# Ems around the globe



## Belgian EMT/nurse (Jan 7, 2009)

Hi to all fellow collegues all over the world. Thought it would be fun to start a thread.

All over the world there are different EMS systems.. In the USA there's the emt-B/paramedic system, here in belgium poorly trained ambulance-personnel with ALS back up from a medical team (ER doc + Nurse with a ER and intensive care degree), in holland there's a ambulance driver + a specially trainend ambulance nurse and 4 trauma helicopters (doc+nurse) spreid over the country in case the ambulance nurse needs back up. In germany highly trainend ambulance personnel with back up from a doctor (notartz), and so on..

So guys give me your idea's about the different systems, pro's vs contra's, what's good what's not good, etc...


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## medicdan (Jan 7, 2009)

A quick inro to the EMS system in Israel (at some point I will write a full synopsis for this forum).

The system is run by Magen David Adom of Israel, an arm of the International Red Cross/Red Crescent Societies and provides all ambulance services and certification in the country. 

Two types of ambulances are staffed in the country, Ragil/Lavan, and Natan/Atan (translated as Regular/White and an acronym for mobile intensive care unit). 

The Ragil is staffed by an equivilant EMT/driver and 2 often high school volunteer First Responders. The idea is that any major stabilization that needs to happen on scene is done by the EMT, and ongoing assessments can be done by the FRs. Ragil is very basic, carrying no drugs other than O2. 

In contrast, Natan/Atan are very advanced. Some of the Natan/Atan ambulances in the country are staffed with and MD, others with just a paramedic and equivilant Intermediate driver. With an MD, the level of care on board increases, and they have had trials with such things as pre-hospital TPA (interesting application without CT, but I digress).

The attitude towards pre-hospital medicine clearly has it's roots in military medicine. There is a strong emphasis on diesel medicine for the Ragil (loading the patient and getting to a hospital ASAP), while Natan tends to stay and play because of their advanced capacities. 

Israel has pioneered in the art and science of mass casualty and terror response medicine. I wont go into the details here, but all of their EMTs are trained in IV insertion, and just about every patient on a terror scene gets a bag of NS, wide open. They keep 2-3 times the normal number of ambulances on shift accessible and available (and checked out every morning), so they can be grabbed at a minute's notice and used. Finally, a fairly large percentage of the population is trained to the FR/EMT level, and per-capita a large percentage to the paramedic and MD level. 

Lastly, compared to the US system, there is much less emphasis on paperwork and CYA in order to avoid lawsuit. The assertion is that whatever needs to be done for the patient pre-hospital, should be done, no questions asked. The Ragil PCR is one 8.5x11" piece of paper, mostly check boxes, with one line of narrative. The natan is a little more complicated, but remains manageable. 

I hope this quickly provides an overview of Israeli pre-hospital medicine. At some point, I will come back to revise and add to this.

How about other countries?


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## Flight-LP (Jan 7, 2009)

All about international EMS..........................

http://www.international-ems.com/forum/


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## CHITOWNMEDIC (Mar 10, 2009)

*EMS & Quebec.*

Quebec province Canada still has Technicien Ambulanciers. They only use an airway device called a 'Combitube' an A.E.D. & administer 4 symptom relief meds. 3 by mouth,1 by aerosol. In 2001 there were 17 techniciens that went through an advanced Paramedic course (SPA = Soins Prehopitalier Avance') & graduated, one month into their service the Quebec college of Doctors put a stop to it. For some reason the higher ups in Quebec DO NOT want advanced Paramedics. Before the ambulance in Montreal (Urgence Sante') Montreal had actual ambulance companies with full ALS services (ie: Medic-One, Resusci-Car,etc) While most of North America enjoys having ALS Paramedics, I believe Quebec is the only part that still does'nt have ALS. Like their saying goes: "On a une Urgence, a' re'guler".   C'est la vie Je croire..


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## LIFEGUARDAVIDAS (May 13, 2009)

*EMS chaotic situation in Argentina 1/2*

In my case, I was born in Israel but have been living in Argentina for the last 15 years. (I work counter-seasonally in the US). Since in EMT Life there are many experienced MDA (Magen David Adom) members I will stick to comment about Argentina’s EMS.

