1. Franco-German pre-hospital system:from call to hospital M.P. Poloujadoff, MD, PhD Assistant Professor Emergency Department and Ambulance Service Poissy – Saint Germain en Laye Hospital France MPP/SAMU/2013

2. Prehospital Emergency Organisations • Tel 15/112 : EMS - SAMU “Service d’Aide Médicale Urgente” Emergency Medical Calls Center • Tel 17/110 : Police Department • Tel 18/112 : Fire Department MPP/SAMU/2013

3. Prehospital Emergency Organisations • Tel 15/112 : EMS - SAMU “Service d’Aide Médicale Urgente” Emergency Medical Calls Center • Tel 17/110 : Police Department • Tel 18/112 : Fire Department • 24H/day, 7days/week MPP/SAMU/2013

4. Missions of the Pre-hospital EMS • 24 hours dispatching and reception center for all medical emergencies calls MPP/SAMU/2013

5. Missions of the Pre-hospital EMS • 24 hours dispatching and reception center for all medical emergencies calls • find the best solution for eachmedicalproblem MPP/SAMU/2013

6. Missions of the Pre-hospital EMS • 24 hours dispatching and reception center for all medical emergencies calls • find the best solution for each medical problem • organize critical care transportation to and between hospitals MPP/SAMU/2013

7. Missions of the Pre-hospital EMS • 24 hours dispatching and reception center for all medical emergencies calls • find the best solution for each medical problem • organize critical care transportation to and between hospitals MPP/SAMU/2013

8. Missions of the Pre-hospital EMS • 24 hours dispatching and reception center for all medical emergencies calls • find the best solution for each medical problem • organize critical care transportation to and between hospitals • organize the admission MPP/SAMU/2013

9. Missions of the Pre-hospital EMS • 24 hours dispatching and reception center for all medical emergencies calls • find the best solution for each medical problem • organize critical care transportation to and between hospitals • organize the admission • coordinate all public and private systems related to prehospital emergency medical services (general practitioners, firemen, paramedics, private ambulance companies) MPP/SAMU/2013

10. Prehospital care organization • EMS : nationwide and regionalized (community/service/department area) • Component of the key tasks – public safety • informally created in France in the 1970s • creation of a nationwide hotline for medical emergencies (dial 15 / 112) MPP/SAMU/2013

11. Prehospital care organization • law /strict regulationdefining characteristics missions of the EMS staff qualification, job performance, response time, vehicle types, materialrequired MPP/SAMU/2013

12. Principles of franco-german organisation • Our concept : the hospital must go to the patient with life-threateningemergency MPP/SAMU/2013

13. Principles of franco-german organisation • Our concept : the hospital must go to the patient with life-threatening emergency • Hospital paramedics+/-doctors in the pre-hospital phase • Take in charge the most severe cases • Control and upgrade techniques, training, equipment MPP/SAMU/2013

14. Principles of franco-german organisation • Our concept : the hospital must go to the patient with life-threatening emergency • Hospital paramedics+/-doctors in the pre-hospital phase • Take in charge the most severe cases • Control and upgrade techniques, training, equipment • Integration of all the resources • Offer the patient a global service • Upgrade network and partnership MPP/SAMU/2013

15. Principles of franco-german organisation • Our concept : the hospital must go to the patient with life-threatening emergency • Hospital paramedics+/-doctors in the pre-hospital phase • Take in charge the most severe cases • Control and upgrade techniques, training, equipment • Integration of all the resources • Offer the patient a global service • Upgrade network and partnership • Medical co-ordination by the call centres • Find a suitable solution for each case • Optimise the use of resources MPP/SAMU/2013

16. Principles of franco-german organisation • Our concept : the hospital must go to the patient with life-threatening emergency • Hospital paramedics+/-doctors in the pre-hospital phase • Take in charge the most severe cases • Control and upgrade techniques, training, equipment • Integration of all the resources • Offer the patient a global service • Upgrade network and partnership • Medical co-ordination by the call centres • Find a suitable solution for each case • Optimise the use of resources • Responsibility of the hospitalover the pre-hospital phase • Improve co-ordination between pre-hospital and hospital • Optimise the use of hospital’s resources MPP/SAMU/2013

