 |
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 Many diseases are more easily prevented
than cured. The prevention of disease plays a very
important part in the practice of medicine, and in no
place is it more important than on board ship.Conditions at sea may not be as conducive to health as those ashore. Opportunities for recreation, exercise, and a hygienic lifestyle are necessarily restricted; living quarters may be less commodious, and there are fewer opportunities of obtaining fresh food. For long periods of time, seafarers are separated from their families; they spend months in the restricted area of their ship, with a small number of fellow crew-members around them. Such conditions create boredom and stress, which may contribute to some of the ailments and, diseases that occur among seafarers . Ships' masters should therefore pay particular attention to the health and welfare of their crews, ensuring that appropriate preventive measures are taken. |
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Prevention of
communicable diseases |
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| Measures for the prevention or control of communicable diseases are intended to break the chain of infection at its weakest link. In general, control measures attempt to prevent exposure to infection. These measures are strengthened by increasing the resistance of the susceptible host. This can be achieved by active or passive immunization or by the prophylactic use of drugs. | |||
 Isolation |
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The isolation of an ill patient will prevent the
spread of disease to other persons on board. It is
convenient categorize isolation into two types : strict standard |
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| Strict
isolation |
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| The patient is confined to the ship's hospital or to
a cabin that is set aside for his sole use in a quiet
part of the ship and has been stripped of all unnecessary
furnishings and carpets to facilitate cleaning and
disinfection. The patient must be seen only by the person who nurses him and this person should be instructed to carry out the appropriate nursing procedures. If disposable eating and drinking utensils are available, these should be used and later destroyed. Should ship's dishes and cutlery have to be used, they should be washed and sterilized (by boiling for 20 minutes) after use and kept in the cabin or hospital. They should never be washed up with utensils used by other members of the crew. All used bed-linen and towels should be boiled or disinfected. Feces and urine should be passed into bedpans or urine bottles and, at sea, disposed of in a flushing water-closet set aside for the purpose. The attendants should wear disposable gloves when handling these items, and care should be taken not to splash the contents about. The pans and bottles should be boiled after use. In port, feces and urine should not be flushed away but should be disinfected and disposed of after consultation with the port health authority. It is important to dispose of any used syringes and needles in the correct way. Place the needle-container back on the needle while it is still attached to the syringe. Enclose the syringe and needle in a plastic bag and seal the neck. Place this in another plastic bag and seal the neck. At sea, it can then be weighted and thrown overboard. In coastal or shallow waters, the bags should be kept in the isolation room until arrival in port when they should be handed to the port health authority for disposal. The attendant's gloves should be disposed of in the same way. Note. The attendant should wash his hands each time the gloves are removed. |
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| Standard
isolation |
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| The patient is isolated in the ship's hospital or in a cabin set aside for his use. There is no need to observe the stringent rules for strict isolation. While the patient is ill, visitors should be discouraged. When he shows signs of recovery, this ban can be lifted but visitors should be instructed to stay only for short periods. While he is convalescing, visiting should be encouraged to relieve boredom. | |||
| Immunization |
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| Every seagoing person, if only for self-protection
and convenience, should be immunized against diphtheria,
tetanus, and poliomyelitis. Booster immunizations for
diphtheria and tetanus at 5-year intervals
should be kept up to date. Protection against tetanus
(lockjaw) by the injection of a toxoid vaccine is
universally recommended as part of good preventive
medical practice. Tetanus is common on land throughout
the world. At sea, exposure to tetanus is especially high
on ships carrying cattle, horses, hides, or similar
cargoes. The need for seafarers to be immunized against yellow fever, cholera, and typhoid fever depends on the route and destination of the vessel. The medical services of the shipping company or the health authorities of the home port can provide the necessary advice on the subject. Yellow fever vaccination at 10-year intervals is required for disembarkation in many tropical American and African countries. Cholera vaccination may required at 6-month intervals for travel to certain parts of the world. |
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| Environmental
sanitation |
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| Environmental sanitation, which is very important in the control of communicable diseases, is intended to prevent the spread of pathogens by eliminating both sources and modes of transmission. Examples include: the sanitary treatment, handling, distribution, and dispensing of water, milk, and food; the treatment and disposal of sewage to avoid contamination of water and food supplies; and the control of vectors of disease. | |||
