Throughout the world the necessity of high quality prehospital emergency care has been recognized and, if not yet established, is on the way to developing in most countries. Two major models in out-of-hospital emergency care exist in today’s world: The first model, founded in America, brings the patient to the doctor with the help of physician extenders known as the so-called “Anglo-American System” (AAS). In contrast, the second system, mainly found in Europe, brings the physician to the patient and initiates definitive patient treatment in the prehospital setting, often referred to as the “Franco-German System” (FGS).
Almost all countries recently developing emergency medical services (pink) adopt the American model (red), putting paramedics in charge of the prehospital emergency care.
A shortage of doctors and high maintenance costs in the FGS on the one side versus a lower quality of care provided by paramedics in the AAS on the other side. This causes an incalculable increase in follow-up costs such as longer hospital stays, rehabilitation expenses and potential economic loss due to a prolonged inability to work. Considering such evidence, it’s quite amazing that recently almost every developing emergency medical service in the world has adopted the American model.
This new “integrative concept” (IC) for prehospital emergency care was developed to offer an alternative to the existing models. It aims to be applicable in most regions of the world, specifically those who are currently in the process of establishing emergency medicine. At the same time the IC for prehospital emergency care seeks to exceed the existing models in economic efficiency without compromising the quality of care, but by enhancing it. In order to do so, this new concept combines the advantages of the FGS, the AAS and the latest communications technology.
Dr. von Bergh extracting a patient from a car wreck after a frontal collision in October 2005. The patient (protected by a helmet) was immediately put under full anaesthesia due to severe pain while still trapped.
Specially trained emergency physicians are best qualified to diagnose and treat the patients at the place where the emergency occurred. However, in contrast to the FGS the physician will only be physically present at the patient’s side if absolutely necessary. In other life-threatening cases when paramedics or first-responders are at the scene and need help from a physician without him/her actually being at the patient’s side, the medical extenders (paramedics) can place a video conference call to consult a specialized physician. With a portable communication unit, a video conference call can be placed, which is answered by a physician working in the medical specialty that relates to the patient’s disease or injury (cardiology, neurology, pediatrics etc). If the shortage of medical professionals in a developing country does not allow the involvement in prehospital care, those calls could even be transferred globally to developed countries with adequate human resources. The consulted doctor can see a live video of the patient, diagnose the patient with special equipment hooked up to the communication unit, for example an Electrocardiogram, see the listed vital signs on the screen, be able to auscultate (listen to) the heart and stomach and possibly see an ultrasound image. After establishing a diagnosis the physician can expand the pharmaceutical treatment spectrum of the paramedics and triage the patient, while bi-directionally communicating with the patient and the ambulance crew. To ensure the physician extenders are able to put the doctor’s instructions into action, their education would have to focus more on executing invasive treatments.
One technological approach to guarantee the video-communication between a mobile ambulance crew and a physician via conference call, is delivered by Cisco Systems, the Cisco 3200 Mobile Access Router. This technology uses or adds onto pre-existing communication infrastructures of multiple sources by connecting a wireless local area network with mobile phone networks (GPRS) and fairly new communications technology (UMTS) with the possibility of an extremely high data transfer.
The Cisco 3200 Mobile Access Router from Cisco Systems creates a local area network surrounding the ambulance to guarantee a high data transfer by combining multiple telecommunication networks (GPRS, UMTS, Radio).
If physician extenders would act as “first responders” to all emergency calls and only request help when the patient requires prehospital stabilization, it is most likely to reduce any physician involvement in over 70% of all cases.
The retrospective analysis of the German system showed that with the ability of video conferencing technology about 20% of all serious emergencies could have been treated through a computer terminal without sending an emergency physician to the scene.
In cases of severity, the video conferencing physician is able to send a specially trained emergency physician to the scene with a helicopter, or in another emergency vehicle to “rendezvous” with the patient and ambulance crew. The exceeding benefits for patients in actual life-threatening conditions were seen in a direct comparison of the FGS with the AAS by evaluating process efficiency and cost-effectiveness between Bonn and Birmingham in 2003. It showed that critically ill or injured patients had a significantly higher benefit when being treated by a physician. The primary success rate of resuscitations was also dramatically higher under the treatment of an emergency physician; 40.4% of all patients reached the hospital with self-sustained circulation compared to 10.7% under paramedic treatment.
1000 German emergency protocols with the involvement of an emergency physician were analysed. The new “integrative concept” (IC) proposes an involvement of doctors in about 20% of all cases via video-conference call and less than 10% require an emergency physician physically present at the patient’s side.
The advantage of a doctor’s treatment can only be seen the more severe the patient’s condition is. In all other cases the immediate transport by physician extenders should be efficient. The necessity of activating an emergency physician to be “hands-on” at the patient’s side could be reduced to less than 10% of all emergencies. These remaining patients would benefit from the higher education- and skill levels of a physician by presumably causing a shorter hospital length-of-stay and reducing the follow up costs through a better patient outcome.
Taking into account the flexibility of the system, as well as the accessibility of technology, this new concept could be implemented in most areas of the world. It constitutes a real alternative to the existing systems of prehospital emergency care by possessing a substantial chance to increase quality and reduce healthcare expenditures.
