Emergency Medical Services (EMS) Prototypes Around the World 2016 Jim Holliman, M.D., F.A.C.E.P., F.I.F.E.M. President, International Federation for Emergency Medicine Professor of Emergency Medicine and Public Health Sciences Penn State University, Hershey, Pennsylvania, U.S.A. Professor of Military and Emergency Medicine Uniformed Services University of the Health Sciences Bethesda, Maryland, U.S.A. April. 2016
Disclosures Medical Consultant, National Hot Rod Association I like South Africa And I don t get paid anything from the International Federation for Emergency Medicine or its Foundation
EMS Prototypes Around the World Lecture Objectives - Describe the structural components of different national EMS systems in different countries - Describe the different training programs for EMS personnel in these countries - Compare & contrast other EMS systems and training with those in the U.S. - Stimulate more interest in participation in international EMS activities by EMS personnel
EMS Systems Basis for Interest in Development - Recent awakening by a number of countries that they should develop Emergency Medicine (EM) and EMS - EM and EMS in the U.S. act as relatively "mature" systems to emulate - Collapse of Communism has opened up multiple countries to people & ideas from outside - Increased number of international EMS conferences over the past decade
Reasons for Recent Increased Interest in EMS Development in Countries Throughout the World - Improving overall medical system development in most countries - Rapid urbanization - Demonstrated success of EMS in the U.S. Increased expectations by the public International exposure from TV shows like "E.R." and "Rescue 911 and Casualty Increased international travel Terrorist and mass casualty events
The Two General Types of EMS Systems - "American-Anglo" system Prehospital care by "physician extenders" (paramedics) Patients delivered to hospital-based emergency departments staffed by emergency medicine specialist doctors - "Franco-German" system Prehospital care by physicians Patients delivered directly to inpatient services
General Operational Philosophies of the Two Types of EMS Systems - American-Anglo system "Bring the patient to the doctor" - Franco-German system "Bring the doctor to the patient"
Which of the Two Types of EMS Systems is Better? - Often debated, but really is not an answerable question because so many nation-specific factors influence the systems' structures and operation - Remember the U.S. paramedic based system was developed NOT because it was thought inherently better, but because of economic reasons and a relative shortage of available physicians
Background Reasons for Development of Paramedic-Based EMS in the U.S. - It costs less and takes less time to train paramedics compared to physicians - Paramedics are paid less money than physicians - Physicians are "maldistributed" with concentrations in urban areas - The number of available residency training positions exceeds the number of graduating U.S. medical students
Essential Features for a High Quality Paramedic EMS System - Standardized training - EM physician oversight (quality assurance) - Integration with : Local and regional hospitals Fire and police services - Continuing medical education - Non-overlap with other EMS services
Other Unique Features of the U.S. EMS System - Dependence on volunteers in many places - Fairly standard First Responder and Emergency Medical Technician-Basic (EMT-B) training from state to state - Nonstandard paramedic training and protocols from state to state - Mix of service types - Many aeromedical programs
Various Types of U.S. EMS Services - Private company (for profit) - Local government - Fire department - Hospital based - Military - Police
Countries Utilizing the "American- Anglo" EMS System Type - U.S.A. - Canada - United Kingdom - Ireland - Australia - Hong Kong - Mexico - South Korea - Iran
European Countries in Which Physicians Provide Most Prehospital Care - Germany - France - Austria - Russia - Ukraine - Italy - Spain - Poland - Estonia - Croatia - Slovenia - Switzerland - Hungary - Czech Republic - Slovakia - Portugal
Countries with "Mixed" Physician & Non-physician Staffed EMS Units - Sweden - Norway - Belgium - Israel - Argentina - Turkey Note that the Netherlands mainly uses a nurse staffed system
Theoretical Advantages of Physician-Based EMS Systems - Allows use of greater medical knowledge & perhaps procedural skills by the doctor - Can treat more patients at home without transport - Potential for more accurate prehospital triage or referral decisions
Status of Emergency Medicine (EM) as a Specialty in the "Franco- German" System - EM not recognized as a separate or unique specialty (until 2006 in France) - Breadth of EM thought to only comprise CPR cases - Resuscitation attempts mainly by anesthesiologists, not by other doctors - No training programs equivalent to U.S. EM residencies
