Medical care volume 1 1 15

Foreword Since its inception the International Maritime Organization has recognized the importance of human resources to the development of the maritime industry and has given the highest priority to assisting developing countries in enhancing their maritime training capabilities through the provision or improvement of maritime training facilities at national and regional levels IMO has also responded to the needs of developing countries for postgraduate training for senior personnel in administration, ports, shipping companies and maritime training institutes by establishing the World Maritime University in Malmo, Sweden, in 1983 Following the earlier adoption of the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers, 1978, a number of IMO Member Governments had suggested that IMO should develop model training courses to assist in the implementation of the Convention and in achieving a more rapid transfer of information and skills regarding new developments in maritime technology IMO training advisers and consultants also subsequently determined from their visits to training establishments in developing countries that the provision of model courses could help instructors improve the quality of their existing courses and enhance their effectiveness in meeting the requirements of the Convention and implementing the associated Conference and IMO Assembly resolutions In addition, it was appreciated that a comprehensive set of short model courses in various fields of maritime training would supplement the instruction provided by maritime academies and allow administrators and technical specialists already employed in maritime administrations, ports and shipping companies to improve their knowledge and skills in certain specialized fields IMO has therefore developed the current series of model courses in response to these generally identified needs and with the generous assistance of Norway These model courses may be used by any training institution and the Organization is prepared to assist developing countries in implementing any course when the requisite financing is available W A O'NEIL Secretary-General Introduction • Purpose of the model courses The purpose of the IMO model courses is to assist maritime training institutes and their teaching staff in organizing and introducing new training courses, or in enhancing, updating or supplementing existing training material where the quality and effectiveness of the training courses may thereby be improved It is not the intention of the model course programme to present instructors with a rigid "teaching package" which they are expected to "follow blindly" Nor is it the intention to substitute audiovisual or "programmed" material for the instructor's presence As in all training endeavours, the knowledge, skills and dedication of the instructor are the key components in the transfer of knowledge and skills to those being trained through IMO model course material Because educational systems and the cultural backgrounds of trainees in maritime subjects vary considerably from country to country, the model course material has been designed to identify the basic entry requirements and trainee target group for each course in universally applicable terms, and the skill necessary to meet the technical intent of IMO conventions and related recommendations • Use of the model course To use the model course the instructor should review the course plan and detailed syllabus, taking into account the information provided under the entry standards specified in the course framework The actual level of knowledge and skills and prior technical education of the trainees should be kept in mind during this review, and any areas within the detailed syllabus which may cause difficulties because of differences between the actual trainee entry level and that assumed by the course designer should be identified To compensate for such differences, the instructor is expected to delete from the course, or reduce the emphasis on, items dealing with knowledge or skills already attained by the trainees He should also identify any academic knowledge, skills or technical training which they may not have acquired By analysing the detailed syllabus and the academic knowledge required to allow training in the technical area to proceed, the instructor can design an appropriate pre-entry course or, alternatively, insert the elements of academic knowledge required to support the technical training elements concerned at appropriate points within the technical course Adjustment of the course objectives, scope and content may also be necessary if in your maritime industry the trainees completing the course are to undertake duties which differ from the course objectives specified in the model course Within the course plan the course designers have indicated their assessment of the time which should be allotted to each learning area However, it must be appreciated that these allocations are arbitrary and assume that the trainees have fully met all the entry requirements of the course The instructor should therefore review these assessments and may need to reallocate the time required to achieve each specific learning objective MEDICAL CARE • Lesson plans Having adjusted the course content to suit the trainee intake and any revision of the course objectives, the instructor should draw up lesson plans based on the detailed syllabus The detailed syllabus contains specific references to the textbooks or teaching material proposed to be used in the course An example of a lesson plan is shown in the instructor manual on page 31 Where no adjustment has been found necessary in the learning objectives of the detailed syllabus, the lesson plans may simply consist of the detailed syllabus with keywords or other reminders added to assist the instructor in making his presentation of the material • Presentation The presentation of concepts and methodologies must be repeated in various ways until the instructor is satisfied, by testing and evaluating the trainee's performance and achievements, that the trainee has attained each specific learning objective or training outcome The syllabus is laid out in learning objective format and each objective specifies a required performance or, what the trainee must be able to as the learning or training outcome Taken as a whole, these objectives aim to meet the knowledge, understanding and proficiency specified in the appropriate tables of the STCW Code • Implementation For the course to run smoothly and to be effective, considerable attention must be paid to the availability and use of: • • • • • • properly qualified instructors support staff rooms and other spaces equipment textbooks, technical papers other reference material Thorough preparation is the key to successful implementation of the course IMO has produced Guidance on the implementation of IMO model courses, which deals with this aspect in greater detail and is included as an attachment to this course • Training and the STCW 1995 Convention The standards of competence that have to be met by seafarers are defined in Part A of the STCW Code in the Standards of Training, Certification and Watch keeping for Seafarers Convention, as amended in 1995 This IMO model course has been revised and updated to cover the competences in STCW 1995 It sets out the education and training to achieve those standards set out in Chapter VI Table A-VI/4-2 Part A provides the framework for the course with its aims and objectives and notes on the suggested teaching facilities and equipment A list of useful teaching aids, IMO references and textbooks is also included INTRODUCTION A Part B provides an outline of lectures, demonstrations and exercises for the course suggested timetable is included but from the teaching and learning point of view, it is more important that the trainee achieves the minimum standard of competence defined in the STCW Code than that a strict timetable is followed Depending on their experience and ability, some students will naturally take longer to become proficient in some topics than in others Also included in this section are guidance notes and additional explanations A separate IMO model course addresses Assessment of Competence This course explains the use of various methods for demonstrating competence and criteria for evaluating competence as tabulated in the STCW Code Part C gives the Detailed Teaching Syllabus This is based on the theoretical and practical knowledge specified in the STCW Code It is written as a series of learning objectives, in other words what the trainee is expected to be able to as a result of the teaching and training Each of the objectives is expanded to define a required performance of knowledge, understanding and proficiency IMO references, textbook references and suggested teaching aids are included to assist the teacher in designing lessons The new training requirements for these competences are addressed in the appropriate parts of the detailed teaching syllabus The Convention defines the minimum standards to be maintained in Part A of the STCW Code Mandatory provisions concerning Training and Assessment are given in Section A-I/6 of the STCW Code These provisions cover: qualification of instructors; supervisors as assessors; in-service training; assessment of competence; and training and assessment within an institution The corresponding Part B of the STCW Code contains non-mandatory guidance on training and assessment As previously mentioned, a separate model course addresses Assessment of Competence and use of the criteria for evaluating competence tabulated in the STCW Code • Refresher Training The Document for Guidance recommends that seafarers who have completed the more advanced medical training and such other seafarers as may be required by a national administration should undergo refresher courses to maintain and update their knowledge at approximately five-year intervals Such refresher training should cover the principal elements of medical first aid, including lifesaving measures, and should also encompass relevant recent developments in medical care and diagnosis • Medical Care Required for Masters and Chief Mates In general the competence required of those who provide the medical care on board exceeds that required of the master and chief mate under Regulation 11/2 The competence required in Table 11/2is limited to organizing and managing the provision of medical care on board Masters and chief mates who themselves provide the medical care on board must therefore meet the higher standard in Table VI/4-2 MEDICAL CARE • Responsibilities of Administrations Administrations should ensure that training courses delivered by colleges and academies are such as to ensure officers completing training meet the standards of competence required by STCW Regulation VI/4 • Validation The information contained in this document has been validated by the Sub-Committee on Standards of Training and Watch keeping for use by technical advisors, consultants and experts for the training and certification of seafarers so that the minimum standards implemented may be as uniform as possible Validation in the context of this document means that the Sub-Committee has found no grounds to object to its content The Sub-Committee has not granted its approval to the documents, as it considers that this work must not be regarded as an official interpretation of the Convention In reaching a decision in this regard, the Sub-Committee was guided by the advice of a Validation Group comprised of representatives designated by ILO and IMO PART A: COURSE FRAMEWORK Part A: Course Framework Aims This model course aims to provide the training for candidates to provide medical care to the sick and injured while they remain on board ship, in accordance with Section A-V1/4 of the STCW Code Objective This syllabus covers the requirements of the 1995 STCW Convention Chapter VI, Section AV1/4, Table A-VI/4-2 On meeting the minimum standard of competence in medical care, a trainee will be competent to participate effectively in co-ordinated schemes for medical assistance on ships at sea and to provide the sick or injured with a satisfactory standard of medical care while they remain on board Entry standards The course is open to seafarers to be designated to be in charge of medical care on board ships Those entering the course should have successfully completed training in medical first aid on board ship, such as specified in the IMO Model Course 1.14 Medical First Aid The course is also open to seafarers who have previously completed this Medical Care training and wish to comply with the recommendation in the IMO/llO Document for Guidance, 1985 that a refresher course should be undertaken at intervals of approximately five years Course certificate On successful completion of the course and demonstration of competence, a document may be issued certifying that the holder has met the standard of competence