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In Argentina EMS is at a very improvable status. It is a bit better than in other South American countries but still… disastrous. It is called Sistema de Emergencias Medicas (Medical Emergencies System) instead of Servicio Medico de Emergencia (Emergency Medical Service). Some hospital now have signs that say Emergencias (Emergencies) but most still describe their areas equivalent to ERs as Urgencias (Urgencies). There are also public and private clinics that deal with medical emergencies. Their areas are usually called “Guardia” (guard / watch). The term is used since doctors and nurses are “on guard” / “on watch” (~ on call).

Budgets are a main problem but does not justify the low level of training on behalf of EMS personnel. Over 90% has knowledge under a USDOT FR level. It is rare to find a CPR Mask (Pocket Mask® or other brand on an ambulance that is over a year old) and Nitrile gloves are unknown to most, Latex gloves are still the ones in use.

Paperwork is still taken as a joke in some areas (non existent) and in others it is not taken very strictly.

*ORGANIZATION*

Ambulance services are provided by governmental agencies (mostly at the province government level, but there are a few municipal and national services), private companies and non-profit organizations.

Government departments and divisions are called ministries and secretaries and usually those in charge of Public Health operate public hospitals and ambulance services. Public ambulances are stationed at hospitals and respond to calls from there. Argentina has different emergency phone numbers that are used nationally:

1-0-0   = Fire
1-0-1	= Police
1-0-2	= Child abuse
1-0-3	= Civil Defense / Civil Protection / Municipal emergencies
1-0-5	= Environmental emergencies (Park Rangers)
1-0-6	= Nautical emergencies (Coast Guard)
1-0-7	= Medical emergencies (Ambulance)

In the last years some of Argentina’s largest metropolitan areas started using 9-1-1 as an emergency phone number parallel to the 1-0-1 since most people never got to learn the proper emergency numbers but knew the world famous 9-1-1 from movies and TV shows. The change is just in the number since it is still entirely operated by province or federal police and does not function as a central emergency system phone number.

In Argentina, Fire services are also in quite a chaotic situation. The only entirely professional firefighters are those few working for private fire squads at petrol-oil companies in the fields and refineries. Most fire services in Argentina are provided by Volunteer Firefighters Associations all at some point related to a National Federation. Then, law enforcement only exist at the Province and Federal levels. Non of Argentina’s municipal governments have their own police or fire agency. All provincial police agencies (equivalent to state police) have a firefighters division. These divisions only provide fire-rescue services to the province capital city and sometimes some other major cities. In a few provinces, all fire stations (even in rural areas) have a mixed staff. A commander / supervisor who belongs to the province police fire division and a crew of volunteer firefighters. There are also two federal law enforcement agencies that have their own fire divisions. One if the PFA (Policia Federal Argentina = Argentine Federal Police) and the PNA (Prefectura Naval Argentina = Argentine Naval Prefecture) which is the Coast Guard service provider. Then the APN (Administracion de Parques Nacionales = National Parks Administration) has in addition to its park rangers some brigades specialized in wild fires. Some provinces have their own wild fire brigades too.

A few fire services have their own ambulances, some (being imported) tend to be better equipped that those ambulances from public hospitals and private companies. However, they are usually only used as transport for lightly injured patients and transporting EMS equipment to MVAs and general rescues. On rare occasions they are used for transportation of patients in critical conditions or injured firefighters.

Private ambulance companies usually provide services in different categories: non-emergency patient transport, doctor house calls, emergency response to private business (from small stores to large shopping malls), highway emergency medical response (mostly for private toll / highway administrating companies), events (sport events, concerts, expositions, etc.), and (very few) emergency medical response calls through 1-0-7 (the public EMS). –The latter is similar to some areas in the US where private ambulance companies are contracted to provide a public EMS either in addition to governmental EMS or instead of (like in jurisdictions where there are non). In the event of a mass incident / disaster private ambulance companies have to render support (free of charge) in addition to public ambulance services by law.

Some private Health / Medical Insurance / Social Security (~ private “Medi-Care”) entities have their own ambulances which generally just function as non-critical patient transport. –Usually when one of their clients gets transferred from a public medical facility to a private clinic or when geriatrics (being their customers) need transport from or to a medical facility.