| Port health
clearance |
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| Measures for the prevention and control of the spread
of epidemic diseases by international transport are
governed by the International Health Regulations, which
have been agreed to by practically all the maritime
countries of the world. The Regulations are applied in
most countries by port health officers. In any of the circumstances indicated below, it is advisable to seek advice and to give information by radio, preferably within 4-12 hours of the estimated time of arrival at the port. The
occurrence on board during the voyage of death other than by accident;
illnesses where the person concerned had a temperature of
38°C or greater, accompanied by a rash, glandular
swelling, or jaundice, or persisting for more than 48
hours; diarrhoea severe enough to interfere with work or
normal activities. The
presence on board of a person suffering from an
infectious disease or who has had symptoms that may
indicate the presence of infectious disease. The
occurrence on board, during the voyage, of abnormal
mortality among rats, suggesting the possibility of an
outbreak of plague among them. |
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Prevention of other
diseases |
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| Balanced diet |
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| A balanced diet, containing the correct proportions
of protein, carbohydrate, fats, vitamins, and essential
minerals such as iron, is vital to the maintenance of
good health. Protein is derived from foods such as meat, fish, and beans; carbohydrates from cereals and bread; and vitamins and essential minerals from all of these and from fruit and vegetables. In the seafarer's diet, a correct balance of different foodstuffs should be sought. Fresh vegetables and fruit should always be provided in the necessary quantities. It is also important that the ship's cook should prepare meals that are suitable for the crew, bearing in mind that food requirements in cold, mild, and tropical climates vary. Nowadays, there is practically no risk of deficiency diseases occurring among crews of ships. However, overeating may present a health risk for individual seafarers, particularly those whose duty on board ship does not involve much physical exercise. The resultant obesity could be the first step to various diseases. Also, moderation in alcohol consumption and smoking will help maintain seafarers in good condition and reduce the risk of disease among them. See also:  'Effects of
Alcohol Abuse' |
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| Personal
hygiene |
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| Hygienic living protects the health of the
individual. The health of a seaman depends in part on his
own efforts to maintain standards of cleanliness and
neatness. Personal cleanliness includes good care of the skin, hair, nails, mouth, and teeth, and proper maintenance of clothing, towels, and other personal gear. A daily bath or shower, particularly in hot weather or after working in hot compartments, is conducive to good health and lessens the possibility of cuts or scratches becoming infected. Brisk rubbing with a rough towel after a bath or shower stimulates circulation, promotes good skin tone, and gives a feeling of well-being. Clean clothing should be put on following a bath or shower. Care of the mouth and teeth by regular use of a toothbrush after meals is an essential factor in the prevention of gum disease, infection, and tooth decay. Before brushing natural teeth, any partial dentures should be removed and carefully cleaned with a brush and mild soap or special denture cleanser. Unclean removable dentures are particularly harmful to the remaining natural teeth. Full artificial dentures should be cleaned regularly after meals, and particularly at bedtime, to remove food residues which can cause mouth odour and encourage infection. The importance of washing hands at appropriate times cannot be overemphasized. Crew-members should wash their hands before eating. It is also of vital importance, if cleanliness is to be maintained and the spread of infection reduced, that hands should be washed immediately after urinating or defecating. Adequate sleep is necessary for health, well-being, and efficiency. Sleep requirements may vary considerably, and the sleeping habits of crew-members may be quite dissimilar. However, unbroken periods of rest for everyone are desirable. Hair should be shampooed frequently, cut at regular intervals, and preferably kept short. Cleanliness aboard ship can be encouraged by providing sufficient hot water in convenient wash-places. A laundry and drying-room for washing clothes also help to maintain a high standard of cleanliness. Each member of the crew should use only his own towels and be responsible for their cleanliness. Wet towels should not be folded and stowed away, dirty towels should be laundered as soon as possible and not allowed to accumulate. |
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| Preventing heat
illness |
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| In very hot conditions, the minimum of clothing
should be worn to allow the largest possible surface for
free evaporation of sweat. If there is much direct heat
from the sun (radiant heat), light white cotton clothing
will reflect the heat and keep the body temperature,
below danger limits. Fair-skinned people should remember
that they burn more easily and should take precautions.