specified in Table AV1/4-2 of STCW 1995 A certificate may be issued only by centres approved by the Administration Course intake limitations The maximum number of trainees attending each session will depend on the availability of instructors, equipment and facilities available for conducting the training It should not exceed six trainees per instructor Staff requirements The course must be under the control of a qualified medical doctor who is experienced in casualty work and assisted, as appropriate, by other qualified medical staff Training facilities and equipment Ordinary classroom facilities and an overhead projector are required for the lectures When making use of audiovisual material such as videos or slides, make sure the appropriate equipment is available Smaller rooms for practical instruction, demonstration and application should be available, and visits to casualty sections of a local hospital would be of benefit MEDICAL CARE: COMPENDIUM International Medical Guide for Ships Scarlet fever Incubation period Isolation period Specific treatment to days Until all throat and nasal symptoms have disappeared, 14 days in uncomplicated cases Scarlet fever is not often contracted by adults It has features similar to those of measles (page 139) and German measles (page 132) The onset is generally sudden and the temperature may rise rapidly to 40°C on the first day With the fever, the main early symptom is a sore throat, which in most cases is very severe The skin is hot and burning to the touch The rash appears on the second day and consists of tiny bright red spots so close together that the skin assumes a scarlet or boiled lobster-like colour It usually appears first on the neck, spreading very rapidly to the upper part of the chest and then to the rest of the body An area around the mouth may be clear of the rash The tongue is at first covered with white fur and, when this goes, it becomes a very bright red (strawberry colour) The high fever usually lasts about a week As the rash fades, the skin peels in circular patches The danger of scarlet fever arises from the complications associated with it, such as inflammation of the kidneys (test the urine for protein once a day, page 107), inflammation of the ear due to the spread of infection from the throat (page 192), rheumatism (page 222), and heart disease (page 203) These complications can be avoided by careful treatment of the disease General treatment The patient must stay in bed and be kept as quiet as possible He should be isolated, as the disease is very infectious-the infection coming from the inflamed throat and nose The patient can be given acetylsalicylic acid tablets to relieve the pain in the throat, which may also be helped if he takes plenty of cold drinks He can take such food as he wishes 144 Give the patient benzylpenicillin in (see the precautions page 308), followed antibiotic treatment 600000 units of procaine an intramuscular injection regarding giving penicillin, after 12 hours by standard (see page 308) Tetanus (lockjaw) Incubation period Isolation period 4-21 day~, usually 10 Until landed Tetanus is caused by the infection of a wound by the tetanus germ which secretes a powerful poison (toxin) The germ is very widespread in nature, and the source of the wound infection may not always be easy to trace Puncture wounds are particularly liable to be dangerous and overlooked as a point of entry In most countries inoculation against the disease usually begins in childhood, but it is necessary to have further periodic inoculations to maintain effective immunity Fortunately the disease is very rare on board ship The first signs of the disease may be spasms or stiffening of the jaw muscles and, sometimes, other muscles of the face, leading to difficulty in opening the mouth and swallowing The spasms tend to become more frequent and spread to the neck and back, causing the patient's body to become arched The patient remains fully conscious during the spasms, which are extremely painful and brought on by external stimuli such as touch, noise, or bright light The patient is progressively exhausted until heart and lung failure prove fatal Alternatively, the contractions may become less frequent and the patient recovers Treatment The patient should be isolated in a darkened room as far as possible from all disturbances If a case of tetanus should develop aboard ship, prompt evacuation to an appropriate medical faciUty is indicated The patient must have constant nursing care, and the utmost quiet is essential to prevent the exhausting painful spasms INTERNATIONAL MEDICAL GUIDE FOR Communicable There will be a need for treatment with sedative and muscle-relaxant drugs such as diazepam injection, mg RADIO MEDICAL ADVICE should be obtained for specific drugs and dosage, both aboard ship and during evacuation to a medical facility During a convulsion, the jaws should be separated with a pencil wrapped in gauze to keep the patient from biting his tongue A liberal fluid diet should be given, if tolerated; otherwise no attempt should be made to give fluids or food by mouth Prevention A person can be protected (immunized) against tetanus by injections of adsorbed tetanus toxoid Every seaman should obtain his primary immunizations and booster shots as required (see also Immunization, page 298, and General care of wounds, page 67) All seafarers employed on board a ship carrying horses, cattle, or hides must have their tetanus immunity status checked (whether they were fully immunized in childhood and when they received the last booster dose of the vaccine) If necessary, a booster dose of tetanus toxoid must be given to any crewmember not yet protected against the disease Tuberculosis (T8, consumption) This infectious disease is caused by the tubercle bacillus Although the lung (pulmonary) disease is the most common, TB bacteria may attack other tissues in the body: bones, joints, glands, or kidneys Unlike most contagious diseases, tuberculosis usually takes a considerable time to develop, often appearing only after repeated, close, and prolonged exposures to a patient with the active disease A healthy body is usually able to control the tubercle bacilli, unless the invasion is overwhelming or resistance is low because of chronic alcoholism, poor nutrition, or some other weakening condition st.s diseases nothing more than a persistetrt cough, slight loss of weight, night sweats, and a continual "all-in" or "tired-out" feeling that persists when there is no