Maritime Health Seminar

1. Maritime Health Seminar DIGGING DEEPER When to refer for tests, or ask for specialist advice

2. Housekeeping • Fire alarms, exits, muster point • Mobile phones to silent/vibrate

3. Programme for Today Speakers topics relate to frequent requests for advice: • Renal stones • Immunosuppressant drugs • ADHD and autism • Obesity Two sessions of table discussions around these and other topics, as well as seafarers who have appealed, with time for discussion afterwards Updates – Online Medical Database, Audit reports

4. DIGGING DEEPER Why this theme? • There are many occasions where it is not possible to cover every eventuality in the statutory standards and guidance. • Very often the answer to your certification queries is simple – you need to look for further advice, or seek further tests, prior to issuing a certificate. • We will explore just a few examples today.

5. Aims of the day: To discuss areas where certification can be difficult, and improve understanding of some specific conditions. To update you on: • Fees! • ILO 188 and medicals for fishermen • Change to MSN 1839 and AD Manual revision as a result • Online Medical Database Learn from one another!

6. A few changes… • More focus on clinical topics • As last year, we will discuss the cases at the end of each session so that they are fresh in your mind • As several referees are not available there will not be a session for referee feedback • As ever we will welcome feedback on how to improve for next year!

7. Slido

8. Maritime Health Seminar DIGGING DEEPER When to refer for tests, or ask for specialist advice

9. Matt Bultitude

10. Maritime Health Seminar DIGGING DEEPER When to refer for tests, or ask for specialist advice

11. Louise Hancock

12. Maritime Health Seminar DIGGING DEEPER When to refer for tests, or ask for specialist advice

13. Julie Carlton

14. Maritime Health Seminar DIGGING DEEPER When to refer for tests, or ask for specialist advice

15. Case discussions 60 minutes for table discussions 30 minutes for open forum discussion Please introduce yourselves to each other before starting discussion

16. A. Nut allergy. 18, deck cadet, history of nut allergy since age 8, throat and lip swelling. History of asthma. He carries an Epipen What further information would be useful Never anaphylactic reaction, never admitted to hospital, never used Epipen. Skin prick testing allergic to cashew, pecan, walnut, almond and hazelnuts, but not to peanuts. Felt to include an element of Oral Allergy Syndrome (pollen food syndrome). Advised must continue to carry an epipen. Is this sufficient information for you to make a decision or would you wish to ask for more information from the specialist?

17. A. Nut allergy ctd The specialist clarifies. Oral Allergy Syndrome (OAS) is a cross reactivity with pollen, true nut allergy can co-exist in the same patient. He recommends undertaking the various component tests then arranging oral challenges to each nut type, according to the results. This has been done, and the challenges just illustrate typical OAS symptoms of lip swelling ie a low risk of anaphylaxis. Discuss how you would certify, given the results above.

18. A. Nut allergy ctd To consider a different case, with a history of true anaphylactic reactions requiring treatment with epinephrine, but going to work on board a cruise ship with a doctor on board, who would be capable of treating passengers with anaphylactic reactions, what would be your decision?

19. B. Ankylosing Spondylitis Humira 30 year old engineer, superyachts. Diagnosed with Ankylosing Spondylitis 4 years ago, at first treated with Methotrexate. Now on Humira. What further information would you need, and how would this affect your decision? No AS complications, nor side effects from medication. Bloods normal. His contracts only 2 months duration. Specialist feels likelihood of serious infection < 2% pa. With this information, how would you certify him?

20. C. CPAP, BMI Fisherman, first ENG 1, working in fishing for 15 years. BMI is 48.3, and he is using CPAP. What further information would you require? He brings a letter from employer confirming fit for role, just completed his sea survival course. CPAP printout confirms compliance and satisfactory response How might you be able to certify him, what restrictions/other considerations are necessary?

21. D. Kidney stones 63 year old Chief Engineer, recurrent kidney stones, long history. 1.3 cm right parenchymal stone remains, unchanged in size since 2011. He is otherwise stone free now, and metabolic studies are normal. What would your fitness decision be? Would further information alter this decision? How would you certify him if he did not have the parenchymal stone?

22. Maritime Health Seminar DIGGING DEEPER When to refer for tests, or ask for specialist advice

23. LUNCHTIME! Please be back for 14.00

24. Maritime Health Seminar DIGGING DEEPER When to refer for tests, or ask for specialist advice

25. Michael Craig

26. Maritime Health Seminar DIGGING DEEPER When to refer for tests, or ask for specialist advice

27. Jane Lloyd

28. Maritime Health Seminar DIGGING DEEPER When to refer for tests, or ask for specialist advice

29. Case discussions 14.50 – 16.00 40 minutes for table discussions 30 minutes for open forum discussion

30. E. Asthma, Fishing 43 year old fisherman, cook, and guts catch, fishing for 25 years. Severe childhood asthma, now stable, using salbutamol once or twice a month. He smokes, respiratory infections treated with antibiotics and steroids in 2015 and 2017. Not severe, continued working. • How would you assess his fitness to work with the above information if he were not a fisherman? • Would further information from the GP be valuable? • As he is a fisherman, could you apply the Grandfather rights once they come into force?

