International

Notes

Emergency Medical Systems in Czechoslovakia KENNETH ELAM, MD,* RICHARD A. HARVEY, The year 1987 witnessed the “velvet revolution” of Vaclav Have1 and the beginning of democratic reform in Czechoslovakia. As the country struggles to build a market-based economy, it maintains a well-developed socialist system of health care that is patterned after the former Soviet system and is free to all (Am J Emerg Med 1984;2:455-458). Formal private medical practice does not exist. Non-emergency care is provided by multispecialty, primary-care oriented clinics (polyklinka) where afterhours visits are possible due to the presence of on-call physicians. In small towns such an on-call doctor would be a general practitioner, but in large cities an internist, pediatrician, and surgeon might all be available. (Am J Emerg Med 1992;10:593-594. Copyright 0 1992 by W.B. Saunders Company)

ORGANIZATION OF EMERGENCY MEDICAL SYSTEMS Each of the Czech and Slovakian Republics has a minister of health who oversees emergency services. In Prague, the largest city, an emergency medical systems (EMS) director supervises the entire system. In Bratislava, the second most populous city, the director of EMS for one hospital also supervises the program citywide. Ambulances are staffed by physicians (generally anesthesiologists), sometimes nurses, and drivers who have 100 hours of training in first aid and cardiopulmonary resuscitation. They carry the same equipment as in the United States (defibrillator, spine boards and collars, suction devices, and tools for imubation and airway maintenance) but they also carry chest tubes and as many as 30 types of drugs for use in the field by the physician. Ambulances are based in different locations depending on the city. Prague has three based at fire departments and three at independent stations throughout the city. Bratislava has two based at hospitals and a third at a polyclinic until a hospital under construction is completed. The ambulance is the first tier of response to emergencies, although Prague is experimenting with “rendezvous” cars (drivers and physicians in automobiles that race to the scene ahead of the ambulance). Other vehicles that comprise the prehospital system include transport cars that take patients to and from hospital and clinic appointments, and first aid cars that respond to From the *Carson-Tahoe Hospital, Carson City, NV; and the TUniversity of Vermont Medical Center, Department of Emergency Medicine, Burlington, VT. Manuscript received May 27, 1992; accepted June 1, 1992. No reprints available. Key Words: Ems, Czechoslovakia system. Copyright 0 1992 by W.B. Saunders Company 07356757/92/l 006-0020$5.00/O

MD-f

patients at home for non-emergencies. The transport cars are staffed by drivers with the same training as those in ambulances. First aid cars consist of a driver and a generalist physician who is essentially doing a house call: should a true emergency be encountered, a true emergency ambulance will be dispatched to the scene. Medical transport by helicopter is available, stationed at an airport (along with physician and assistant for crew) in Prague, and at a teaching hospital in Bratislava. By US standards, this mode of transport may be underutilized; In Bratislava, for example, a city the size of Seattle, helicopter transports average less than one per day. Dispatch from a central communications center can be reached by using a three-digit number via telephone. Nonmedically trained individuals and a supervising nurse provide the bulk of dispatch, which consists of triaging of calls to the various types of prehospital vehicles. Prearrival advice is not dispensed. Depending on the time of day, a physician may be available to aid in triage decisions. PHYSICIAN TRAINING After a 6-year course of study following high school and 4 years of general internship, physicians are eligible for general practice. The completion of an additional 3 months of postgraduate work and the passing of an examination results in a level 1 certification. Level 2 certification requires 4 more years of specialized residency training, followed by completion of 3 months in a postgraduate medical center and an additional examination. Level I physicians are permitted to work in polyclinics and emergency departments where the acuity is generally low. Only those of level 2 status may staff the ambulances, where the majority of true emergencies are encountered. Approximately 80% of physicians in ambulances are anesthesiologists who also serve rotations in areas more akin to their western counterparts, the operating room and the intensive care unit. Surgeons, internists, and pediatricians with variable extra training constitute the remainder of EMS physicians. By US standards, physician salaries are abysmal at roughly $200 per month. THE CONCEPT OF “TREAT IN THE STREET”

While Czechoslovakian physicians understand how a paramedic system allows physicians to remain at hospitals, they see clear advantages to providing prehospital care themselves. Thirty percent to 40% of patients visited by an ambulance are simply treated at home and never trans593

594

AMERICAN

JOURNAL

OF EMERGENCY

ported. In critical cases, physicians initiate stabilization and treatment at the scene and in the ambulance so that the patient can be admitted to the intensive care unit or the operating room directly, completely bypassing the emergency department. Physicians in the ambulances decide which hospital is appropriate for the patient. A carefully planned trauma system does not exist. In Prague, a former hospital for members of the communist party has been designated an “EMS” hospital and receives many critical patients. Its location in a residential area on a scenic hillside, however, is a disadvantage. THE FUTURE Physicians in Czechoslovakia expressed specialty of emergency medicine either as or as a subspecialty of anesthesia (formally siology and resuscitatology). They would

openness to the a separate entity termed anesthelike ambulance

MEDICINE

n Volume

10, Number

6 n November

1992

drivers to have paramedic-like skills to better assist them in the provision of advanced life support, but question what those skills should be. The concept of semiautomatic defibrillation by nonphysicians has been embraced by EMS leaders in both republics, and the first Emergency Medical Technician-Defibrillation type course was taught by the authors in Bratislava in 1991. Lack of hard currency for any expansion of the present system, of course, remains a nationwide problem, and experiments in limited health care privatization are being planned. With the application of very current concepts of medical care in a setting of limited resources, Czechoslovakian emergency providers have a difficult job that they perform admirably well. The authors thank Physio-Control, Redmond, WA, for the donation of automatic external defibrillators to Bratislava, Czechoslovakia.

Emergency medical systems in Czechoslovakia.

The year 1987 witnessed the "velvet revolution" of Vaclav Havel and the beginning of democratic reform in Czechoslovakia. As the country struggles to ...
192KB Sizes 0 Downloads 0 Views