good reason for it More definitive signs pointing to tuberculosis are a cough that persists for more than a month, raising sputum with each cough, persistent or recurring pains in the chest, and afternoon rises in temperature When he reaches a convenient port, a seaman with one or more of these warning signs should see a physician Treatment Every effort should be made to prevent a man who has active tuberculosis from going to sea, since this would present a risk to the crew's health as well as his own The treatment of tuberculosis by medication will not usually be started at sea, since the disease does not constitute an emergency To prevent the spread of tuberculosis, every patient with a cough, irrespective of its cause, should hold disposable tissues over his mouth and nose when coughing or sneezing and place the used tissues in a paper bag, which should be disposed of by burning The medical attendant should follow good nursing isolation techniques (see Isolation, page 297) No special precautions are necessary for handling the patient's bedclothes, eating utensils, and personal clothing Tuberculosis control The pulmonary form of the disease is spread most often by coughing and sneezing A tuberculosis control programme has three objectives: (1) to keep individuals with the disease from signing on as crew-members; (2) to locate those who may have developed the disease while aboard ship and initiate treatment; and (3) to give preventive treatment to persons at high risk of developing the active disease The first objective can be achieved by periodic, thorough physical examinations including chest X-rays and bacteriological examination of sputum A person may have tuberculosis for a long time before it is detected Symptoms may consist of To identify those who might have developed active tuberculosis, a chest X-ray should be MEDICAL CARE: COMPENDIUM International Medical Guide for Ships taken and a medical evaluation including bacteriological examination of sputum requested when in port, if a crew-member develops symptoms of a chest cold that persist for more than two weeks Also, when any active disease is discovered, survey should be made of close associates of the patient and others in prolonged contact with him Such persons are regarded as contacts and are considered at risk for the disease; they should be given a tuberculin test and chest X-ray when next in port If they develop symptoms, full medical examination, including bacteriological examination of sputum, should be requested Yellow fever Incubation period Iso/ation period to days 12 days, only if the mosquito vectors (Aedes aegypti) are present in the port or on board This is a serious and often fatal disease caused by a virus that is transmitted to humans by a mosquito The disease is endemic in Africa from coast to coast between the south of the Sahara and Zimbabwe, and in parts of Central and South America Symptoms and signs The severity of the disease differs between patients In general, from to days after being bitten the patient fluctuates between being shivery and being too hot He may have a fever as high as 41°C, headache, backache, and severe nausea and tenderness in the pit of the stomach He may seem to get slightly better, but then, usually about the 4th day, he becomes very weak and produces vomit tinged with bile and blood (the so-called "black vomit") The stomach pains increase and the patient is constipated The faeces, if any, are coloured black by digested blood Bleeding may occur from gums and nostrils The eyes becomes yellow (jaundice) and the mind may wander After the 5th or 6th day the symptoms may subside and the temperature may fall The pulse can drop from about 120 per minute to 40 or 50 This period is critical, leading to recovery or death Increasing jaundice and extreme scantiness, or lack, of urine are unfavourable signs Protein in the urine occurs soon after the start of the illness, and the urine should be tested for it (page 107) General treatment The patient must go to bed and stay in a room free from mosquitos The patient must be encouraged to drink as much as possible; fruit juices are recommended If there is a case of suspected yellow fever on ADVICE board ship, RADIO MEDICAL should be obtained As soon as practicable, the ship's master should notify the local health authorities at the next port of call that there is a suspected case of yellow fever on board He should then take such measures for prevention of spread of the disease as the authorities direct Prevention Travellers to yellow fever areas should be inoculated against the disease Many countries require a valid International Certificate of Vaccination against Yellow Fever for those who are going to, or have been in or passed through, such areas See also the note on avoidance of mosquito bites in the section dealing with malaria (page 135), and the section on immunization (page 298) INTERNATIONAL CHAPTER Sexually transmitted diseases MEDICAL GUIDE FOR SHIPS (See also: Viral hepatitis B, page 134) The following diseases are, or can be, transmitted by sexual contact: gonorrhoea, chlamydial infections, chancroid, genital herpes, syphilis, chlamydial lymphogranuloma, granuloma inguinale, genital warts, pubic lice, scabies, viral hepatitis B (see page 134), acquired immunodeficiency syndrome, trichomoniasis, candidiasis, and bacterial vaginosis Sexually transmitted diseases in sailors are generally acquired through unprotected casual and promiscuous sexual contacts, often with prostitutes The most common symptoms of sexually trans· mitted diseases include discharge, redness and swelling of the genitalia, genital ulcers, lymph node enlargement, warts, and the presence of lice or mites on or in the skin In some sexually transmitted diseases a single organ is affected, while in others the infection spreads throughout the body Clinical and laboratory facilities are necessary for accurate diagnosis of sexually transmitted diseases Since such facilities are not likely to be available on board ship, the medical attendant can make only a presumptive diagnosis, based on rough clinical criteria If the ship is more than one day from port, the medical attendant should start antibiotic treatment immediately when a sailor is thought to be suffering from a sexually transmitted disease The subjective and objective symptoms, treatment, and response to treatment should be carefully recorded On arrival in port, the patient should be referred as soon as possible to a specialist who can perform