Non-profit organizations such as the Cruz Roja Argentina (Argentine Red Cross) and others have their own ambulances. These are few and rarely are used for actual emergencies. –Mostly for events, disaster relief and non-critical patient transport.   


*EQUIPMENT*

Equipment wide, mostly are nothing else but a van or sometimes even a pick up truck with a camper on its box / bed, a stretcher and an old fixed Oxygen tank. Some others are elevated roof vans with basic trauma equipment, portable Oxygen tanks, defibrillator, etc… Then just in recent years full size nationally made ambulances have been customized in order to have a design similar to type III ones.  Due to Argentina’s and Brazil strong automotive industries, there are very few imported ambulances. –Those few are mostly American types I, II and III (generally Ford F-350 / E-350).


*STAFF & TRAINING*

Ambulances are staffed by 2-3 people depending on the agency budget, jurisdiction, and location. Those that have only 2 crew members include a driver and a “camillero” (“stretcherer”). The driver only has to have a professional driver’s license and on occasions some first aid and basic CPR knowledge. The “stretcherer” usually only has first aid and basic CPR skills plus Oxygen administration –only sometimes. 

In metropolitan and high-tourism-rural areas  there’s a third crew member. A doctor. This doctor hardly ever has specialized training in emergency medical care (neither hospital nor pre-hospital) other than the one provided at University.

Pre-hospital emergency medical care in Argentina is still viewed by the general public and most medical professionals as “scoop and run” other than treat at scene and in transit. Hence the low probabilities of critical patients to survive. –A bad mix: poor quality pre-hospital emergency medical care and incredibly long response time frames. (Average in metropolitan areas: 20-30 minutes. Rural areas: 30 minutes to never / “no show”).

In the last years, thanks to organizations such as AHA (American Heart Association) and NAEMT (National Association of Emergency Medical Technicians) (among others) BLS, ACLS and PHTLS courses became a bit more known to EMS personnel. National organizations such as Cruz Roja Argentina (Argentine Red Cross) and Fundacion Cardiologica Argentina (among others) now provides nationally recognized CPR certification based on ECCs to a wider public.

A few universities started offering paramedic careers but due to the mostly European influenced medical / public health systems and resistance from doctors those careers are only valid at the province level and are not nationally recognized yet. 

Some ambulance personnel, firefighters, military personnel, lifeguards, mountain guides, ski patrol staff, divers and park rangers obtain training from North American and European internationally recognized organizations in subjects such as BLS, ALS (ACLS / AMLS), PHTLS (formerly BTLS and ATLS), WFA, WFR, Oxygen administration and AED use, on their own (out of one’s pocket), or through their own agencies / organizations.

Lifeguards graduated from Superior Education Institutes and their lifeguard schools (only those either belonging to the Argentine Red Cross or in the Province of Buenos Aires) can work as crew members on ambulances –not as drivers (unless they posses a professional driver’s license). Also, some lifeguard schools are encouraging their students to take training in addition to their curriculum such as BLS (either from AHA, FCA, …) and PHTLS (from NAEMT).


CONTINUED BELOW>>>


Guri


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## LIFEGUARDAVIDAS (May 13, 2009)

CONTINUED FROM ABOVE>>>

EMS chaotic situation in Argentina 2/2


*GENERAL PUBLIC*

Lay people who are trained / certified in basic first aid and basic CPR are still a very small minority even in modern metropolitan areas. The average person has no basic concepts of first aid even less of CRR. Since 1-0-7 dispatchers are just that, dispatchers, they are not trained, capable or willing to provide over-the-phone instructions to callers, the probabilities of critical patients in the pre-hospital setting are very very low. In addition, the average person is aware of the bad response time frames of Argentine ambulances and considers them merely a means of transportation to an hospital, so transporting a patient on their own with a private car is still a popular choice for him/her. 

The lack of common knowledge in recognition of actual medical emergencies, the widely common Latin American costume of self-medicating, superstitious culture, and an increasing alcohol/drug related violence are all factors that help decreasing the chances of a person in critical medical condition in the Argentine pre-hospital setting to survive. 


