When psychiatric crises strike hundreds of miles offshore, ship crews face emergencies without immediate medical backup, according to Vincenzo Barretta, a psychiatrist and scientific director of the Centro Noesis in Naples. Barretta authored the first decalogue for the management of psychiatric emergencies during navigation.
“On an offshore boat, between the moment a person loses control and the moment they encounter a healthcare worker, hours can pass,” Barretta states. “In those hours, the person deciding isn’t a doctor: it’s a captain, a sailor, a ship’s hostess.”
Triggers and Risks of Psychiatric Decompensation on Boats
Confined spaces and unique environmental pressures during boat vacations can trigger a decompensation, according to Barretta. Common catalysts include alcohol consumption, substance use, sleep deprivation, dehydration, heat stroke, and relational tensions in restricted spaces.
One of the most overlooked triggers is the interruption of therapies. Patients who feel stabilized often stop taking their prescribed treatments because they associate vacations with a suspension of rules, frequently doing so without informing anyone, according to Barretta.
The Ten-Point Emergency Protocol for Ship Crews
To bridge the gap before professional help arrives, the first Italian vademecum for captains, crews, hostesses and stewards outlines ten specific steps to manage acute mental health episodes safely:
- Prioritize safety: Immediately evaluate danger to the individual and others, remove potentially harmful objects such as knives, ropes, tools, medications, and alcohol, and prevent access to areas with a risk of falling into the sea.
- Maintain calm: Use a calm, reassuring tone of voice while avoiding shouting, threats, provocations, or authoritarian attitudes that can fuel a crisis.
- Reduce stimuli: Move the person to a quiet, well-ventilated space, limit the number of bystanders, and lower music, noises, and bright lights.
- Engage in non-confrontational dialogue: Introduce yourself by name and role, listen without interrupting, and avoid arguing about the truthfulness of delusions or hallucinations.
- Formulate rapid hypotheses: Consider alcohol abuse, substance use, suspension of medications, panic attacks, psychotic or manic episodes, depression with suicide risk, recent trauma, heat stroke, dehydration, hypoglycemia, or other medical conditions.
- Estimate risk levels: Treat threats of jumping into the sea, self-harm or harm to others, marked confusion, imperative hallucinations, extreme agitation, disorientation regarding people or place, or violent behavior as an emergency.
- Notify the captain immediately: It may be necessary to modify the route, head for the nearest port, request support from the Coast Guard, and prepare for medical intervention upon arrival.
- Contact emergency services promptly: Reach out to the Coast Guard, 112, 118, or the competent service for the country and navigation area, communicating the vessel’s position, number of people involved, observed symptoms, substance use, suicide risk, and aggressive behavior.
- Avoid dangerous interventions: Refrain from immobilization unless to prevent immediate harm, do not administer non-prescribed medications, never leave the person alone, do not challenge or humiliate them, and do not use disproportionate force.
- Document the incident: Record the onset time, symptoms, preceding events, consumption of alcohol or substances, interventions carried out, people present, and communications with rescue services.
Treating Mental Health as a Medical Emergency
The guiding principle of the document requires treating any acute alteration of mental state as a potential medical emergency as well as a psychiatric one. Hypoglycemia, strokes, traumatic brain injuries, infections, intoxications, and heat strokes can manifest with symptoms identical to those of a psychiatric disorder, according to Barretta.
“Calling what is actually a cerebrovascular event a ‘nervous fit’ is the mistake paid for most dearly on board,” Barretta warns. The protocol suggests equipping vessels with operational protocols, emergency contact numbers, information on the nearest ports, first aid kits, and the possibility of consulting a doctor via radio or satellite phone during deep-sea navigation.
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