the appropriate diagnostic tests and, if necessary, give additional treatment If possible, all sexual contacts of the patient should be traced and told to seek medical advice In case of any doubt concerning or treatment, RADIO MEDICAL should be obtained diagnosis ADVICE INTERNATIONAL MEDICAL GUIDE FOR SHIPS Sexually transmitted oedema and redness It is sometimes associated with pain (or a history of pain), urethral discharge, and a burning sensation on urination (see Urethritis and urethral discharge, page 148) The swelling of the scrotum is usually confined to one side Among ships' crews most cases of swollen scrotum are caused by inflammation of the epididymis, produced by sexually transmitted organisms Such a cause should be strongly suspected in patients with urethral discharge or a recent history of it The onset of epididymitis is often acute, but in some cases, it may develop over 24-48 hours There may initially be an "unusual sensation" in the scrotum, which is rapidly followed by pain and swelling The pain is of a dragging, aching nature This condition must be distinguished from testicular twisting (see p 232) In the latter case, the testis can become non-viable within 4-6 hours of onset of vascular obstruction This condition occurs most frequently in children and is very rarely observed in adults over the age of 25 The presence of a history of urethritis would exclude the diagnosis In cases of testicular twisting the testicle is often slightly retracted and elevation of the scrotum does not decrease the pain This condition needs urgent referral Other conditions that may lead to scrotal swelling include trauma (injury), incarcerated or strangulated and inguinal hernia, tumours, tuberculosis, mumps Balanitis and posthitis Balanitis is an inflammation of the glans of the penis, and posthitis is an inflammation of the prepuce The two conditions may occur simultaneously (balanoposthitis) Lack of good hygiene, in particular in uncircumcised males, is a predisposing factor, as is diabetes mellitus In balanitis and balanoposthitis, a mild to profuse superficial secretion may be present from This must be carefully distinguished urethral discharge Wearing disposable gloves, retract the prepuce in order to determine the origin of the secretion diseases Other signs include itching and irritation, causing considerable discomfort Sometimes, the penis is swollen and retraction of the prepuce may be painful Redness, erosion (superficial of the skin of the defects ), desquamation prepuce, and secretions of varying aspects and consistency can be observed Treatment The glans of the penis and the prepuce should be washed thoroughly with water three times daily After washing, the penis should be bathed in warm potassium permanganate solution (the solution should have a faint pink colour) Dry carefully and apply 2% miconazole nitrate cream If there is no improvement within one week, the patient should be referred to a specialist ashore Patients with recurrent balanitis or balanoposthitis should be tested for diabetes Genital ulcers Genital ulcers are a common reason for consultation, in particular in tropical countries If not treated appropriately serious complications may arise from some of these conditions Ulcers may be present in a variety of sexually transmitted diseases, including chancroid, genital herpes, syphilis, chlamydial lymphogranuloma, and granuloma inguinale The prevalence of these diseases varies according to geographical area In Africa and SouthEast Asia, for instance, chancroid is the most common cause of genital ulcers, whereas in Europe and the USA, herpes genitalis is most common Chlamydial lymphogranuloma and granuloma inguinale are much less common, and occur mainly in specific areas of the tropics Chlamydial lymphogranuloma is endemic in West Africa and South-East Asia, while granuloma inguinale is prevalent in east Africa, India, certain parts of Indonesia, Papua New Guinea, and Suriname Each of these diseases is described in more detail in the following pages Patients with one of these diseases usually complain of one or more sores on the genitals or the adjacent area If the ulcer is located on the glans INTERNATIONAL MEDICAL GUIDE FOR SHIPS Sexually transmilled Treatment Patients with suspected syphilis should be given 2.4 million units of benzathine benzylpenicillin in a single dose, administered intramuscularly If the patient is allergic to penicillin, give either 500 mg of tetracycline hydrochloride by mouth, times a day for 15 days or 500 mg of erythromycin by mouth, times a day for 15 days The patient should be referred to a specialist clinic at the next port of call Caution When treated with penicillin, about 50% of patients with primary or secondary syphilis will develop the so-called JarischHerxheimer reaction, which usually appears 6-12 hours after the injection This reaction is characterized by fever, chills, joint pain, increased swelling of the primary lesions, or increased prominence of the secondary rash It is caused by the sudden destruction of a great number of spirochaetes and should not give rise to alarm Analgesics may help to reduce the symptoms Chlamydial lymphogranuloma Chlamydiallymphogranuloma is a systemic disease of venereal origin The incubation time ranges from to 21 days The primary lesion is usually an ulcer, a vesicle, a papule or a pustule, not more than 5-6 mm in size and often located on the groove on the head of the penis in the male patient Commonly single, the lesion is painless, transient, and heals in a few days without scar formation In most cases, the patient does not even notice this primary ulcerative lesion After the lesion has healed, the commonest symptom in heterosexual men is acute swelling of the lymph nodes in the groin, often on one side only The swelling starts as a firm hard mass, which is not very painful, and usually involves several groups of lymph nodes Within 1-2 weeks, the glandular mass (bubo) becomes attached to the skin and subcutaneous tissue and painful fluctuation occurs, followed by formation of pus Not all buboes become fluctuant, some evolving into firm masses The inguinal ligament sometimes divides the matted glands into an upper and a lower part, which is the diseases characteristic "sign of the groove" Perforation of a bubo may occur, whereupon pus of varying aspect and consistency will be discharged Ultimately scarring will occur If not treated, chlamydial lymphogranuloma can produce severe anatomical changes in the urogenital