Recently, a close friend, a highly respected offshore worker and former saturation diver, experienced an acute cardiovascular event. It happened onshore, just days after he returned from a routine offshore rotation in an advisory role. At first glance, one might think: "At least it didn’t happen offshore." But that thought offers no comfort. What haunts me is this: What if it had occurred offshore? Would the vessel have had a competent medic on board and a fully equipped hospital? A reliable telemedicine link to specialists? Was a medical evacuation plan designed, tested, and ready to deploy? A dependable medical team to treat him upon arrival at the quayside or heliport, and then admit him to a trusted hospital? Or would my friend have been left to improvise, his life hanging in the balance while "cost-effective" medical arrangements failed him? This isn’t hypothetical. It’s a reality for thousands of offshore workers, across all categories of personnel and professions, including divers, supervisors, ROV, survey, marine and client personnel who are just one subtle symptom away from a life-threatening emergency. And too often, the systems meant to protect them are underfunded, untrained, or outright ignored in the name of budget cuts and "efficiency.". This isn’t just about my friend. It’s about an industry that too often preaches "Safety First" while awarding contracts to the technically qualified but also the lowest bidder, gambling with lives in the process. It’s about employers who know the risks but choose to roll the dice, betting that disaster won’t strike this time. Some even pray for false reassurance, choosing to ignore the fact that prayer is no substitute for professionalism. This article calls for accountability, preparedness, and action. Because the next time a medical emergency strikes offshore, and it will, will your team be ready? The risk of a medical or surgical emergency on an onshore worksite is significant, and is increasingly compounded by an ageing demographic, something our clients are very aware of; even their own appointed “Representatives” are generally in the later stages of their careers. This raises the question: was the risk foreseeable? The same applies offshore, including on diving support vessels. The question is not if an emergency will occur, but when, and whether the response will be adequate. Diagnosis is not always straightforward. Mediocre management and improvisation do not work. For instance, acute coronary syndrome can present with atypical symptoms (sharp, stabbing pain; dyspnoea; fatigue) in fit, middle-aged adults with no prior history, yet still escalate to cardiogenic shock or death within hours. Beyond cardiac events, there is a vast spectrum of subtle-onset, rapidly escalating emergencies (e.g., trauma, sepsis, metabolic crises, neurovascular events, decompression illness, toxic exposures, etc) that often begin with vague symptoms before becoming life-threatening within hours. Subtle onset does not mean low risk. Without trained medics, accurate diagnostics, adequate treatment and reliable evacuation plans, these conditions can become fatal. Due diligence is essential and non-negotiable. It is both a legal and ethical obligation. Employers, including diving contractors, vessel owners, and oil and gas companies, have a legal and moral duty of care to prepare for foreseeable risks. The ALARP principle, which involves reducing a given risk as low as reasonably practicable, is not just a slogan; it is a strong legal reference. Courts have established that cost cannot justify inadequate safety measures when lives are at risk. While diving contractors remain accountable for their employees, oil and gas companies, as the "top employers," cannot fully delegate safety responsibilities to contractors. Awarding projects to the lowest bidder, when safety resources are unaffordable at that price considering the project location, scope, and environment, is negligent and could potentially be challenged in a Court of Law: if a project budget does not allow for a comprehensive Medical Emergency Response Plan (MERP) to be designed, audited, tested, and reevaluated throughout the project mobilisation, execution, and demobilisation, the project should not proceed. Note that medical certificates for fitness to work offshore or for fitness to dive are no substitute for proper emergency preparedness and readiness. The reasonably achievable state of the art is a proven MERP that aligns with demanding legal requirements, such as those in the North Sea and Australia. .In other words, regardless of the location, the project-specific ERP should include: • Onboard Medic: Depending on the project, a certified physician or a nurse/paramedic, experienced and regularly refreshed through a certified competencies assessment and enhancement programme. A reliable way to ensure the high performance of such a programme is to engage the certified medical assistance provider to