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 "AmericanAnglo" 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 "FrancoGerman" 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 exCommunist 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