Programme September 7, 2012

• Emergency medicine• ABCDE approach• Anaphylaxis• Water, electrolytes• EOLD in Pacific

Štefan Trenkler, MD, PhD

Emergency medical system in Slovakia

Stefan Trenkler, MD. PhD.

Kaim UPJS LF a UN LP Košice

Košice 2012

Anaesthesia – 4 elements

1. Anaesthesia

2. Intensive (Critical) care medicine

3. Emergency medicine

4. Analgesia

Chain of survival

Emergency medicine

• Goal: emergency medical service1. prehospital 2. intrahospital 3. interhospital 4. mass disasters

• Patients- life threatening situations, 1th hour quintet- damaged organs- damaged extermities- pain therapy

ACS

Cardiac arrest

Respiratory arrest

Stroke

Polytrauma

Emergency situations

Emergency

Life threatening situations, death probable wt intervention

a) Airwayb) Breathingc) Circulationd) Neurology

E.g. polytrauma, cardiac arrest

Urgent

Wt urgent therapy the situation wil progress to severe damage

E.g. ACS, stroke

< Urgent

Low probability of worthening

E.g. fracture

Emergency medical system

• Patient oriented• Availability 24/256

- geografical (distance, time)- social (for all)- financial

• Capacity- prehospital- emergency department

Emergency medicine - structure

1. Dispatcher centres of EMS

2. Emergency medical system –Zdravotná Záchranná Služba (ZZS)

3. Emergency department Oddelenie (klinika) urgentnej medicíny / pracovisko urgentného príjmu

Integrated rescue system since 2006

Koncepcia organizácie a rozvoja IZS do r. 2010, Osob príloha ZdN č. 26, jún 2006

Ministry of interiorMinistry of health

EMS dept.

Police dept.Fire dept.

Mining dept.

Mountain dept.

EMS stations

8 Dispatcher centres

Training center

Fire stations

Regional crisis centre

Legislative rules - EMS

Act: • Act No. 129/2002 Coll. on the Integrated rescue

system• Act No. 579/2004 Coll. on the Emergency medical

services and on the amendment and supplement of certain laws

• 6 Acts – Healthcare reform (2005)

Regulation: • No. 30/2006 Emergency medical services

(fundamental change of the system)

Integrated rescue system - Dispatcher centres

• Goverment organized• 8 regional integrated centres – EMS department, Fire

department, Police department• 1x Mining department (Prievidza); 1x Mountain

department (Poprad)• GPS tracking system of ambulances• Unified telephone number 112 (temporary operational

direct calls 155 EMS, 150 fire, 158 police)• Staff: 4 – 6 operators: former ICU nurses, paramedics

1 medical doctor present• Training centre

EMS system – mixed system

• Two types of ambulances: 1. medical: physician + paramedic + driver (paramedic) 2. paramedical: paramedic + driver (paramedic)

• Dispatcher decides which ambulance will be sent• Ambulances: mostly Mercedens and Volkswagen• Equipment: goverment defined list of standard technology,

medicaments and materials• EMS providers: There are ~25 state/hospital/private

providers (1 to 91 stations); licence 2010 - 2014• No official fire department ambulances in the system• Payment: fixed monthly payments (government regulated)

for medical/paramedical ambulances + kilometers• Source: Health insurance companies

Záchranná zdravotná služba (ZZS)

• ambulance physician based RLP• ambulance paramedics based RZP• ambulance mobile intensive care unit (MIJ)• ambulance - helicopters

Stations of medical/paramedical EMSSLOVAKIA 2001

Weaknesses: •Low number of amb/long resp. time (=>30 min)•High number of emerg. call centers (155 =>80)•Differences and insuficiency of facilities, premisses, equipment•Splited organization and management

91 STATIONS

110 ambulances

1 amb/50 000 inhab

Strengths:•Better access (response time < 15 min)•Less emerg call centers (80 => 8)•Good premisses, equipment - uniformity•Unification in organization and management, education, standards, protocols

Stations of medical/paramedical EMSSLOVAKIA 2010

270 stations

1 amb/25 000 inhab

EMS Slovakia 2010 – 270 stations

• Falck Záchranná a.s., Košice 90• Záchranná služba Bratislava 53• Záchranná služba Košice 38• Zamed s.r.o., Komárno 20• LSE s.r.o., Limbach 19• NsP: Trnava, Nitra, Trenčín, Poprad, Prešov Martin,

Levoča, Dolný Kubín, N. Zámky, Trstená, Čadca, L. Mikuláš, Krompachy, Brezno, Skalica, SNV, Bardejov, Komárno, Skalica ...

50

220

HEMS

• 7 regional heliports around the country; 7 private• Direct call 18155• Incorporated in EMS – dispatcher centres• Helicopters: Agusta A109 K2, AS355 F2 Ecureuil. • Night operations

Emergency department

Interhospital transport

Paramedics - competences

• Intravenous kanyla• Normal saline• Peroral analgesics• BLS• Mask/bag ventilation

• Using of medicaments should be consulted with the dispatcher centre doctor or doctor of own company

• In complicated cases they ask for doctor based ambulance

Education

• Drivers- 101 hours introductory course- 2 years study at nursing school

• Paramedics: - 3 years bachelor study of emergency medicine (for high school graduated)- 1 year specialized study for nurses with praxis- specialization in anaesthesia and intensive medicine accepted

• Medical doctors- Postgraduate specialization in emergency medicine, 5 years- Specialization in anaesthesia and intensive medicine accepted

Qualification of EM specialists II.

Education and training – indipendent speciality, 5 years, final board examination

1. 22 months of practicing at prehospital EM care department,

2. 12 months at ICU3. 1 month at dispatch center4. 6 months at Surgical dept.5. 6 months at Internal and cardiology dept.6. 3 months at Pediatric dept 7. 2 moths at Neurology and Psychiatry8. 2 months at Obstetric dept9. 6 months at CPO (central addmition dept)

• Accreditation – education program was accredited with Accreditation commitee of Ministry of Health

Qualification of EM specialists I.

• Scope of practice - diagnosis- emergency procedures – CPR, intubation, coniotomy, i.v. and c.v. access- emergency procedures of vital functions support (vasoactive drugs, sedation, anaesthesia, volume resusccitation etc.), chest drainage, pericardial drainage, cardiostimulation, artificial ventilation, delivery, etc

START triage

Triage label

Public relations

Education

Thank youStefan.trenkler@upjs.sk