*EXAMPLE*

In Christmas of 2005 a disco called Cromañon (Cromagnon) in the city of Buenos Aires (Argentina’s capital city, largest and most populated city, and a federal district) set on fire during a rock concert. Due to common and almost accepted corruption, municipal inspectors and federal police fire inspectors “missed” the blocked emergency exits during their monthly inspections, as well as the many building code violations. Fireworks thrown by fans during the concert set on fire un-approved sealing materials and as in most cases like this the place got on fire in a matter of minutes. (Incidents like this due to reasons like these have happened in many countries around the world). Federal Police, Federal Police-Fire, SAME (the city’s municipal EMS), private ambulance companies, Civil Defense, city emergency service, and good Samaritans / lay responders, and, victims friends and relatives alerted by the news channels all responded.

Lack of perimeter “taping” and crowd control allowed new victims to enter the disco. Lack of IC system and Triage execution ended in patients with minor injuries being transported urgently to hospitals and critical still savable ones having to wait for an ambulances. Firefighters who entered without SCBA ended up turning into patients. Patients carried on improvised boards such as fence pieces and doors by well intentioned but ignorant lay responders ended up damaging permanently the few survivers. On live news one could observe ambulance crew members committing abandonment and standard of care violations due to poor training. The evacuation was unnecessarily too fast –about two hours.

Outcome: 193 people died. There were two known cases of patients waking up at the morgue since they were left for dead by poorly trained ambulance personnel. After autopsies were done, it was found that 153 out of the 193 died due to mal praxis, wrong / non-sufficient / slow / lack of, pre-hospital emergency medical care.      

Later on, heads of the Federal Police Fire division, the city’s EMS, CD, and the chief of government (mayor) rolled. Trials against the federal and municipal emergency services, federal and municipal inspectors, the former mayor, the disco owner, the rock band and others are still in progress. Justice is slow and in Argentina is slower. (Calling it Justice is merely a formality). It is still a recurrent controversial subject on today’s news and origin to many demonstrations. Many post-incident deaths are still occurring due to suicides and cardiac arrests on behalf of survivers, friends and relatives of victims, and those who are both. Aside from the media and political circus, few changes were actually made in today’s city inter-agency emergency management plans and if such an incident happens again, the result will very likely be a similar one.


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Hope readers found this typical Latin American country’ EMS situation interesting. Looking forward to reading about other countries,


Guri


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## LIFEGUARDAVIDAS (May 13, 2009)

Oops, sorry for those typos and spelling mistakes. (Ment survivors not survivers).  

Guri


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## Volunteer_EMT_Ph (Jun 16, 2009)

Hi all and Mabuhay! (A greeting in the Philippines similar to Hola! in Mexico. etc.)

As of now I represent the Philippines in this thread.

The best EMS providers here in the Philippines are private and voluntary.  Most of these  providers operate ambulances and firetrucks.  Organizations vary, like for instance, one group have a doctor on duty for the day at their HQ.  When a unit is dispatched, the crew communicates with the doctor when treating the pt.  Some groups have part-time doctors riding along in their rigs.  In our case, we operate under protocols made by doctors, who are also our trainors.  Our group is only in the beginning stages and we are on the process of straightening our procedures.  Private EMS were organized and are being organized here in our country because the government doesn't give much attention to this important service.  Government agencies such as the fire department, coast guard, etc, have a lousy EMS system, often outdated and only a little more than a basic first aid training.  Sorry guys but that's what it seems.  I'm not putting them down but then they're not doing their jobs.  Well thanks to retired EMT's and firefighters from the U.S. and other countries who live here in the Philippines, they made the effort to share their knowledge with us.  It is a very valuable lesson to us EMS providers.  We're doing as much as we can to provide emergency care, taking the successful EMS system of the U.S. and European countries.  It worked for them, ther's no reason why it will not work fo us.  Currently, big cities such as Manila, Baguio and Cebu have well-established EMS providers.  Our city (Dumaguete City) is small and we are learning from the EMS of the bigger cities as we establish an EMS system in our city.  Basically that's how the EMS work here in the Philippines.


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## emt1994 (Jun 17, 2009)

Thanks for sharing all the differences around the globe its interesting how different it is in treating people and how you run your calls.


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## SES4 (Jun 17, 2009)

*Wow.*

It is amazing how different things are around the world yet we aim to achieve the same goals.  

In any given event, stay safe out there and remember the reason we all do what we do!


