Challenges to remote medical support at sea in Bulgaria: legislative gaps, operational needs, and integration of TMAS-SAR system.

BACKGROUND: Remote medical assistance at sea is a critical component of maritime safety. Bulgaria's Telemedical Maritime Assistance Service (TMAS) framework remains underdeveloped despite new national telemedicine laws in 2025. The aim of this paper is to evaluate the effectiveness, efficiency, and compliance benefits of a unified TMAS-Search and Rescue (SAR) system in Bulgaria, assessing its impact on medical care access, coordination between maritime and healthcare authorities, and the economic and safety outcomes of maritime emergencies. MATERIAL AND METHODS: A policy and systems analysis reviewed Bulgarian legislation, EU and IMO/ILO conventions, and operational case records from Maritime Regional Coordination Center (MRCC) Varna (2018-2025). Comparative benchmarking was performed with Romania, Greece, Turkey, and Germany. International "one-door" TMAS-SAR models were reviewed. Findings are supported by six data tables. RESULTS: Bulgaria's 2025 telemedicine law regulates remote care but provides no TMAS-specific provisions, no designated provider, and no legal integration with SAR. Best-practice "one-door" systems abroad enable faster, better-coordinated medical and SAR responses. Bulgarian case series illustrate delays and frag-mented responsibilities. Comparative countries show functioning TMAS-SAR structures even without dedicated TMAS legislation. CONCLUSIONS: Bulgaria needs supplementary maritime-specific provisions, formal TMAS provider designation, SAR integration, and quality monitoring to align with international standards and protect seafarer health.