Paramedic versus emergency physician emergency medical service: role of the anaesthesiologist and the European versus the Anglo-American concept. Curr Opin Anesthesiol

Department of Anaesthesiology, Emergency and Intensive Care Medicine, Georg-August University, Goettingen, Germany.
Current Opinion in Anaesthesiology (Impact Factor: 1.98). 05/2008; 21(2):222-7. DOI: 10.1097/ACO.0b013e3282f5f4f7
Source: PubMed


Much controversy exists about who can provide the best medical care for critically ill patients in the prehospital setting. The Anglo-American concept is on the whole to provide well trained paramedics to fulfil this task, whereas in some European countries emergency medical service physicians, particularly anaesthesiologists, are responsible for the safety of these patients.
Currently there are no convincing level I studies showing that an emergency physician-based emergency medical service leads to a decrease in overall mortality or morbidity of prehospital treated patients, but many methodical, legal and ethical issues make such studies difficult. Looking at specific aspects of prehospital care, differences in short-term survival and outcome have been reported when patients require cardiopulmonary resuscitation, advanced airway management or other invasive procedures, well directed fluid management and pharmacotherapy as well as fast diagnostic-based decisions.
Evidence suggests that some critically ill patients benefit from the care provided by an emergency physician-based emergency medical service, but further studies are needed to identify the characteristics and early recognition of these patients.

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    • "Therefore, in Sweden, ambulances have generally been staffed with nurses specialized in prehospital care and physicians have been mainly used in helicopters and a few specialized ambulances [3] [4] [5] . Other countries use " paramedics " , who have a shorter, more focused and specialized education [6] . "
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    ABSTRACT: Objective: To evaluate the outcome of physician-staffed ambulances in a pilot study. Methods: All physician-staffed ambulance missions conducted in Gothenburg, Sweden, in 2013 were retrospectively reviewed and evaluated for the type of missions and the need of a physician. Results: Out of 1381 physician-staffed missions, 511 were cancelled or managed by telephone. Around 239 (17%) missions required active intervention, of which only one was considered directly life-saving. Conclusions: Most of the missions neither required the interventional skills of a physician, nor could they be performed at distance. However, the added medical value of physicians was found to be in other prehospital situations, such as critical decision-making, staff education and research.
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    • "Teleconsultation was treated solely as an additional option. In cases that require complex, invasive procedures, such as pharmacologically assisted intubation, teleconsultation can only act as a support as shown in case 3. Qualified physician-staffed EMS offer better care and outcomes for patients in critical condition than some paramedic-staffed systems [17-19]. However, case 3 demonstrates that even an EMS physician can benefit from telemedical support. "
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    ABSTRACT: Legal regulations often limit the medical care that paramedics can provide. Telemedical solutions could overcome these limitations by remotely providing expert support. Therefore, a mobile telemedicine system to support paramedics was developed. During the implementation phase of this system in four German emergency medical services (EMS), the feasibility and possible limitations of this system were evaluated. After obtaining ethical approval and providing a structured training program for all medical professionals, the system was implemented on three paramedic-staffed ambulances on August 1st, 2012. Two more ambulances were included subsequently during this month. The paramedics could initiate a consultation with EMS physicians at a teleconsultation centre. Telemedical functionalities included audio communication, real-time vital data transmission, 12-lead electrocardiogram, picture transmission on demand, and video streaming from a camera embedded into the ceiling of each ambulance. After each consultation, telephone-based debriefings were conducted. Data were retrieved from the documentation protocols of the teleconsultation centre and the EMS. During a one month period, teleconsultations were conducted during 35 (11.8%) of 296 emergency missions with a mean duration of 24.9 min (SD 12.5). Trauma, acute coronary syndromes, and circulatory emergencies represented 20 (57%) of the consultation cases. Diagnostic support was provided in 34 (97%) cases, and the administration of 50 individual medications, including opioids, was delegated by the teleconsultation centre to the paramedics in 21 (60%) missions (range: 1--7 per mission). No medical complications or negative interpersonal effects were reported. All applications functioned as expected except in one case in which the connection failed due to the lack of a viable mobile network. The feasibility of the telemedical approach was demonstrated. Teleconsultation enabled early initiation of treatments by paramedics operating under the real-time medical direction. Teleconsultation can be used to provide advanced care until the patient is under a physician's care; moreover, it can be used to support the paramedics who work alone to provide treatment in non-life-threatening cases. Non-availability of mobile networks may be a relevant limitation. A larger prospective controlled trial is needed to evaluate the rate of complications and outcome effects.
    Full-text · Article · Jul 2013 · Scandinavian Journal of Trauma Resuscitation and Emergency Medicine
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    • "It is also important to note here the existence of relevant worldwide differences in emergency systems that can be significant in the care of patients in a palliative care setting who are in acute emergency situations [35]. These differences were noted by the experts questioned and would be partially integrated into outpatient palliative care. "
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    ABSTRACT: Background To determine the international recommendations and current practices for the treatment and prevention of palliative emergencies. The primary goal of the study was to gather information from experts on their nationally practised concepts. Methods One hundred and fifty self-report surveys were distributed by email to selected leading experts (palliative and emergency medical care) in Europe, North and South America, Africa, Asia, and Australia. An expert in this context was defined as an author of an article that was ranked by three reviewers as relevant to outpatient palliative and emergency medical . Results The total response rate was 61% (n = 92 experts). Survey responses were obtained from 35 different countries. The following standards in the treatment of palliative emergencies were recommended: (1) early integration of “Palliative Care Teams” (PCTs) and basic outpatient palliative care systems, (2) end-of-life discussions, (3) defined emergency medical documents, drug boxes, and “Do not attempt resuscitation” orders and (4) emergency medical training (physicians and paramedics). Conclusions This study detected structurally and nationally differences in outpatient palliative care regarding the treatment of palliative emergencies. Accordingly, these differences should be discussed and adapted to the respective specifications of individual single countries. A single established outpatient palliative emergency medical care concept may be the basis for an overall out-of-hospital palliative care system.
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