Also, they should be warned that very long exposure
(i.e., over a period of years) to sun, and therefore to
ultraviolet radiation, increases the risk of skin cancer. Perspiration is the body's best heat control mechanism, but the sweat consists mainly of salt and water which must be replaced. The salt is best taken with food and supplemented by salt-containing drinks to prevent heat cramps. A person requires at least 4 litres of fluid per day in conditions of moderate heat. For work in high temperatures, the requirement may rise to 6-7 litres. When the ambient temperature is above 32°C in very humid climates, or above 43°C in dry a air there will be a risk of heat illness, especially when work has to be carried out. This applies particularly to work in Engine Rooms and other enclosed spaces. Air temperature, movement of air, humidity and radiant heat all combine to cause heat exhaustion, heat cramps, or heat stroke. Extreme caution should therefore be exercised in allowing work in conditions of excessive heat. In emergency situations where the work has got to be done, short spells of work (say 10 minutes) may be permitted, but people must be allowed to cool off completely before being allowed back into the hot environment. |
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| Exposure |
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| Sunburn, frostbite, heat illness, and hypothermia may occur in the course of routine duty and must be guarded against. Sunburn, although often only a minor discomfort, can be dangerous. A person drowsy after drinking alcohol who decides to sleep in the sun may very well wake up suffering from serious burns. Special care should also be taken against frostbite and hypothermia (lowering of the body temperature). Hypothermia will most frequently be present in persons who have fallen overboard. Normal body temperature cannot be maintained in water at temperatures below 20°C. Removal of clothing and swimming movements accelerate heat loss. | |||
| Lifting heavy
weights |
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| Backache, sciatica, lumbago, and slipped disc are frequently caused by attempting to lift heavy weights or by lifting weights incorrectly. If the legs are not bent and the object is lifted by straightening a bent back, there will always be a risk of damage to the spinal column. The leg and thigh muscles are the most powerful in the body and they should be used when lifting, the torso and head being kept straight to avoid bending stresses. Everyone should be properly instructed in the correct technique for lifting and carrying, and should not be allowed to attempt to lift excessively heavy objects. | |||
| Exercise and
boredom |
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| Very few seamen aboard ship exercise hard enough to
cause them to become breathless or to increase the rate
of their heart-beat. Unused muscles and organs tend to
atrophy. On long, tedious voyages, people are also likely
to suffer from boredom and lack of interest, which can
also be detrimental to health. Drug abuse, various ailments, and neuroses frequently stem from boredom and lack of absorbing leisure-time activities on board ship. The ship's master should therefore initiate and encourage various recreational and learning activities to occupy his crew during off-duty hours at sea. A good ship's library, arts and crafts, language lessons, games, contests, hobbies, discussions, etc. can contribute towards creating a more lively and involving climate aboard ship. |
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Mental illness |
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| Many people feel low-spirited or irritable when
physically ill, but this feeling gradually disappears as
their physical condition improves. What we may term true
mental illness occurs on its own. There is a change in
behaviour, which may be just slightly unusual, or bizarre
and completely abnormal. It is important to realize that
the person who is mentally ill may or may not know that