Operational Problems with the Franco-German EMS System Type - Patients are directly admitted from the "field" to inpatient services based on presenting chief complaint - Results in higher admission rates and greater per capita hospital use and bed occupancy - Mis-triage is common, especially for patients with complex or multisystem medical or trauma conditions
Results of the Operational Problems of the Franco-German System - Mortality for major or combined systems trauma is poor (> 14% versus 1 to 4 % in the U.S. and in the U.S. and U.K. militaries) - On scene times for trauma cases are long (> 20 minutes typical) - Inefficient, and in fact often dangerous interfacility transfers are more frequently required - Requires much larger number of vehicles and on-duty physicians per unit population
Other Problems with the Current Franco-German EMS System Operation - No quality assurance or care supervision programs are in place - Many prehospital physicians are young and inexperienced - Prehospital work is often regarded just as a temporary stepping stone to another specialty - There are not well defined or in-depth training programs or certification for prehospital physicians
Features of the 1997 Princess Diana Debacle Showing Deficiencies in the Franco-German System - Very long on-scene time - Very long transport time despite proximity to hospital - Poor prearrival notification & care coordination with the hospital - No effective quality assurance review of case management
Features Making Paramedic System Implementation Difficult in Some Countries - Legal system restrictions on nonphysicians performing medical care Thus paramedics in some countries may not be allowed to utilize procedural skills until the doctor is physically present onscene - Surplus of physicians due to excessive medical school graduation rates For example : Italy, Spain, Turkey
Other Problems with EMS System Implementation in Europe - Non standardization of the emergency telephone number in different countries - Economic problems in some ex- Communist countries - Lack of regional trauma system coordination - Public expectation to always demand to have a doctor respond for house calls
Features of the EMS System in France - Two-tiered Basic Life Support (BLS) fire department ambulances (VSAB) Physician-staffed ambulances (SMUR) based at hospitals (320) - Emergency Medical Aid Services (SAMU) provide phone triage (by doctors), medical control, & dispatch (105) - Limited helicopter availability - Showed effective and efficient response to the recent Paris attack
More Features of the EMS System in France - Options for responses by triage physicians to incoming emergency calls : Fire dept. (VASB) ambulance (44%) Hospital ambulance (SMUR) (12%) Private ambulance (3%) Helicopter (< 1%) Local physician referral (23%) Advice only (11%) - For < 60% of calls is an ambulance dispatched
Aspects Related to EMS Personnel in France - Usual staffing for SMUR ambulance : Driver Anesthesiologist +/- resident physician - Firefighters trained in extrication & BLS National law limits performance of any medical acts to physicians or nurses directly supervised (this currently prohibits semiautomatic defibrillation by nonphysicians) Rendezvous with physician ambulance used when ALS needed
Features of the EMS System in Germany - About 7 million EMS runs annually About 2.5 million Advanced Life Support (ALS) runs annually 50 % of ALS runs for medical emergencies - Regional EMS dispatch centers - State legislation requires median response interval 5 to 15 minutes - No standard nationwide emergency phone # - Entire country covered by helicopter services (but mainly restricted to daytime operations)
Aspects Related to EMS Personnel in Germany - Helicopters staffed by one doctor, one paramedic, & 2 pilots - On-scene physician decides if treat & release, physician accompaniment to hospital, or non-physician ALS or BLS transport will be done 39 % of ALS cases have physician accompaniment - Physician response vehicles usually are non-transport vehicles
Training of EMS Personnel in Germany - 1989 law requires 2 year training for EMT's 1 year paramedic school & 1 year on-the-job Most EMT's certified before the requirement - Requirements for prehospital physicians : 1.5 years postgraduate training 6 months ICU experience 80 hour EMS training course 20 supervised ambulance runs No ACLS or ATLS requirement Some are hospital-based & some are in private practice
Administrative Aspects of the EMS System in Germany - Governed by non-physicians - Physicians serve as advisors - Only medical skill delegated so far to nonphysicians is semi-automatic defibrillation Requires EMT precertification & case review by M.D. - Capital expenditures paid by government Operations costs paid by run fees & insurance Run fees are $ 200 to $1500 Escalating costs are major concern
Features of the EMS System in the United Kingdom - Closest to U.S. in structure - Paramedic training and protocols similar to U.S. Less use of "on-line" command Most administrators are non-physicians - Physicians staff ALS vehicles in some big cities (London, Edinburgh) General practice physicians staff rural area vehicles - Daytime helicopter service available nonuniformly