17. The dispatching center • located in a major hospital of each administrative district • connected (phone, radio) to all the other public and private emergencies facilities • equiped with important technical means to carry out its missions MPP/SAMU/2013

18. The dispatching center • located in a major hospital of each administrative district • connected (phone, radio) to all the other public and private emergencies facilities • equiped with important technical means to carry out its missions - staff : dispatchphysicians (emergency physicians or anaesthesiologists) and/or specializedswitchtboardoperators - privatepractitionersparticipate to the activity MPP/SAMU/2013

19. The 4 functions of a SAMU CENTER : • AnRESPONSE CENTERfor treating all emergency medical complaints (from citizens, ambulances, physicians, nurses, policemen…) MPP/SAMU/2013

20. The 4 functions of a SAMU CENTER : • AnRESPONSE CENTERfor treating all emergency medical complaints (from citizens, ambulances, physicians, nurses, policemen…) • ADISPATCHCENTERfor emergency care resources (basic ambulances, Hospital Medical Intensive Care Units MICU, general practicioners) MPP/SAMU/2013

21. The 4 functions of a SAMU CENTER : • AnRESPONSE CENTERfor treating all emergency medical complaints (from citizens, ambulances, physicians, nurses, policemen…) • ADISPATCHCENTERfor emergency care resources (basic ambulances, Hospital Medical Intensive Care Units MICU, general practicioners) • A real timeDATA PROCESSING CENTERfor regional emergency resources (receives, records and diffuses them in real time) and for emergency activity monitoring (epidemiology and health authorities) MPP/SAMU/2013

22. The 4 functions of a SAMU CENTER : • AnRESPONSE CENTERfor treating all emergency medical complaints (from citizens, ambulances, physicians, nurses, policemen…) • ADISPATCHCENTERfor emergency care resources (basic ambulances, Hospital Medical Intensive Care Units MICU, general practicioners) • A real timeDATA PROCESSING CENTERfor regional emergency resources (receives, records and diffuses them in real time) and for emergency activity monitoring (epidemiology and health authorities) • A MEDICAL CONTROL CENTER with medical regulation by an emergency physician MPP/SAMU/2013

23. Dispatch Dispatchers usingalgorythms MedicoSanitaryregulation of emergency case Access to a physicianonly on the base hospital phone connnexion THE GERMAN EMS DISPATCH / ARMS MPP/SAMU/2013

24. Medical Regulation • The regulator is an emergency physician, in charge of a team of medical dispatching operators MPP/SAMU/2013

25. Medical Regulation • The regulator is an emergency physician, in charge of a team of medical dispatching operators Evaluating the priorities and deciding the most appropriate responses for medical emergencies MPP/SAMU/2013

26. Medical Regulation • The regulator is an emergency physician, in charge of a team of medical dispatching operators Evaluating the priorities and deciding the most appropriate responses for medical emergencies • Different kinds of responses: • redirecting non medical or non emergency demands • providing medical advice • dispatching First Aid, Basic Ambulances or MICUaccording need • Orienting patients towards the most efficient care emergency resources MPP/SAMU/2013

27. THE FRENCH AND GERMAN EMS ARMS MPP/SAMU/2013

28. Staging and deploying resources • MICU RENDEZVOUS SYSTEM • Emergency ambulance / doctor’s car • STATION SYSTEM • Physician on duty will staff the ambulance • More serious cases, more difficult tasks without delay THE GERMAN EMS DISPATCH / ARMS MPP/SAMU/2013

29. MICU= Physician manned Mobile Intensive Care Unit for intervention on the spot of out-hospital medical emergencies THE «ARMS» OF FRENCH SAMU : decentralized hospital based MICU SMUR = Service Mobile d’Urgence et de Réanimation one department in the hospital, running one or more MICU. 300 Hospital SMUR services >>> one SAMU may manage several SMUR, each one composed of one or several MICU MPP/SAMU/2013