and rectal regions Treatment Rest in bed is essential for patients with chlamydial lymphogranuloma, because continued activity will prolong the inflammatory process, discomfort, and period of recovery An ice-bag should be applied to the inguinal region for the first two or three days of treatment to help relieve local discomfort and tenderness Thereafter, local application of continuous heat from a hot-water bottle will get rid of the inflammation The patient should be given either 500 mg of tetracycline hydrochloride, times a day, for at least weeks, or 100 mg of doxycycline by mouth, twice daily for at least weeks or 500 mg of erythromycin by mouth, times daily, for at least weeks Fluctuating buboes require aspiration If the bubo persists, RADIO MEDICAL ADVICE should be sought Granuloma inguinale Granuloma inguinale is an infectious bacterial disease, with insidious onset The sites usually affected are the genitals, the groin, the upper legs next to the groin, and the perianal and oral regions The incubation period ranges from 17 to 50 days The earliest cutaneous lesion may be a papule or a nodule, which ulcerates, producing a single, enlarging, beef-like, velvety ulcer, or a coalescence of several ulcers The typical ulcer in this disease is a raised mass, looking more like a growth than an ulcer It has a smooth, elevated edge, sharply demarcated from the surrounding skin There is no lymph node swelling and the general health of the patient is good If not treated, the lesions may extend to adjacent areas of the body 153 MEDICAL CARE: COMPENDIUM International Medical Guide for Ships The diagnosis can usually be made on the basis of the typical clinical picture At specialized clinics microscopic examination of crushed tissue smears is used to confirm the diagnosis in the untreated patient Treatment The patient should be given either tablets of sulfamethoxazole/trimethoprim (400 mg/80 mg) twice a day, by mouth, for at least weeks, or tetracycline hydrochloride, 500 mg, times a day for at least weeks The patient should be referred to a specialist clinic at the next port of call Table Sexually transmitted diseases ing lymph node swelling Disease Characteristics of swelling Chancroid Painful, tender, sometimes suppurating Genital herpes Tender Primary syphilis Rubbery, regional Secondary Rubbery, hard, painless, generalized syphilis caus- hard, painless, Chlamydial lymphogranuloma Matted, sometimes painful, sometimes suppurating, often divided by inguinal ligament Acquired immunodeficiency syndrome In general painless, generalized Lymph node swelling Lymph node swelling is the enlargement of already existing lymph nodes It is unusual for lymph node swelling to be the sole manifestation of a sexually transmitted disease In most cases, inguinal lymph gland swelling is accompanied by genital ulcers, infection of the lower limbs, or, in a minority of cases, severe urethritis The swelling may be accompanied by pain and may be on one or both sides Pain and/or fluctuation can sometimes be evoked by palpation The lymph node swelling may be regional (for instance in the groin in the presence of genital ulcers, etc.) or may involve more than one region (for instance in the case of secondary syphilis or acquired immunodeficiency syndrome) The prepuce of patients suffering from lymph node swelling should always be retracted during examination in order to detect genital ulcers or scars of genital ulcers The sexually transmitted diseases that cause lymph node swelling, and the corresponding clinical characteristics of the swelling, are shown in Table Treatment The patient should be treated as described under Genital ulcers, page 149 If no improvement is noted within one week, RADIO MEDICAL ADVICE should be obtained 154 Vaginal discharge Sexually transmitted diseases in women often produce an increase in the amount, or a change in the colour or odour of, vaginal secretions Vaginal discharge is probably the most common gynaecological complaint It may be accompanied by itching, genital swelling, a burning sensation on urination, and lower abdominal or back pain Various infections can produce such symptoms Trichomoniasis is a very common disease, particularly in tropical areas It is characterized by a sometimes foul-smelling, yellow, or green foamy discharge Vaginal candidiasis is also a very common disease throughout the world It is characterized by a white, curd-like discharge, vulvar itching, and sometimes a red and swollen vulva and vagina Bacterial vaginosis is very common, particularly in promiscuous women In general, there is no itch The typical discharge is a grey, sometimes foamy, fishy-smelling paste Other infections, e.g., gonorrhoea, may produce a white or yellow, watery or purulent discharge Infection with herpesvirus usually produces painful lesions (redness, blisters, ulcers) on the vulva INTERNATIONAL MEDICAL GUIDE FOR SHIPS Sexually transmitted It should be remembered that more than one infection may be present at a time Treatment In a situation without gynaecological exam in ation facilities and in the absence of laboratory equipment the following practical approach should be followed First the patient should be treated for trichomoniasis and/or bacterial vaginosis (treatment A) If the condition does not improve, this treatment should be followed by an anti-gonococcal and anti-chlamydial treatment regimen (treatment B) If the symptoms still persist, an anti-candidiasis treatment (treatment C) should follow, or the patient should be referred to a specialist at the next port of call Treatment A Give 2.0 g of metronidazole, by mouth, in a single dose, followed by 500 mg of metronidazole by mouth, twice daily for the next days Caution Metronidazole should not be given to pregnant women Patients should abstain from alcohol during treatment Treatment Give one of the treatments described under Urethritis and urethral discharge, page 148 Treatment C Miconazole nitrate 2% vaginal cream should be inserted high up in the vagina, using an applicator, once daily (preferably just before the patient goes to bed) for I week Pelvic inflammatory disease Pelvic inflammatory disease is a general expression covering various pelvic infections in women, caused by microorganisms, which generally ascend from the lower genital tract (vagina, cervix) and invade the mucosal surface of the uterus, the fallopian tubes, and the peritoneum Pelvic inflammatory disease, caused by sexually transmitted pathogens, is a major cause of infer- diseases