he is acting in an abnormal way. The common symptoms of mental disease are an abnormal suspiciousness and irritability. It can be very hard to decide at times whether the person concerned is just a complainer or a loner, or whether he is mentally ill. The distinction is easy if he speaks about hearing voices when nobody is around or seeing people who are long dead. It is not so easy, however, if he speaks about things that could be true, such as not getting overtime because his supervisor doesn't like him, or being discriminated against because he belongs, to a religious minority. At times, the person may become unusually quiet and withdrawn for no known reason. He may move very slowly or awkwardly, seem dazed or preoccupied, and be unable to carry out instructions or reply to questions. If he speaks, what he says may not have much to do with what is going on around him. He may even sit or lie entirely motionless for long periods, although not really stuporous or in a coma. He may show no interest in food. To diagnose mental illness in detail is a highly skilled job, and all that needs to be done at sea is to recognize the condition, handle the situation correctly, and deliver the patient into skilled hands at the earliest opportunity. This may not be an easy task with someone who may be irrational, suicidal, or even violent. A great deal of time and effort may be needed. |
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| How to handle
someone who is mentally ill |
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| Approach the person in a quiet, calm and friendly
manner, remembering to accept him as he is, for what he
is experiencing is very real to him. Try to establish a
sympathetic relationship by talking to him about his
feelings and problems. Give the impression you want to
understand him. Do not contradict or argue, however
irrational his remarks, as this might provoke more
withdrawal or even aggression. Offer comfort and help
where you think it is needed. Try to inquire at some
point about previous episodes of a similar nature. Above
all keep the tone of the interview calm, friendly, and
sympathetic. Three types of mental illness may be seen at sea: anxiety, depression, and obvious madness. |
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| Anxiety |
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| A worried and anxious person is usually aware of his
state of mind, but is unable to cope with the situation
that is provoking the anxiety. Physically, he may not be
able to sleep or may have gone off his food. By
encouraging him to share his problems, you could help a
great deal. Listen sympathetically to what he has to say.
Your own common sense and independent opinion might give
him another perspective on the matter. Remember also that an anxious person might show depressive tendencies and that it is important to look out for this development (see below). |
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| Treatment |
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| For anxiety without depression, the drug of choice is
diazepam. Begin by giving a 5-mg diazepam tablet three
limes a day. If, after 24 hours of treatment, the anxiety
is not calmed, give 10 mg of diazepam three times a day.
The dose of diazepam can be adjusted upwards or
downwards, when you can observe the effect of a
particular dose rate over a 24-hour period. A sedative should always be given at night to any anxious person, so that he has a good night's sleep. For people who are mildly anxious, not very restless, and who are of average size or below, give 5-mg of diazepam (tablet) about half an hour before bedtime. For people who are very anxious and restless and whose body size is large, give 10-mg of diazepam. After the first night, adjust the dose of this drug in line with the effect produced by the previous dose. If the person slept well or very well, give the same dose or a reduced dose. If the person did not sleep well on 5-mg of diazepam, give 10-mg the next night. For anxiety with depression, give the treatment indicated below for depression. |
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| Depression |
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| Two kinds of depression are usually described. The
first has an obvious cause, such as the death of a close friend or relative.
The second kind of depression occurs without apparent
cause. In both kinds of depression the symptoms are
similar, ranging from feeling miserable to being
suicidal. Every intermediate stage can be found. The
person may be emotionally up one day and down the next.
