Fit for purpose?
A fit is a convulsion, a convulsion is a seizure, a seizure is a fit – these words all describe the same unfortunate experience which we normally associate with epilepsy but which can affect any of us if the conditions are sufficiently severe. I have had a number of queries recently about fitness for seafaring with a history of fits or with definite epilepsy.
Someone suffering from epilepsy can have a fit in ordinary everyday circumstances because there is a trigger in their brain which is set too low – their “seizure threshold” is exceeded in circumstances which do not cause a problem to the majority of people. It causes them to drop to the ground unconscious and with their muscles in intense spasm causing their back to arch and their arms to flex, their breathing to become erratic and their jaws to clench, sometimes resulting in a bitten tongue or cheek and blood-stained saliva drooling from the mouth – hence the traditional picture of “foaming at the mouth”. This tense period is followed by a period of intense and rapid muscular contractions causing a convulsion of movement which can continue for a few minutes. If first aid help is on hand, this convulsive stage is shortened by administering a liquid sedative (diazepam) into the rectum but otherwise it is best left to itself and the affected person be put on their side (recovery position) until the acute event settles and they fall into a deep sleep, as is often the case after a major event. They often have urinary incontinence and sometimes faecal incontinence which helps to differentiate the attack from a simple faint and, taken together with reliable witness accounts, can help to clinch the diagnosis although normally the definitive conclusion has to wait for a laboratory report after electrical testing.
It is important to get the diagnosis right because epilepsy has far-reaching implications for future management and for employment and the UK Department of Transport guidelines are particularly strict for vocational driving licences for lorry and bus drivers. The MCA guidelines are also very strict for seafarers. After only one spontaneous epileptic fit the ENG1 certificate is withheld for a year after the episode and a year off any anticonvulsant medication and this increases to ten years for two or more epileptic fits (possibly only two years on a case-by-case basis for non-watchkeeping near-coastal crew). In any event, epilepsy is a health and safety problem for seafarers and almost always marks the end of a career at sea.
As pointed out already, epilepsy is not the only cause of fits. Most of us have seizure thresholds set at a normal level which means we are never affected but, in extreme circumstances, we can all exceed the trigger and experience a fit. A near-drowning accident, a severe head injury, a stroke, neurosurgery to the brain, an electric shock, a low blood glucose in diabetes – these are all situations which can precipitate a fit in otherwise normal individuals. The seafarer fitness guidelines are not as strict as for epilepsy-associated fits but they are still limiting in their effect. Anyone having a fit caused by one of these readily identified causes is not regarded as fit for seafaring for a year after the fit and a year off anti-convulsant medication and this all increases to five years if more than one fit has occurred with rather more lenient guidelines, on a case by case assessment, for non-watchkeeping near coastal work.
The reasons for these various controls are obvious when one thinks of life at sea and the risk to the individual and to fellow crew who are depending on them if they suddenly are disabled by a fit – it is never easy to apply restrictions to applicants looking for an unrestricted seafarer certificate but, unfortunately, fits are not fit for purpose.
Dr Ken Prudhoe, MCA Approved Doctor, can be contacted at Club de Mar Medical Centre, Palma de Mallorca.