tility and chronic abdominal pain, and may resuIt in ectopic pregnancy A vigorous approach to treatment is therefore justified The symptoms abdominal pain with fever and discharge, page include mild to severe lower on one or both sides associated vaginal discharge (see Vaginal 154) The use of an intrauterine device often promotes the development of pelvic inflammatory disease It should be noted that it is difficult to diagnose pelvic inflammatory disease without appropriate gynaecological and laboratory investigations; moreover, it is difficult to differentiate this disease from other causes of acute abdominal pain, e.g., appendicitis (see Fig 122, p 161) Treatment In a case of suspected pelvic inflammatory disease, RADIO MEDICAL ADVICE should be obtained Drugs regimens of choice are either spectinomycin hydrochloride, 2.0 g, administered intramuscularly, or sulfamethoxazole/trimethoprim (400 mg/80 mg), 10 tablets daily in one dose, by mouth, for three days Either treatment should be followed by a course of doxycycline, one IOO-mg capsule or tablet twice daily for 10 days in combination with metronidazole, 1.0 g, by mouth, twice daily, for 10 days Caution Metronidazole should not be given to pregnant women Patients should abstain from alcohol during treatment Genital warts Genital warts are caused by a virus, and occur most frequently in young adults In male patients, warts may be present on the penis, around the anus, and in the rectum In females, the usual sites of infection are the vulva, the area surrounding the anus, and the vagina Warts are soft, flesh-coloured, broad-based or pedunculated lesions of variable size They may occur singly, or several may coalesce to form a large mass, often with a cauliflower-like appearance Small warts cause little discomfort, but large MEDICAL CARE: COMPENDIUM International Medical Guide for Ships genital or anal warts are embarassing and uncomfortable to the patient and are liable to ulcerate; secondary infection and bleeding may then occur Diagnosis is usually made on clinical grounds Treatment There is no appropriate treatment that can be given on board ship The patient should be referred to a specialized clinic at the next port of call Pubic lice Pubic lice are nearly always sexually transmitted The infection has become endemic in many countries, usually affecting young adults The main symptom is moderate to severe itching, leading to scratching, redness, irritation and inflammation The lice may be observed as small brown spots in the groin and around the genitals and anus (see Fig 121) The nits attached to the hairs may be seen with the aid of a magnifying glass Treatment Lindane cream, I %, should be applied to the affected areas (pubic area, groin, and perianal region) at 8-hour intervals over a period of 24 hours The patie.nt should take a shower immediately before each application At the end of the 24-hour period, the patient should again shower, and put on clean clothes Scabies Scabies, caused by a mite, is now recognized as a sexually transmitted disease in industrialized countries The most common symptom is itching, particularly at night The lesions are roughly symmetrical The usual sites of infection are the fingerwebs, sides of the fingers, wrists, elbows, axillary folds, around the female breasts, around the umbilicus, the penis, the scrotum, buttocks and the upper part of the back of the thighs With the naked eye, only papules, excoriations and crusts may be seen Using a magnifying glass, it is possible to detect the burrows of the mites Diagnosis is usually made on the basis of the clinical picture At specialized clinics microscopic examination of skin samples can be performed, to detect the female scabies mite and her eggs Treatment A thin applied left for patient change layer of lindane cream, I %, should be to the entire trunk and extremities and 8-12 hours At the end of this period, the should take a shower or a bath, and his clothes and bed linen Acquired immunodeficiency syndrome The acquired immunodeficiency syndrome (AIDS), recognized as a disease in 1981, has become a major public health concern throughout the world In western Europe and north America, the disease has been observed mainly in male homosexuals, while in central, eastern and southern Africa and in some countries in the Caribbean, it is seen primarily in heterosexuals Other groups at risk are recipients of blood or blood products, (e.g., people with haemophilia), intravenous drug abusers, and partners or offspring of infected persons This condition is caused by the human immunodeficiency virus (HIV), which has been found in various body fluids of infected persons Nearly INTERNATIONAL MEDICAL GUIDE FOR SHIPS Sexually transmitted all infections appear to result from contact with semen, vaginal and cervical secretions, blood, or blood products of a person infected with the virus There is no evidence that the virus is transmitted through casual contact with an infected individual, e.g., at the workplace The risk of infection to health workers is very low The virus specifically attacks certain white blood cells that playa central role in the body's immune defence The virus may remain in a state of latency in the white blood cells or may multiply without causing any symptoms in the infected individual Whether or not they develop clinical symptoms, infected individuals should be regarded as potentially infectious to others Following a latency period of between and 60 months, about 20-25% of infected individuals may develop a nonspecific condition known as AIDS-related cpmplex, which is characterized by vague symptoms such as fatigue, low-grade fever, night sweats, generalized enlargement of the lymph nodes, persistent diarrhoea, and a weight loss of more than 10% The lymph nodes are hard and not painful, and the enlargement often involves more than one site and is usually symmetrical Some 25-50% of infected patients may develop the full clinical picture of acquired immunodeficiency syndrome within 5-10 years after infection, either directly after the period of latency or after passing through the stage of AIDSrelated complex The clinical manifestations may be directly attributable to infection with the virus or a direct consequence of the breakdown of cellular immunity, which can lead to a variety of opportunistic infections, autoimmune and neurological disorders, and several types of malignancy In addition to severe weight loss or diarrhoea lasting for more than a month, patients may