Sleep may be disturbed, the person waking in the early
hours of the morning and then staying awake. Morose and
even sullen in appearance, the person retires within
himself and speaks only when spoken to. It may be
difficult to get a clear story from him, because he is
deep in misery and simply wants to be left alone. When he
is alone, he may sit and cry, so inquire sympathetically
about this, because it helps to indicate the level of
depression. A severe depression sometimes progresses into a stupor, which may be a symptom of other diseases. The patient may lie awake in bed, but do nothing of his own accord. He may respond very slowly to orders. Mentally dull, he may not know where he is or what day it is. His face will resemble a mask, and he will be able to think of little besides death and dying. RADIO MEDICAL ADVICE should be obtained without delay when the patient is stuporous. Very depressed people may try to commit suicide. It is essential to recognize those at risk so that correct precautionary measures can be taken. By a natural progression of questioning about the patient's general feelings, it should be possible to establish whether suicide has been contemplated. |
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| Treatment |
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| The drugs used to treat depression are slow acting
and generally take 2 - 3 weeks to produce significant
benefit, so do not be discouraged if you observe little
immediate effect. Make sure that the patient takes the
drug by watching him swallow it on every occasion. Give
50-mg of amitriptyline about half an hour before bedtime
on the first day, and the same dose twice (morning and
evening) on the second and subsequent days. Amitriptyline
has sedative as well as antidepressant properties, so DO
NOT GIVE ANY OTHER SEDATIVE. Treatment should begin as soon as depression is diagnosed and should continue until the person is handed over to medical care. A common minor side-effect of amitriptyline is dryness of the mouth; this is not a reason to stop giving the drug. Alcohol adversely affects the treatment and should be prohibited. Get medical advice at the next port of call. |
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| How to deal
with a potential suicide |
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| Anyone who appears to be deeply depressed or who talks of suicide or threatens suicide should never be left alone. This is not an easy thing to accomplish in practice. The person should be confined to a cabin and kept there under supervision. The deck is a dangerous place and the ship's side may be a temptation to suicide. The person must be escorted, even to the toilet, the door being left ajar. All medicines and drugs must be removed, as well as all string, rope, and sharp, or potentially sharp, objects (razors, knives, mirrors, bottles, and so on), and the person should eat only with a spoon. Details of the nursing care needed by such people are given below (see 'Care of mentally disturbed patients'). | |||
| Obvious madness
(acute psychosis) |
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| Any person who is obviously mad will require a good deal of looking after. In such cases it is always wise to assume that the person's behaviour is so unpredictable that he may at any time become violent or suicidal, often without provocation or warning. Anyone who shows signs of severe mental illness should at once be sedated with chlorpromazine and kept under close observation. He should in the early stages be approached by two people. Failure to observe these precautions can result in injuries. Refer to the section 'Care of mentally disturbed patients' on nursing cases of severe mental illness for further guidance. | |||
| Treatment |
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| On the first day give chlorpromazine, 25-mg three
times a day by mouth. On the second and subsequent days,
give 50-mg three times a day; if this is not enough to
control symptoms, 100-mg three times- a day may be
required. If the patient is very excited and/or unwilling to take chlorpromazine by mouth, give the drug by intramuscular injection in doses of 50-mg twice or three times a day, as necessary to control symptoms. |
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Care of mentally
disturbed patients |
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| Certain guiding principles must be borne in mind when
dealing with any patient who, in the opinion of the
ship's master, is of unsound mind. Every such case should
be considered to be actually or potentially suicidal
or homicidal. All possible steps must therefore be
taken to have a constant watch kept on the patient. Should the master deem it necessary to place the patient under restraint, then the patient should, if possible, be housed in a single-berth cabin. Before the patient enters this accommodation, it must be carefully examined to ensure that it contains no object that the patient might use to injure himself or another, i.e., mirrors, stools or chairs, unperforated plastic bags, or electric bulbs unprotected by a strong shield. Knives and forks should not be allowed; a spoon only should be supplied. A soft plastic or paper mug and plate should be substituted for ordinary crockery. Razors and matches should be removed from the patient's possession. If water is laid on to the cabin, steps should be taken to control the flow from an outside point to prevent the risk of flooding. Great care must be taken to see that the patient has not concealed in his pockets any weapon such as a knife. It may not be easy to find this out when dealing with a truculent patient, but he must be persuaded to undress, which provides an opportunity to remove