Legal aspects
Some advice …
All ships, regardless of their flag state, have to
respect the international regulations concerning
medical equipment on board.
• In case of medical emergency always call a
telemedical assistance service (TMAS) for
further instructions!
International Maritime Dangerous Goods Code
• Try to get information about the national regulations
on controlled substances in your ports of call.
Usually the best contact for this information would
be the local port health authority.
The IMDG-Code is valid for all ships carrying
dangerous cargo. Concerning the necessity of
medical equipment the IMDG-Code refers to the
Medical First Aid Guide (MFAG). In MFAG
Appendix 14 you will find a list of all the obligatory
drugs, like morphine (see table below).
Area
Medicine
Morphine sulphate, injection fluid,
Min. quantity
A
B
C
40
10
5
10 mg/ml in 1ml ampoules
Areas: A = next port > 24 hours, B = 2 - 24 hours, C < 2 hours
National regulations of the flag state
Every flag state should have a national regulation
how a ship’s pharmacy of merchant vessels has to
be equipped. For instance in its directive 92/29 the
European Union determines the groups of
medicines that European ships must have.
Regulation for German merchant vessels:
Area
Medicine
Morphin-HCl, Injection fluid, 10 mg
A
B
C
10
0
0
A German ship that transports dangerous cargo
has to respect the IMDG-Code & MFAG too!
International recommendations by the
World Health Organisation (WHO)
If your flag state doesn’t have a national law, the
rd
recommendations by WHO are obligatory. The 3
edition of the International Medical Guide for
Ships (IMGS) strictly recommends carrying
morphine on board.
Be aware that the port health authorities will
check your medical facilities including
controlled substances and documentation.
Any inconsistencies may cause severe
consequences.
• In case of any problems we do appreciate
receiving a report about these problems via e-mail.
If the local port health authority needs information
on German regulations, don’t hesitate to contact
us.
Morphine on Board?
Why strong pain killers are
mandatory on board seagoing merchant vessels
• If there are any expired controlled substances you
are allowed to destroy them if this is verified by two
witnesses. But the better way is to wait and destroy
the old drugs together with the authorities or
pharmacy staff. Anyway, you have to document this
procedure in the narcotic registry book.
• To be prepared for inspection of controlled
substances in Germany you should have checked
the following positions:
Narcotic registry book is up to date
Narcotics list is prepared
All controlled substances are stored in a safe or
on the narcotic shelf in the medical chest
Quantity of ampoules is the same as in the
registry book and narcotics list
• Ask a ship supplying pharmacy if you need to order
morphine for your ship´s medical chest in a
German port. The German port health authority will
issue a narcotic prescription.
Zentralinstitut für Arbeitsmedizin und Maritime Medizin (ZfAM)
Hamburg Port Health Center
Seewartenstraße 10, Haus 1
20459 Hamburg
GERMANY
Tel: +49 (40) 428 894-458
Fax: +49 (40) 428 894-511
E-Mail: [email protected]
Erstellt von Dipl.-Ing. Ch. Sevenich (HPHC) / Stand: 1.8.2008 / Es besteht kein Anspruch auf Vollständigkeit
oder Rechtsverbindlichkeit. Bildquelle: Rettungshubschrauber, Mohnpflanze, Herzinfarktpatient: Christoph
Sevenich; Verbrennung und offene Fraktur: Berufsgenossenschaftliches Unfallkrankenhaus Hamburg
Hamburg Port Health Center
What is morphine?
A few examples …
Morphine is one of the pain
relieving ingredients of poppy
plant extracts. For several
hundred years this substance is
well known for its ability to fight
strong pain.
Used correctly, it is a safe, approved and frequently
used drug. Since decades morphine is the medical
standard for treating accidents and illnesses like
broken bones, severe skin burns and heart attacks all
over the world.
Case 1
We have seen many times that tramadol has been
offered by pharmacies to the ships instead of
morphine. The suppliers justify this with the rationale
that tramadol is not classified as a controlled
substance in some countries and that its handling is
more user-friendly. But the problem is: The pain
reliever tramadol is not comparable with morphine. It
is useful against pain of average intensity, but will not
show the same effect with strong pain. And last but not
least, tramadol will not be accepted as a substitute for
morphine by the governmental authorities.
Don’t accept a delivery of tramadol as a substitute
for morphine!
Frequently asked questions
1. Does morphine lead to addiction?
No! If morphine is used as a treatment against heavy
pain for a few days, you don´t need to be afraid of
addictive effects.
2. Is the use of morphine difficult?
No! You need to have a morphine solution suitable for
injection on board. This solution can easily be
injected intravenously or intramuscular on advice by
physicians of a telemedical assistance center.
3. Morphine is very expensive, isn’t it?
No! If you compare the prices of tramadol with the
prices of morphine you will find no big difference.
4. Is it difficult to order morphine?
No! In German ports, the port health doctor will issue a
prescription that allows you to order the morphine at
the ship´ s supplying pharmacy.
Heart attack
A crew member started to
complain about heavy chest
pain. No telemedical assistance was requested. He was
repatriated 16 days later and
had been taken to a hospital
A myocardial infarction was
diagnosed at the hospital. The patient received
neither a medication against heart attacks nor a pain
killer. Morphine would have been the best choice to
fight against his pain. Especially in acute heart
attacks morphine shows positive side effects, like
relieving anxiety.
Case 2
Severe skin burn
A ship’s cook had an
accident with boiling oil
flowing over his body. The
skin burns caused very
strong pain. After a couple of
hours he was disembarked
with a rescue helicopter.
He received antibiotics and was given paracetamol
tablets and tramadol drops against the strong pain.
Remember: With these drugs, a treatment of injuries
like these is very often not efficient enough.
Case 3
Results of our morphine study
In 2007 the Hamburg Port Health Center performed a
survey as regards how well sea-going merchant
vessels are equipped with controlled substances.
Hamburg port health inspectors interviewed officers of
307 ships in international trade concerning their
medical equipment. Therefore the international
standards and requirements (e.g. IMDG-Code) were
compared with the actual stock of drugs.
The majority (88%) of all 307 ships from 38 different
nations were operating worldwide, 58% of the ships
were carrying dangerous cargo. Just to remember: A
ship that is carrying dangerous cargo has to store
morphine according to the International Maritime
Dangerous Goods Code (IMDG).
Only 85 ships (28%) had a sufficient quantity of
morphine on board. 73 (24%) ships just carried
tramadol instead of morphine, and on board 46 ships
(15%) no strong pain killer was available at all.
Open fracture
A crew member suffered
from a painful open leg
fracture after falling down a
stairway. He was repatriated
7 days later. In the meantime
he
received
a
local
anaesthetic that is only
effective for a few minutes, antibiotics and tramadol
drops. Again: Tramadol is not the right choice for
severe injuries like this one.
In all these cases morphine is the first choice as a
pain killer. But it was not used. Why? Maybe because
the crew had not been informed how to handle this
effective pain killer or just because it was not
available on board?
A brief look at the difference between “dangerous
cargo ships” and “normal” ships shows that the
situation on dangerous cargo ships is considerably
better. But only 28% of these vessels are also
equipped according to the international standard.
72% of all inspected ships were
insufficiently equipped!
The main reason that was given to our inspectors was
the fear of being punished by different governmental
authorities. We can’t deny that
countries have
different approaches But if you have accurately
prepared all documents (e.g. narcotics list), and if you
store all controlled substances in your safe, the risk of
getting into trouble will be reduced.