suffer from pneumonias caused by various organisms, skin ulcerations, meningitis and other severe infections, as well as malignant vascular tumours in the skin AIDS is fatal in the large majority of cases, because patients have so little ability to restore cellular immune functions after they have been destroyed by HIV diseases White patches of yeast infection on the mucosal surface of the mouth (thrush), usually extending into the pharynx, are a common sign of breakdown of the body's resistance to infection, and should raise suspicion of the presence of an AIDS virus infection in people with behaviour that places them at high risk These symptoms can also be associated with other infectious diseases, and an accurate diagnosis cannot be made without specialized clinical and laboratory assistance Treatment To date, there is no therapy that can restore the immune functions of a patient with AIDS Treatment of AIDS patients consists of specific therapy for the opportunistic diseases occurring in the individual case Patients suspected to be suffering from AIDS or AIDS-related complex should be referred to a specialist at the next port of call (see also Instructions for medical attendants, p 158, Instructions for patients, p 158, and Prevention of sexually transmitted disease, p.158 Proctitis Proctitis is an infection of the rectum, often caused by sexually transmitted pathogens In symptomatic infections, a discharge of pus from the anus, sometimes mixed with blood, can be observed Itching around the anus may be present In females, proctitis is usually due to a secondary infection with vaginal discharge containing gonococci (see Vaginal discharge, p 154, and Rectal infection, p 148) In male homosexuals, proctitis is caused by anal sexual contact with an infected person Treatment Patients should be treated according to the regimens outlined for urethritis and urethral discharge, page 148 If there is no response to treatment within one week, RADIO MEDICAL ADVICE should be obtained 1~7 MEDICAL CARE: COMPENDIUM International Medical Guide for Ships Treatment centres at ports Many ports have one or more specialist centres, where seafarers can obtain treatment for sexually transmitted diseases Where they exist, these centres should be used in preference to the services of a general practitioner, since they have ready access to the necessary laboratory facilities, and experience of dealing with a large number of cases of sexually transmitted disease The clinic staff will advise on any further treatment and tests that may be necessary A personal booklet is given to the seaman, in which is recorded the diagnosis (in code) and the treatment given, and which he should take with him if he visits a clinic in another port Instructions for medical aUendants The medical attendant should wear disposable gloves when examining any infected site in patients suspected of suffering from sexually transmitted disease If the attendant accidentally touches any genital ulcer or discharge, or any material contaminated with pus from ulcers or discharge, he should immedjately wash his hands thoroughly with soap and water If there is a sore on the penis or discharge from the urethra, a clean gauze dressing should be kept on the penis This dressing should be changed frequently In female patients suffering from genital ulcers or vaginal discharge, gauze or sanitary pads should be used Contaminated materials should be discarded in plastic bags, so that they will not be touched or handled by others Instructions for patients The patient should avoid all sexual contact until a medical specialist confirms that he is free from infection He should also make a special effort to practise good personal hygiene; for instance, he should use only his own toilet articles (toothbrush, razor, towels, washcloth etc.) and his own clothes and linen During the examination and treatment, the opportunity should be taken to inform the patient 158 about his condition, sexually transmitted diseases in general, and the precautions to be taken to minimize the risk of acquiring them (see below) Prevention of sexually transmiUed disease Being outside their normal environment and often in circumstances that allow for promiscuity, sailors are at special risk of contracting sexually transmitted diseases Avoidance of casual and promiscuous sexual contacts is the best way of minimizing the risk of infection Failing this, a mechanical barrier, such as a condom, can give both heterosexual and homosexual men and women a certain degree of protection against a number of sexually transmitted diseases A supply of condoms should be available on board ship The condom, or rubber, is a thin elastic covering that forms a protective sheath over the penis If properly used, it should prevent infection during intercourse, unless the point of contact with an infected lesion is beyond the area covered by the condom The condom comes rolled before use It must be placed over the penis before sexual contact The tip of the condom should be held to form a pocket to receive the ejaculate and the rest of the condom unrolled to cover the entire penis As soon as the male has had an orgasm, the penis should be withdrawn from the vagina before it softens, because loosening of the condom may expose the penis to infection The condom is removed by grasping the open end with the fingers and pulling it down quickly so that it comes off inside out The condom should be discarded without further handling in case it contains infectious material In women, the use of a diaphragm in combination with a spermicide cream offers some protection against the acquisition of some sexually transmitted diseases; however, condoms offer better protection In risk situations, the male partner should urinate at once after possible exposure Each partner should subsequently wash his or her genitals and other possible infected areas ... as part of model course 1. 15 The chapters and annexes of IMGS which directly relate to the syllabus of course 1. 15 are: Chapters 4,5,6,7,8 ,10 ,11 ,12 ,13 ,14 ,15 ,16 ,17 ,18 and 19 , and Annexes and Table... (Code No 2 71) V10 Dental First Aid for Non -Medical Personnel (Code No 19 9) V 11 Alcohol Beware! (Code No 348) V12 Drugs - Way Off Course (Code No 486) V13 Cold Water Casualty (Code No 527) V14 Man... York, Springer-Verlag, 19 84) (ISBN 0387 12 95 61) T3 Maritime and Coastguard Agency The Ship Captain''s Medical Guide 19 85 (London, The Stationery Office Ltd) (ISBN 11 5 516 58 1) Available from: The