30. THE «ARMS» OF SAMU : decentralized hospital based MICUSeine Saint Denis Department MPP/SAMU/2013

31. M.I.C.U. • MICU = physician + nurse + ambulance driver • car, ambulance, helicopter • equiped with high standard devices for diagnosis and treatment MPP/SAMU/2013

32. M.I.C.U. MPP/SAMU/2013

33. M.I.C.U. MPP/SAMU/2013

34. Diagnosis : ECG Mini laboratory Ultrasound - Doppler Medications refrigirerator Anaesthesia IV/gaz Intensive care electrical device electric syringues, Defibrillation Oxygen Vacuum 220V Monitoring : Scope Sao2 MICU MPP/SAMU/2012

35. Pediatric MICU MPP/SAMU/2012

36. Special Transfer… MPP/SAMU/2012

37. MICU Physician: emergency pratician or anesthesiologist Nurse: general nurse or anesthesiologist nurse MICU driver: Ambulance driver with « FAE » • clinical evaluation in the field • establishment of prehospital diagnosis • stabilization before transportation to the hospital • information to the medical dispatcher of the patient’s status, treatment given and diagnosis MPP/SAMU/2013

38. Main MICU activities • Cardiology • Traumatology • Neurology • Pneumology • Toxicology • Transportation from one hospital to another MPP/SAMU/2013

39. What kind of responses does the SAMU give to medical complaints after telephone assessment? MPP/SAMU/2013

40. ORIGIN OF THE EMERGENCY CALL Origin of emergency calls Patient, witness or relative • patient, witness or relative • police • firemen • general practitioners • private ambulance, paramedics • public or private hospitals H MPP/SAMU/2013

41. The emergency call DISPATCH CENTER Specialized switchboard operator first directed to a specialized switchboard operator who gathers general information and establishes a medical file MPP/SAMU/2013

42. The emergency call DISPATCH CENTER Specialized switchboard operator first directed to a specialized switchboard operator who gathers general information and establishes a medical file then is transmitted to a physician who is responsible for all medical actions (medical decision, appropriate orders and correct management) Medical dispatcher MPP/SAMU/2013

43. Several possible responses to an emergency call DIFFERENT RESPONSES Medical advice • give a medical advice • send a general practitioner for a home visit • send a private ambulance or first-aid workers • send a fire fighter ambulance • send a Mobile Intensive Care Unit (MICU) when a life-threatening emergency is suspected MICU MPP/SAMU/2013

44. DIFFERENT RESPONSES ORIGIN OF THE EMERGENCY CALL DISPATCH CENTER Medical advice Specialized switchboard operator Patient, witness or relative Medical dispatcher H MICU MPP/SAMU/2013

45. DIFFERENT RESPONSES ORIGIN OF THE EMERGENCY CALL DISPATCH CENTER Medical advice Specialized switchboard operator Patient, witness or relative Medical dispatcher H EVALUATION MICU • is aware of the current avalaibility of beds • chooses the most appropriate hospital to receive the patient : • the nearest hospital is not always the most appropriate for the management of the patient!!! MPP/SAMU/2013

46. Principles of action • As an emergentist :go to • For the severe cases, and when in doubt : go • Take the patient in charge from the very beginning • Act on the spot MPP/SAMU/2013

47. Principles of action • As an emergentist :go to • For the severe cases, and when in doubt : go • Take the patient in charge from the very beginning • Act on the spot • Reverse the vicious circle and stabilise MPP/SAMU/2013

48. Principles of action • As an emergentist :go to • For the severe cases, and when in doubt : go • Take the patient in charge from the very beginning • Act on the spot • Reverse the vicious circle and stabilise • If it is possible, treat the cause • If it is suitable, avoid hospitalisation MPP/SAMU/2013

49. Principles of action • As an emergentist :go to • For the severe cases, and when in doubt : go • Take the patient in charge from the very beginning • Act on the spot “ More haste, less speed ” MPP/SAMU/2013

50. Principles of action • “ More haste, less speed ” • Assess the situation • Anticipate, prepare the next step : orientation, admission • Turn, as soon as possible, to more appropriate means MPP/SAMU/2013