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## WolfmanHarris (Jun 22, 2009)

Canada has a system with some regional differences among the ten provinces and three territories. I'll focus on Ontario and make comment about differences where I'm aware of them. 

Delivery Model:
- Provincial Direct Delivery
- Provincial Contracted Delivery
- Municipal
- Hospital Based
- Private
- Fire-based

Currently Provincial Contracted Delivery is the big change in EMS in Canada. The eastern provinces (Nova Scotia, New Brunswick, PEI, but not in this case Newfoundland and Labrador) have recently moved to buy out all the old services (private, volunteer, hospital, fire, etc) and create a single provincial service. This service is owned by the province but they then contract out to Medavie Blue Cross to operate the service. Newfounland and Labrador remain a hodge-podge.

Provincial direct delivery is the model of choice for BC and Alberta. British Columbia has the British Columbia Ambulance Service and Alberta has recently taken over funding and provision of EMS with a few services remaining in operation under contract to the Province, but most switching to direct provincial control. This is a new move for Alberta though and how it pans out remains to be seen. As for BC... well google BCAS and Strike and you'll learn about the issues they're having at the moment.

I'm not too familiar with how Saskatchewan and Manitoba run their systems, but I do know there are some private providers, some Provincial and some municipal. For example, Winnipeg has the Winnipeg Fire-Paramedic Service, but the Province still has some role in EMS as demonstrated by their purchase of new vehicles recently. Hopefully a provider from out there will jump in.

Quebec was referenced above.

The territories are probably best left for FortSmithMan as that's up his way.

Ontario is almost entirely Municipal third service, with the Upper Tier Municipalities (UTM's) providing most of the EMS services. This follows a download from the province in 2001. EMS is the responsibility of the UTM's and most have chosen to run them directly. A few have contracted to private provider but these have been disappearing rapidly as more are choosing to provide the service directly. Only three counties currently have a private provider. There are three services to my knowledge that have a formal relationship with the fire service, but this is at an upper administration level only and not a case of dual role providers. 

Education:
Education still varies significantly from Province to Province. Greater unification is happening thanks to the National Occupational Competency Profiles (NOCP) which were created by the Paramedic Association of Canada (PAC). The NOCP has standardized titles to:
- Emergency Medical Responder (EMR) - Rarely used in EMS outside of rural/remote areas
- Primary Care Paramedic (PCP)
- Advanced Care Paramedic (ACP)
- Critical Care Paramedic

This is of course complicated by Alberta. Alberta uses the titles EMT (for PCP) and Paramedic (for ACP), but now most education programs seems to list the NOCP titles alongside the Alberta one's in their course calenders.

Education still varies greatly, from a 4 month PCP program in British Columbia to a 2 year PCP program in Ontario and a great deal in between. ACP though is a two year program everywhere but Ontario, which has a one year ACP program, but the longest PCP program by far.

We're getting better across the country, but there's still room for improvement. My hope is that by the end of my career (or sooner) we will have a universal 4 year degree for Paramedic with a post-graduate diploma for Critical Care. The University of Toronto has gotten the ball rolling with a combined PCP and BSc program.


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## fortsmithman (Jun 23, 2009)

Here in the Northwest Territories Canada we have no legislation pertaining to EMS.  Even our Motor Vehicles Act makes no mention of ambulance.  It just mention police and fire rescue vehicles.  My service does have members registered in 2 other provinces Alberta and Nova Scotia.  My services co-ordinator informed us that in the future maybe the next 10 years that EMR would no longer be allowed for EMS and the minimum would be that of PCP.


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## Yugosaki (Jun 25, 2009)

I'm in Alberta, canada. Heres how I understand our system.

There are various levels of first aid and first responder, for all intents and purposes they are non-EMS.

EMR is the minimum level to work in EMS. I have been told that our EMR is roughly the same as EMT-B in some states. Many towns allow you to work on an ambulance at this level, and you can work interhospital transport. This is also a prerequisite for other EMS courses and most fire courses.

EMT (also known as EMT-A or PCP) is the typical standard to be a prehospital medical professional in alberta, most major cities consider this the minimum to work on the regular ambulance service.

EMT-P (Paramedic) pretty much what the name implies, paramedic.

As far as i know, you must complete one before the other (ex, i have to be an EMR before EMT, and EMT before EMT-P. No combined courses i know of)


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