Fit for Service?

The seaman is employed as a deckhand on a coastal service. He has been employed for many years on the same run.

For very many years he has been an insulin dependent diabetic. He recently collapsed face down with a “hypo” sustaining a wound which required several stitches and he also reported later that his nose was streaming clear fluid.

He was referred to a local hospital, where a compound skull fracture was confirmed and was kept under close observation until the leak ceased.

I am concerned that he may not be fit for work as a seaman.

CHIRP referred this report to the Chief Medical Adviser to the Maritime and Coastguard Agency, who provided the following comments:

“The purpose of medical fitness standards is to reduce the risks to the vessel, other crew members and the individual from ill health or injury while at sea.  In this case only the person with the condition was injured and this was a consequence of the insulin treatment used to control his diabetes rather than the illness itself.  If he had been alone on bridge duties such a collapse or even the more common impairment of cognition associated with a ‘hypo’ could have endangered the vessel and all its crew.

The statutory medical standards for merchant seafarers and commercial yachtsmen (there are currently none for fishermen or leisure sailors) should have prevented such an incident. Insulin treated diabetes renders a person unfit for distant waters or for watchkeeping, although there is some discretion for non-watchkeeping coastal work; if the examining doctor considers that the condition is well controlled and the risk of a hypo is low. (MSN 1765 section 3.3).

In this case the seafarer may have failed to declare the condition at a medical, the medical may have been unduly lax or the doctor may have made a rational judgement based on the clinical history and the man’s duties. Alternatively the treatment may have been changed or a meal missed – thus throwing the balance between insulin and glucose out of balance.

After such an incident the situation is complex. A return to seafaring, unless duties are very restricted, is unlikely to be acceptable. Also the effects of the skull fracture and any subsequent risks from it would need assessment.

The statutory medical standards used in the UK and elsewhere are based on current evidence and a cautious approach to the risk of impairment. It is, however, all too easy to reject seafarers on health grounds without any valid evidence of excess risk and so a balance must be struck both in the formal standards and in the way they are applied, so that risk is minimised but employment opportunities and skills are not discarded without good cause.

A positive approach by maritime employers to health promotion, as well as ready access to medical advice, can also contribute to reducing the risks from health related impairments of all sorts.”