Emergency medicine

Stefan Trenkler, MD. PhD.

KAIM UPJS LF Košice

2017

Chain of survival

Emergency medicine

• Goal: emergency medical service

1. prehospital

2. intrahospital

3. interhospital

4. mass disasters

• Patients

- life threatening situations, 1th hour quintet

- damaged organs

- damaged extermities

- pain therapy

1th hour quintet

1. Cardiac arrest

2. Respiratory arrest

3. Acute coronary syndrome (STEMI)

4. Ischemic stroke

5. 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 –Záchranná Zdravotná 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, paramedics1 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 13 state/hospital/private providers (1 to 107 stations); licence 2014-20

• 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) (EMS)

• Ambulance physician based RLP

• Ambulance paramedics based RZP

• Ambulance mobile intensive care unit (MIJ)

• Ambulance - helicopters

Hamburg-Altona, Germany 19th century

Stations of medical/paramedical EMS

SLOVAKIA 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 EMS

SLOVAKIA 2010

270 stations

1 amb/25 000 inhab

EMS Slovakia 2014 – 273 stations

• Falck Záchranná a.s., Košice 107 (P)

• Záchranná služba Bratislava 62 (S)

• Záchranná služba Košice 47 (S)

• LSE s.r.o., Limbach 30 (P)

• Zamed s.r.o., Komárno 14 (P)

• HospitalsBrezno 5, Bardejov 2, Skalica 2, L. Mikuláš 1, Čadca 1, Trstená 1, D. Kubín 1

HEMS

• 7 private regional heliports around the country; Direct call 18155

• Incorporated in EMS – dispatcher centres

• Helicopters: Agusta A109 K2, AS355 F2 Ecureuil.

• Night operations

Emergency department

Interface

Emergency department - organization

1. Reception (information)

2. Emergency – internal medicine

3. Surgical - traumatological

4. Resuscitation, shock

5. Expectation beds

6. Diagnostic part (USG, X ray, CT...)

Triage

When you arrive at the ER, your first stop is triage. This is the place where each patient's condition is prioritized into three general categories:

- Immediately life threatening

- Urgent, but not immediately life threatening

- Less urgent

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

Hospitals in Slovakia

Banská Bystrica

Košice (1924)

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

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

START triage

Triage label

C – Woman, car crash

• Waking around, strong pain in the left knee

• Breathing 20/min

• Pulse a. radialis present

H – Man, bus crash

• Lying on the street

• Not breathing after chin lift

• No peripheral pulse

• No pain reaction

B – Woman lying in the green

• Breathing 8/min.

• Peripheral pulse non present, capillary refill time 5 sec

• No pain reaction

A – Adul lying in the street

• He can not stand up

• Breathing 28/min

• Peripheral pulse present

• Confused, slow reactions

Public relations

Education

Organizations in EM

• Slovenská spoločnosť urgentnej medicíny a medicíny katastrof (SSUMaMK)www.urgmed.sk

• European Society of Emergency Medicine (EuSEM)www.eusem.org

• Slovenská resuscitačná rada (SRR)www.srr.sk

• European Resuscitation Council (ERC)www.erc.edu

Thank you

Stefan.trenkler@upjs.sk

Slovak Society of Emergency Medicine

Prof. B. Boettiger, Cologne

President of ERC

Porto 2.12.2010

CEEA course

Košice 22.11.2010

European Diploma Emergency Medicine, Milano 6.10.10