31. F. Type 1 DM Fishing 34 year old fisherman, fishing since age 18. Type 1 diabetes diagnosed 8 years ago. control good, aware of hypos, none in past year. He failed both Ishihara and Lantern tests, but has a seafish CoC. 1. How would you certify him if he were not a fisherman? 2. As he is a fisherman, could you apply the Grandfather rights? What further information would you need?  3. Can you issue a certificate applying grandfather rights, and if so, how would you restrict it?

32. G. Mental health issuesa. ADHD 19 year old, first ENG, to work on ferry. Past issues with anxiety, recently reduced Sertraline to 150mg. Mentions a previous diagnosis of ADD. He seems normal and relaxed, engages well, and has insight. What further information would you require? GP : diagnoses of ADHD, OCD, PTSD ,Tourettes. Not seeing specialist, symptoms much improved. No problems at school, and employed ashore with no problems. GP still has dose of Sertraline recorded as 200mg. Do you still have any concerns, and how would you wish to certify him?

33. G. Mental health issuesb. Autism 16 year old potential deck cadet attends with father. On autistic spectrum, at special school for past 5 years. High functioning. Social skills not good, difficulty meeting new people. He complies with instructions during the examination, calls the examination ‘funny tests’. His father says he has had a case worker since the age of two, but he denies this. He doesn’t understand why more information is needed, nor what work at sea may entail. He does not seem to have insight into his condition. What areas would you wish to explore prior to making a fitness decision, and how would this influence your advice to him?

34. H. Alcohol abuse, PTSD, anxiety 55, deck hand in N. sea. PTSD, referral to Combat Stress, anxiety and poor physical capability, previously restricted ENG 1. Shaking, tachycardic, smelling of alcohol. He is hypertensive takes Thiamine, B12 and folate. Drinks 5 beers 3 times a week, says he hasn’t had a drink for 10 weeks. What further information might you require?  Bilirubin, transaminases GGT and MCV elevated. Improved after stopped drinking. Gastroenterologist diagnosed alcoholic hepatitis  How would you certify him now?

35. Maritime Health Seminar DIGGING DEEPER When to refer for tests, or ask for specialist advice

36. Elaine

37. Maritime Health Seminar DIGGING DEEPER When to refer for tests, or ask for specialist advice

38. Audit of Approved Doctors 2018

39. 240 Approved Doctors (last year 231) 24 new approvals this year Plan to visit (or Skype/VOIP) all at some point depending on when last audited I am averaging 45 visits or video calls per year, so if I haven’t been to you yet, I hope to soon!

40. To meet you! • Review premises and records • Discuss decisions and difficult cases • Get your feedback and opinions • Primarily to ensure that the quality of our medical examination process remains high, and procedures/decisions consistent • Aim to be/remain the best in the world

41. AUDIT VISIT RESULTS

42. Areas for improvement Use pre exam information on crib sheet Template for missing ENG1 certificates Doctor to complete history on ENG 2 Ishihara Test – to be done in a random order, and ensure aware of instructions for test Vision testing – distance, illumination, mark line Full examination, undressing candidate Physical capability testing if BMI over 35: record! USE STATUTORY STANDARDS and CURRENT AD MANUAL.

43. FAKE!

46. Clinical points BMJ Open, Cardiovascular medicine, Research Quantifying the risk of heart disease following acute ischaemic stroke: a meta-analysis of over 50 000 participants One-third of patients with ischaemic stroke with no cardiac history have more than 50% coronary stenosis and 3% are at risk of developing MI within a year.

47. Clinical points Nut allergy. Cases are turning up where a previous AD has noted Nut allergy, with no other comment, giving an unrestricted certificate. Some carry epipens, and some have had anaphylactic reactions. When the next AD acts appropriately this can be devastating for the seafarer’s career.

48. Have we achieved our aims? To discuss areas where certification can be difficult, and improve understanding of some specific conditions. To update you on: • Fees! • ILO 188 and medicals for fishermen • Change to MSN 1839 and AD Manual revision as a result • Online Medical Database Learn from one another!

49. Thank you for your input, which is the most important part of the meeting! Please give feedback See you next year – if not before Safe journey home!