Features of the EMS System in Poland - About 450 ambulance services Most associated with hospitals or health depts. Average operations radius is 12 kilometers (km) for BLS & 18 km for ALS About 4800 ambulances with 165 ALS ambulances Average ALS response time now 30 minutes - 70 % of calls for non-emergent problems Much of population does not have access to cars Service provided free by government - Limited helicopter availability
Features Related to EMS Personnel in Poland - ALS ambulance staffing : Physician, nurse, helper, driver Limited defined personnel training requirements - 75 % of physicians in Poland are specialists No well developed primary care specialty Family Practice only recently defined - Many physicians supplement their low income by working on ambulances - Per capita number of physicians is high
Polish EMS crew at a rural motor vehicle crash
Hong Kong motorcycle EMT for the crowded streets in Kowloon
The world s saddest ambulance in Hyderabad, India
Small mini-ambulance developed by Apollo Hospital in India
Larger Mercedes-style ambulance developed by Apollo Hospital
Mobile ICU vehicle developed by Apollo Hospital in Hyderabad
Nurse dispatchers for Tehran, Iran s EMS system
Features of the EMS System in the Netherlands - 35 ambulance dispatch centers - 86 ambulance services 32 municipal 54 private - 800,000 annual runs - 400 ambulance stations - 637 vehicles - 1500 ambulance nurses & 1400 drivers - Usual vehicle staff is 1 nurse & 1 driver
Other Aspects of the EMS System in the Netherlands - Dispatchers are nurses or paramedics - Specified training for nurses & drivers Prehospital Trauma Life Support Course adopted - Standardized protocols - Quality assurance programs in place - Helicopter coverage available
Features of the EMS System in Italy - 1992 health care reform legislation allocated funds for development of EMS systems Also allowed nurses to do medical procedures per protocol - Wide regional variations in staffing - EM is subspecialty of internal medicine 2 years EM training after 3 years of medicine - Advanced Cardiac Life Support (ACLS) course adopted - Daytime helicopters available in some areas
Aspects of EMS Personnel in Italy - EMS physicians respond to "priority 1" calls in non-transport vehicle Anesthesiologists Some are "EMS Physicians" - 6 months defined training - Other ALS units have one nurse & one driver - Helicopters crewed by 2 pilots, one or 2 nurses, & one anesthesiologist - Relative abundance of physicians
Features of the EMS System in Slovenia - Most ambulances based at one of 25 hospitals or 65 regional health centers - Usual staffing is one physician and one or two nurses or EMT's - Some physicians respond in nontransport vehicles - Most EMS physicians trained in general practice - 264 ambulances to serve population of about 3 million
Interior of Slovene ALS ambulance in Ljubljana, Slovenia
Features of the EMS System in Croatia - Most ambulance services based independent of hospitals Can deliver patient to hospital or to independent "emergency center" - No national standardized protocols - Usual staffing is physician, EMT, and driver - Very prolonged response times in rural areas - National consultant in 2010 recommended establishing hospital based EM but this has not been adopted
Emergency Center for Hitna Pomoc in Zagreb, Croatia
Medications available for Hitna Pomoc physicians in Croatia
Features of the EMS System in Israel Magen David Adom ( Red Star of David is the national EMS system Staffing is a combination of paid and volunteer National coordinated dispatch center Retired ambulance vehicles are held in reserve for mass casualty events
Magen David Adom personnel at a simulated plane crash exercise
Magen David Adom EMT motorcycles
EMS Development Trends Underway in Europe - Specifying training standards New EM residency programs starting - Coordinated dispatch centers - Standard emergency phone number - Clinical protocols - International conferences - Privatization of services & payments - Expansion of helicopter services - Trauma systems regionalization
EMS Prototypes Around the World 2016 : Lecture Summary - There is wide variation in national systems - Most utilize prehospital physicians paramedic based systems may not be applicable in all countries - Current personnel training is often less than optimal - International standardization of clinical and communication protocols is needed
EMS Prototypes Around the World 2016 : Summary (continued) EMS has a key role in any national healthcare system There are a variety of different types of EMS systems worldwide Each country should determine what type of EMS system will work best for it, and this may involve some in-country variations There is great opportunity for E.M. physicians from other countries to interact and collaborate to improve EMS worldwide