medical emergencies at sea

Fuel burns (chemical burns)
One of the most medically distinctive and severe injuries of the central Mediterranean route are so-called fuel burns: deep chemical burns caused by the mixture of gasoline, saltwater and bodily waste that accumulates on the floor of overcrowded inflatable dinghies – often reaching knee height. The fluid seeps into clothing and remains in prolonged contact with the skin, causing severe dermal and subdermal tissue damage. Fuel burns are the leading cause of accidental trauma on the route, accounting for over 52% of all such injuries, and among the most painful and difficult-to-treat conditions encountered on rescue vessels. Women and children are disproportionately affected, and the the most affected area is the groin area – as they are typically seated in the centre of the boat, where this toxic mixture tends to pool.

Near-drowning and aspiration injuries
Among the most life-threatening presentations are near-drowning cases and the aspiration of the contaminated liquid that fills the boats – a toxic mixture of saltwater and fuel. Aspiration of this fluid causes acute chemical pneumonitis and pulmonary oedema, which can result in respiratory failure within hours. Even those who do not lose consciousness may suffer significant pulmonary damage. Near-drowning survivors frequently present with hypoxia, hypothermia and neurological impairment.

Toxic inhalation: fuel vapours, exhaust fumes and contaminated fuel
A further and frequently fatal hazard is the inhalation of toxic gases aboard overcrowded dinghies — and far more devastatingly, aboard wooden vessels with enclosed lower decks. These below-deck spaces are structurally unsuitable for human transport: in addition to the absence of emergency exits, they typically lack any adequate ventilation, causing toxic gases to accumulate to lethal concentrations. Engine exhaust produces carbon monoxide (CO) and carbon dioxide (CO₂), which accumulate rapidly in the enclosed space — silently causing headache, confusion and loss of consciousness, and proving fatal before rescue teams are aware of its cause. The danger is compounded significantly when fuel has been adulterated — a common practice on the central Mediterranean route, where smugglers frequently mix pesticides or other agrochemical compounds into the gasoline. These substances are acutely toxic and, when inhaled as vapour or absorbed through the skin in combination with the fuel mixture on the boat floor, dramatically increase the risk of fatal poisoning. Some of the highest death tolls recorded on single crossings have been linked to contaminated fuel. Survivors may present with seizures, severe respiratory distress, cardiovascular collapse or altered consciousness of unclear origin — symptoms that can be misattributed to exhaustion or dehydration if the possibility of chemical contamination is not actively considered.

Violence-related and intentional trauma
A significant proportion of rescued people present with injuries sustained not at sea but during the journey through Libya: blunt force trauma, stab and gunshot wounds, and burns from deliberate violence. Torture-related injuries are regularly encountered. Medical teams from all the civil flotilla have documented hundreds of cases of sexual and gender-based violence (SGBV) requiring both acute gynaecological care and psychological support.

Obstetric emergencies
Pregnant women make up a consistently documented proportion of those rescued. Multiple births have taken place directly on distress cases or on rescue vessels.

Hypothermia and exhaustion
Prolonged exposure to wind, spray and cold water in overcrowded, unseaworthy vessels leads to mild to moderate hypothermia, extreme exhaustion, dehydration and seasickness. These conditions, though often classified as non-critical, can reinforce and compound one another in a dangerous spiral: hypothermia accelerates exhaustion, dehydration impairs thermoregulation, and seasickness deepens fluid loss — driving what initially appears as a stable presentation towards rapid critical deterioration. This is particularly true for children, pregnant women and those already weakened by months of detention and malnutrition.

Psychological trauma
Post-traumatic stress, acute dissociative episodes and medically unexplained physical symptoms are widespread, though systematically underdiagnosed in the context of onboard triage. Many people have witnessed drownings, deaths in detention or the loss of family members. The cumulative psychological burden – spanning years of displacement, violence and uncertainty – rarely manifests in ways that fit standard emergency medicine categories.

Dermatological conditions
The most frequently diagnosed condition overall is scabies – a highly contagious parasitic skin infestation caused by prolonged overcrowding and lack of hygiene in Libyan detention facilities. Broader skin pathologies, including fungal infections, contact dermatitis and infected wounds, account for nearly a third of all onboard diagnoses.

The true scale of illness and injury among those rescued is almost certainly greater than the figures suggest. Limited diagnostic capacity, space constraints, stigma and the short duration of onboard care all contribute to a systematic underestimation of morbidities — particularly mental health conditions and sexual and gender-based violence. What the data does show is consistent: the most prevalent conditions are directly linked to the journey itself and to time spent in Libya. Those rescued are often relatively young and otherwise healthy — it is the route that makes them sick, and the violence they have survived that leaves the deepest marks. What they need, above all, is urgent access to essential services and protection in a place of safety on land.

Key sources: MSF retrospective analysis, BMJ Open / PMC (2022) |