Drugs, Pain Relief and Medical Stores

Medical Stores under MSN 1905

In short: MSN 1905 (M+F) sets the minimum medical stores a UK ship must carry. Keep them organised, in date, locked where needed, and checked on a schedule.

Managing the medicine cupboard

1. Different cupboards or drawers for different groups of medicines.
2. A small fridge should be available.
3. A secure, locked compartment for Class A drugs (controlled drugs).
4. Every Class A drug used is logged separately.
5. Medicines clearly referenced per Schedule 5.
6. Expiry dates checked and noted.
7. Do NOT change the drugs’ containers — the label, dose and batch go with the original pack.
8. Weekly or monthly inspection by the crew member in charge.
9. At least one check a year by a qualified pharmacist (see the note below).
10. Record and replace all equipment and medicines used.

Two sources, two wordings on the annual check. Medical-stores management guidance says a qualified pharmacist. MSN 1905 (M+F) Amendment 5 asks for a review at least annually by a competent person, does not say who, and calls it good practice for that person to be someone other than the officer responsible for the stores.

Vessel categories A, B and C

• Ready-made medical kits are sold as Category A/B/C kits with a colour-coded inventory by drug class that matches the MSN categories.

Keeping the notice current

• MSN 1905 is amended from time to time. One printed copy in use had had 3 updates since publication, all changes to quantities only. The current version published by the MCA is Amendment 5, which follows the 24th edition of the Ship Captain’s Medical Guide.
• The minimum list can be added to or substituted by the company doctor.

Restocking

• Restock every 3 or 6 months. If you buy medicines yourself, tell the supplier so the inventory stays right.
• Medicines (except narcotics) can be shipped to the next port via the agent.
• Refilling the medical bag on a pharmacy prescription is far cheaper than buying a new pre-packed bag.
• EpiPens are often out of stock — order early.
• Liferafts carry their own anti-seasickness medicine for at least 48 h and one seasickness bag per person (LSA Code 4.1.5.1).

On the bridge

• Before a long passage, the officer in charge of medical care checks expiry dates, the fridge and the controlled-drugs register, and orders what is short while still in port.

Controlled Drugs and Narcotics

In short: strong painkillers are kept locked, every dose is signed for, and they are only bought and returned through official channels.

Storage and records

• Controlled drugs (morphine, tramadol; haloperidol is kept there too): a separate locked compartment and a countersigned log — amount, time, recipient.
• Narcotics:
  • bought in the country only;
  • locked in the captain’s safe;
  • a separate register with a double signature (captain + patient) for every movement;
  • expired stock returned against signature;
  • port health may inspect.

Narcotics are the one group the agent cannot ship to the next port. Plan their supply ahead.

Fridge items

• Tetanus vaccine, tetanus immunoglobulin and oxytocin live in the medical fridge.

First-Aid Boxes and the Emergency Medical Outfit

In short: small first-aid boxes are spread around the ship so help is close to any accident. They only work if someone checks them.

Contents of a first-aid box

• Iodine solution.
• Standard dressings: 1 large + 2 medium + 4 small.
• 8 triangular bandages.
• Cotton wool, safety pins, sticking plaster, scissors.
• Pencil and paper — to note times and treatment.

Where they go and how they are checked

• One box in the medicine locker, ready to carry to an accident site; others at strategic positions on board.
• Crew must know where they are and what is inside.
• Extra boxes get used without a report or pilfered → routine content checks. A muster-station kit audit checklist works well.
• Crews of over 20 → a dedicated emergency medical outfit, readily accessible.

Choosing Medicines from the Chest

In short: know what each category is for, pick the drug that does the most good with the fewest problems, and ask TMAS when in doubt.

The categories

• Category 1 — cardiovascular / circulation: adrenaline, glyceryl trinitrate (under the tongue), ergometrine for bleeding after childbirth. The category is “circulation”, not heart only.
• Category 2 — gastrointestinal: anti-diarrhoeals and antiemetics. Domperidone for seasickness — no drowsiness, so it is safe for crew operating machinery.
• Use the MCA’s English-language guide: it lists uses, side effects and penicillin-allergy warnings.

Smart prescribing

• Use side effects on purpose: codeine for diarrhoea + abdominal pain — its constipating effect means one drug instead of two.
• Men about 50+: avoid drugs that affect urine flow (prostate, urinary retention).
• Don’t recite side effects to the casualty — the nocebo effect can bring them on.
• Fits lasting more than 5 min → risk of hypoxia → give a drug to stop the fit.
• Haloperidol → to restrain someone who is a danger to themselves or others.

