‡ Actual majoritatea firmelor de crewing, la cererea armatorilor solicita ca Radiografia pulmonara sa nu fie mai veche de 12 luni. ‡ Majoritatea armatorilor solicita seturi complete de analize, precum si ecografie ‡ Tendinta actuala este de a solicita tuturor navigatorilor in varsta de peste 40 ani efectuarea testului de efort ‡ Din acestea deriva necesitatea existentei tuturor acestor facilitati in cadrul aceleiasi locatii * * ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Cerinte NMD ( Directorat Maritim Norvegian) FORMULAR NIS 1-CLINIC GENERALA 2 - AUDIOMETRIE 3- RADIOGRAFIE PULMONARA 4-VSH 5-HEMOLEUCOGRAMA 6-EXAMEN SUMAR DE URINA 7-TGO 8-TGP 9-GLICEMIE 10-GGT 11-UREE SERICA 12-CREATININA SERICA 13-COLESTEROL TOTAL 14-TRIGLICERIDE 15-ECOGRAFIE ABDOMINALA 16-ELECTROCARDIOGRAMA * ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Cerinte OGUK ± former UKOOA: Examinare clinica generala audiometrie, Electrocardiograma Certificat dentar Test drog alcool Hemoleucograma VSH Examen sumar de urina Glicemie Colesterol Creatinina Grup sanguin Rh Radiografie pulmonara * ‡ Acreditari: ‡ 1) American P&I - http://www.americanclub.com/index.cfm?objectId=57B56F1E-1185-12E0-578F4CD251C6D714 ‡ (actual in Constanta ± exista o singura clinica concurenta cu aceasta acreditare) ‡ 2) OGUK (Oil&Gas UK, former UKOOA) http://www.oilandgasuk.co.uk/knowledgecentre/doctors-list.cfm ‡ (actual un singur alt medic aprobat ± in Brasov ) ‡ 3) Directoratul Maritim Norvegian ‡ http://www.sjofartsdir.no/en/Fartoy_in_english/Seamens_doctors/ ‡ (actual in Constanta singura clinica. In tara mai sunt acreditati Medicover Bucuresti ± 1 medic si PDR Brasov ± 2 medici) * ‡ 4) Casa Maritima ± Casa Genoa ‡ http://www.salute.gov.it/ministero/sezMinistero.jsp?label=uffici&id=389 ‡ (actual un alt medic in Constanta ± Cermed si altul in Bucuresti ) ‡ 5) Malayesian Maritime Authority aprobare Singapore Botezatu, Marmedic, Cermed) - si indirect ‡ http://www.marine.gov.my/service/doctorlist.pdf ‡ (actual inca 3 medici aprobati ± prin diferiti armatori ± Iuliana * ‡ Reprezinta o medicina de nisa , bazata pe acreditarile internationale ‡ Acreditarile se obtin ³in solidar´ datorita locatiei, dotarilor clincii, experientei si calitatilor medicului aprobat ‡ Firmele de crewing recomanda armatorilor colaborarea cu anumite clinici in baza renumelui in ceea ce priveste calitatea actului medical precum si existenta acreditarilor internationale ‡ Experienta in domeniu reprezinta un punct forte * ‡ Actual in clinica se pot efectua un numar de aproximativ 60 de tipuri de fise maritime, cu particularitati de examinare, de investigatii si analize de laborator ‡ Actual clinica detine aproximativ 60% din piata firmelor de crewing din Romania, cu extindere continua ‡ Cerintele armatorilor sunt in perpetuua schimbare la care trebuie sa ne raliem rapid pentru a mentine standardele * Avantajele noastre: ‡ Experienta in domeniu de peste 10 ani ‡ Locatie acceptata ± situata ultracentral si avand toate dotarile necesare in aceeasi locatie (cabinete, ecografie, radiologie, analize) ‡ Ne-am impus pe piata maritima prin calitatea examinarilor si prin reducerea masiva a cazurilor de repatriere medicala pentru firmele de crewing cu care colaboram ‡ Dotarile clinicii conforme cu cerintele/standardele internationale in domeniu * Dezavantaje: ‡ Existenta clincilor concurente care folosesc politica unui pret de dumping ‡ Datorita specificitatii acestui tip de serviciu± fisele maritime trebuie lucrate in sistem de urgenta ± eliberare in aceeasi zi, maxim a doua zi dimineata ‡ Prin complexitatea fiselor ± navigatorul trebuie sa intre in diferite cabinete si mareste timpul de stationare al acestuia in clinica , lucru care genereaza feed back negativ in conditiile circuitelor comune ± FFS, med muncii, maritima, card.