A crew member has suspected appendicitis that has been deteriorating over 18 hours despite initial treatment. You are 450 miles from the nearest coastguard-assisted MEDEVAC capability in the North Atlantic. Describe the MEDEVAC decision framework and coordination process.

A. MEDEVAC DECISION AND COORDINATION — FRAMEWORK: MEDEVAC DECISION CRITERIA (discuss with TMAS): the IMGS provides clinical criteria for cases requiring evacuation. For suspected appendicitis: (a) Worsening right lower quadrant pain over 18 hours = deteriorating course; (b) Fever, guarding, rebound tenderness = likely peritonitis developing; (c) No surgical capability on board; (d) TMAS will assess and likely recommend evacuation. DISTANCE AND ASSET PLANNING: (1) 450 miles — outside UK coastguard helicopter range (typically 200-250nm); (2) Options: (a) Fixed-wing medical aircraft (lifelined to a vessel or parachute drop) — available via MRCC coordination; (b) Divert to nearest port with hospital capable of appendectomy — calculate ETAs; (c) Rendezvous with another vessel that may have better proximity to coast; (3) Contact: MRCC Falmouth (or nearest MRCC) — they coordinate both helicopter and fixed-wing assets; (4) COMPANY NOTIFICATION: DPA, P&I Club — P&I covers MEDEVAC costs and will appoint agents at the receiving port. INFORMATION REQUIRED BY MRCC: position, course, speed; weather/sea state; patient MIST report; vessel facilities (heli deck Y/N, hoist capable area); contact frequency. DOCUMENTATION: log all decisions, contacts, times, medical adviser advice, patient observations throughout.

B. At 450 miles, MEDEVAC is not possible. Continue the voyage to the next port and manage conservatively with the available medication — MEDEVAC options only exist within helicopter range.

C. Transmit a Mayday on all channels and request immediate assistance. A suspected appendicitis is an immediate life-threatening emergency requiring the highest level of distress alerting.

D. MEDEVAC decisions must be made by the company, not the master. Contact the DPA and wait for company direction before contacting any MRCC.

A. INTERNATIONAL MEDICAL GUIDE FOR SHIPS (IMGS) — MANAGEMENT USE: THE IMGS (3rd Edition, WHO/IMO publication): the authoritative reference for managing medical cases at sea. It is required under MLC 2006 Standard A4.1 and SOLAS Chapter III. STRUCTURE OF IMGS: (1) SYMPTOM-BASED approach — start from the patient's presenting complaint (chest pain, abdominal pain, breathing difficulty, altered consciousness), not from a diagnosis; (2) Assessment tools — vital signs guidance, AVPU scale, pain scoring; (3) Treatment protocols — appropriate to medications available in the ship's medical chest; (4) Evacuation criteria — specific signs that indicate when MEDEVAC must be requested; (5) Medication information — dosing, contraindications, side effects; (6) Specialist chapters — dental, eye, mental health. PROCESS: (1) Start with the patient's MAIN SYMPTOM — locate the corresponding chapter; (2) Follow the clinical assessment guide to narrow the differential; (3) Apply the treatment protocol; (4) Check the EVACUATION CRITERION — is this patient in the evacuate category? (5) Contact radio medical advice — provide: patient demographics, symptoms duration and onset, vital signs, current treatment. RADIO MEDICAL ADVICE: available 24/7 — in UK SAR area contact MRCC Falmouth, who connect to NHS Pathfinder or the relevant service. Document all medical consultations in the Medical Log.

B. The IMGS is only for use by ships' doctors. Officers without a medical qualification should not attempt diagnosis or treatment — radio for immediate evacuation instead.

C. The IMGS provides fixed protocols with no decision points. Follow the protocol for the suspected condition from beginning to end regardless of patient response.

D. The IMGS is an outdated publication replaced by the Ship Captain's Medical Guide (SCMG). Modern vessels are required to carry the SCMG, not the IMGS.

A. RADIO MEDICAL ADVICE — PROCESS AND INFORMATION REQUIREMENTS: CONTACT POINT: Telemedical Assistance Service (TMAS) — in UK SAR area, contact MRCC Falmouth (VHF Ch 16 / DSC Ch 70, or MF DSC). MRCC connects to the NHS emergency medical consultation service. Internationally — CIRM (Italy), Euro-TMAS (Germany), Falck (Denmark) also cover international waters. HOW TO CONTACT: transmit "PAN PAN MEDICO" on Ch 16 or via MF DSC. Provide: (1) Vessel name, position, course, speed; (2) Flag state; (3) Distance from nearest coast or port; (4) ETA nearest port; (5) PATIENT MIST REPORT: Mechanism/onset (chest pain started 20 minutes ago at rest), Injury/Illness (crushing chest pain, radiating left arm, sweating, pallor, score 8/10), Signs (BP 160/95, HR 105, RR 18, O2 Sats if monitor available), Treatment (aspirin 300mg given); (6) Available medications on board; (7) Crew medical training level. WHAT THE MEDICAL ADVISER WILL PRESCRIBE: likely: aspirin (if not already given), GTN spray if available, oxygen, ECG if available, rest and monitoring. EVACUATION DECISION: if symptoms are consistent with MI, TMAS will likely recommend MEDEVAC to nearest hospital with cardiac catheterisation capability. DOCUMENT: time contacted, medical adviser name, instructions given, patient observations throughout.

B. Transmit a Mayday on Ch 16 requesting immediate evacuation. A suspected heart attack is a life-threatening emergency requiring Mayday, not PAN PAN.

C. Treat the patient from the IMGS protocol for chest pain and do not contact radio medical advice unless the patient deteriorates. Medical advisers should only be contacted as a last resort.

D. Radio medical advice is only available in coastal waters within 200 miles. On the open ocean, radio medical advice is not available and the master must rely entirely on the IMGS.