One drug, two jobs. Choose medicines whose side effects help — and keep the side-effect list to yourself.

Anaphylaxis and adrenaline

• Adrenaline is stored with the cardiac drugs.
• Small local sting → cortisone cream only, NO adrenaline.
• Airway swelling or breathing trouble → adrenaline. Full doses and protocol are in the Poisoning and the MFAG topic.

Antibiotics

• Each antibiotic covers specific bacteria: “wide-spectrum” ≠ all.
• Penicillin family = most allergies. Erythromycin is the standard alternative on board; azithromycin is now preferred — a 3-day, once-daily course that people actually finish.
• Don’t overuse wide-spectrum antibiotics — they breed resistance.

Expired medicines

• About 1 month past expiry → ask the TMAS doctor whether to use it.
• Expired swabs and bandages are still usable.

Assessing Pain

In short: pain is personal. Measure it with a scale, so you can see whether treatment works.

Three tools

• Score the pain before and after each drug and write it down.
• Untreated pain slows healing — treat it.

The Analgesic Ladder

In short: start with the mildest painkiller that could work and step up one rung at a time, only if the pain is not controlled.

The on-board ladder

1. Support + ice first.
2. Paracetamol.
3. NSAIDs (COX-1 or COX-2).
4. Codeine / dihydrocodeine — about 5/10 pain is codeine territory.
5. Morphine — last rung. The SCMG tends to reach for it too early.

• Reassess about 1 h after each step before escalating.
• Two painkillers together are fine if they are from different families (e.g. paracetamol + an NSAID).

The WHO pain ladder (1986)

• Patients begin at the first rung and move up rung by rung as the pain worsens — the best effect without jumping to strong treatment.

RICE for muscle and joint pain

• Rest · Ice · Compression of the limb or joint · Elevation.
• It reduces swelling (inflammation) → it reduces pain.

On the bridge: a rib fracture

• Paracetamol → a short NSAID course → codeine. Not straight to morphine.
• Treat the pain properly: a casualty who breathes shallowly to avoid pain can develop a chest infection.

Climb the ladder, don’t jump it — one rung at a time, reassess before stepping up.

NSAID and Opioid Safety

In short: NSAIDs hurt the stomach and slow bone healing; opioids can stop breathing. Know the limits of both.

NSAIDs

• NSAIDs (e.g. diclofenac, naproxen) only work on inflammatory pain. Avoid in asthma.
• COX-1 NSAIDs (e.g. diclofenac, ketoprofen, dexketoprofen) → stomach ulcers and raised BP. Avoid if over 60 or with a stomach history.
• COX-2 NSAIDs (e.g. Celebrex, Arcoxia) are kinder to the stomach.
• Add PPI stomach protection to any NSAID course. Ibuprofen is the mildest.
• NSAIDs delay fracture healing — use for about 7 days at most with a fracture.
• Diclofenac suppositories for renal colic or a patient who is vomiting.

Morphine and other opioids

• The SCMG gives 10 mg. Medical trainers warn that 10 mg can cause fatal respiratory depression in a person not used to opioids — titrate low instead (see Injections below).
• Always by injection and with an antiemetic.
• Naloxone, the antidote, is carried on board.
• Overdose signs: drowsy, pinpoint pupils, breathing slowing down → stop, support the airway.

Morphine: low dose first, antiemetic with it, naloxone ready, and watch the breathing and the pupils.

Injections and Drug Administration

In short: pick the route, angle and site, draw up the right dose, aspirate, and record what you gave and where.

Routes and angles

Step by step: IM or SC injection

1. Choose the route and angle.
2. Choose the site: deltoid (max 2–3 ml) · buttock, upper-outer quadrant (keeps clear of the sciatic nerve) · thigh.
3. Reconstitute if needed: 1 g vial + 10 ml → 500 mg = 5 ml. Expel the air bubbles.
4. Oily injections (e.g. benzathine penicillin): put a warm wet cloth on the site first.
5. Insert the needle, leaving a little of it outside the skin — so you can pull it out if it breaks.
6. Always aspirate. Blood → discard and restart.
7. Insulin-type syringes are graded in UNITS and are for SC only.

Worked example: morphine

• Ampoule: 10 mg in 1 ml.
• Dilute to 10 ml → now 1 mg per ml.
• Give 3 ml (3 mg) first, then titrate up against the pain score.
• Prepare naloxone BEFORE you give the morphine.

Intraosseous (IO) access

• When no vein can be found: the proximal tibia, on the bump below the knee, with a spring-loaded device — SCMG p. 226.