organise and manage it. • Onboard Hospital: Equipped to stabilise patients for a pre-determined amount of time, as stated in the project-specific MERP, with advanced life support and reliable telemedicine capability. • 24/7 telemedicine system: Such as the D-MAS HyperSat, enabling real-time specialist consultation even in hyperbaric environments. • A Reliable medical evacuation (medevac) plan, which is subject to drills, with pre-arranged agreements with audited medevac operators, onshore hospitals, and medical specialists available 24/7. • Reliable high-bandwidth internet, such as Starlink, is required for uninterrupted communication with onshore specialists. • Medical assistance providers: Capable of mobilising specialists 24/7 for video calls and phone consultations. • Reliable Medical equipment and medicines: Sourced and maintained by reputable providers in accordance with the project-specific MERP, DMAC 15, DMAC 28. The resources listed above are critical and essential. They set the baseline for any project management team that repeatedly proclaims “Safety First” and displays “Lifesaving Rules” posters across their organisation. Most offshore end clients, including oil and gas firms, endorse a "Zero Tolerance" policy towards safety breaches. Nevertheless, their procurement methods undermine safety by awarding contracts to the lowest bidder. This creates a distorted incentive to compromise on medics’ skills, the dependability of telemedicine arrangements, and MERPs. When an emergency occurs, the end client, who is also the primary employer, shares legal responsibility for permitting unsafe conditions. The above leads to a call to action: • To end clients, including major oil and gas Firms: - In every call for tender, require a robust project-specific MERP and consider the costs contractors will have to invest in that. - Establish realistic procurement thresholds and approval levels to facilitate fair bidding. - If a bid lacks a fully resourced MERP, then disqualify it. • To contractors: - Invest in effective project-specific MERPs or do not operate. • To classification societies: - Update the classification rules to require verified project-specific MERPs to obtain the Class Certificate. - Audit for compliance. Failures should result in the withdrawal of the Class Certificate. - Publish transparency reports on medical preparedness. • To all personnel present on a diving worksite, including those on board a Diving Support Vessel: - Demand answers: "What is our project MERP? Who is our medic? What is our medevac plan?" - Refuse to work in unsafe conditions. • To regulators and industry bodies: - Audit and enforce. Withdraw the trade association membership certificates when negligence is evident. Unpreparedness is not just negligence. It is a moral crime. The unavoidable conclusion is that industry stakeholders must choose between accountability and complicity. If you disagree, prove me wrong by providing evidence that justifies ignoring foreseeable risks. If you agree, act now: Acknowledge that an emergency could occur within the next hour, and implement thorough, reliable preparedness without negotiation. The risk is foreseeable. The tools exist. The choice is ours. History will judge those who knew the danger, had the means to prevent the risks, and failed to act. Dr Jean-Yves Massimelli Disclaimer: The views and opinions expressed in this article are solely those of the author and do not necessarily reflect the official policy, position, or views of any other organisation, employer, or entity. The author declares no conflict of interest, direct or indirect, with any equipment supplier, service provider, or commercial entity. This article is written independently and aims solely to promote awareness and discussion on offshore medical emergency preparedness.

Note: For all diving projects (Surface demand or Saturation), therapeutic recompression must always be available, including during the bend-watch. For saturaJon diving projects, the MERP must be linked to the project-specific hyperbaric evacuation plan requirements and to the readiness of an adequate hyperbaric evacuation system (including a hyperbaric rescue unit, a life support package, a nominated rescue vessel, a hyperbaric reception facility, and enough competent crew for ensuring safe decompression and bend- watch).

Note: Although in most locations worldwide there is no legal obligation regarding manned and unmanned underwater intervention, the MERP should always be designed according to the state of the art. Hence, it should be unacceptable that a European Diving Contractor who operates in the North Sea in compliance with all the legal obligations, works without a reliable MERP in other areas of the world where local regulations are absent or unclear, circumventing their home responsibilities by setting up a local incorporated company in the country of operation, issuing a contract under that entity that would execute the project.