and search the clothes. Braces, belts, and cords should also be removed . The cabin door must always be firmly secured. If possible, this should be done without the knowledge of the patient. The state of a mentally disturbed patient is likely to worsen if he knows that he is locked in. Any port must be firmly screwed home and the port key removed. Care should also be taken to see that the patient cannot lock himself into the cabin. It will be an advantage if the cabin the patient is using has a port opening onto a deck or a ventilator in the door, so that the attendant can observe the patient's behaviour before entering the cabin. As a rule only the attendant should enter the cabin, but a second person should be standing by in case assistance is required. Patients should not be allowed out on deck while the ship is' at sea, unless accompanied by two people. Remember the ship's side is always very near, and if the patient does go over the side, the lives of others will be put at risk during the rescue attempt. Many of these patients may have delusions of persecution by their shipmates. Politeness, combined with firmness, must be exercised by the person responsible for nursing such a patient, in order to gain the patient's cooperation and trust. A severely excited (suicidal, violent, or homicidal) patient can be immobilized on a berth or a stretcher by tying him down with two folded bedsheets, one across the chest, and the other across the legs. This should only be done as a last resort. Usually, medication and friendly but firm persuasion are effective in subduing excitement, but the patient should always be kept under observation. Force should only be used as a last resort. If it becomes necessary, then action should be taken coolly, very firmly, and in such a way that it cannot be resisted. It is worth while remembering that a Neil-Robertson stretcher could act as a useful instrument of restraint when dealing with a mentally disturbed patient. |
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| Unconscious
patients |
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| The careful nursing of unconscious people is a
demanding, difficult, and very important task. Their
survival and eventual condition will depend greatly on
the care, skill, and attention given while they are
unconscious. Three MUSTS. An unconscious patient:  MUST have a
clear airway; MUST be kept
in the unconscious position; MUST NEVER
be left alone.The maintenance of a clear airway is essential and requires the patient to be kept in the unconscious position. An airway can be used. Any blood, vomit, or other secretions from the mouth must be mopped out or removed by the use of a sucker. An unconscious patient must never be left unwatched in case he moves, vomits, has a fit, or falls out of his bunk. |
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| Airway
insertion |
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| An airway should be inserted if a patient is
breathing on his own but is doing so with great
difficulty. The function of the airway is to ensure a
clear passage between the lips and the back of the
throat. Use appropriate sizes for adults and children. First remove any dentures and suck or swab out any blood or vomit that is in the mouth to get a clear airway. Then, with the patient's head fully back, slide the airway gently into the mouth with the outer curve of the airway towards the tongue. This operation will be facilitated if the airway is wetted. If you notice any attempt by the patient to gag, retch, or vomit, it is better not to proceed with the insertion of the airway. If necessary, try again later to insert it. Continue to slide the airway in until the flange of the airway reaches the lips. Now rotate the airway through 180° so that the outer curve is turned upwards towards the roof of the mouth. Bring the jaw upwards and push the airway in until the flange at the end of the airway is outside the teeth (or gums) and inside the lips. If necessary tape one or both lips so that the end of the airway is not covered by them. Check now that the casualty's breath is coming through the airway. Continue to keep the jaws upwards and the head fully back, and the airway will be held in place by the teeth or gums and by its shape. As the patient regains consciousness, he will spit out the airway. Make sure it is retained until is fully conscious. |
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| General
management |
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| Make sure that an unconscious patient cannot
injure himself further. Some unconscious and
semiconscious patients may be quite violent, or move
about suddenly, so ensure that they cannot fall onto the
floor or hit themselves against any hard edge or surface.
A cot with sides will probably be the safest place. Do
not put pillows or other padding where the patient might
put his face. The person must be turned from one side to the other at least every three hours to prevent bedsores. Turn the patient gently and roll him smoothly from one side to the other. The head must always be kept back with a chin-up position when actually turning, and at no time must the head be allowed to bend forwards with the chin sagging. This is both to help to keep a clear airway and to prevent neck injuries. If you suspect that the jaw is broken or that the person has fallen from a height and may have a neck or spine injury, you should be especially careful during turning. Check the breathing and make sure that the airway is securely in place as soon as you have turned the person. Make sure that all joints are neither fully straight nor fully bent. Ideally they should all be kept in mid-position. |
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