Franco-German and Anglo-American models of emergency medical care differ. The first brings the physician to the patient on scene, while the latter brings patients to physicians in hospital. In a recent German study, physicians remarked, “Do we really have to study whether a high density of less qualified EMS personnel leads to similar or even better outcome than a system in which highly qualified physicians, providing better transportation stability, take care of the critically ill patient?” Are physicians needed in pre-hospital emergency care settings? If so, in what medical setting is such a system tenable?
On-scene time
Time is of such importance in medical emergencies and trauma that the term, “golden hour” has been designated to the period during which treatment is most likely to have a positive effect on a patient’s outcome. The two EMS models make an effort to treat the patients as soon as possible using different approaches. The Anglo-American model revolves around the “scoop and run” idea, bringing the patient to the physician in a hospital as quickly as possible. The Franco-German utilizes the “stay and play” concept, reflected in longer on-scene time. This time is not wasted though, and may even be considered better utilized as the physician is brought to the patient and can begin advanced and/or aggressive treatment on scene, improving the outcome and chances of survival. In the Anglo-American model, time is lost on many minor cases, because paramedics and EMTs must transport most patients to hospitals in order to be cleared by physicians, whereas in the Franco-German model, physicians can treat patients at the scene and decide which patients do not require hospitalization. Another factor that may prolong on-scene time in a negative way in the Anglo-American model is the skill level of paramedics and EMT. Lastly, there are situations with unavoidably prolonged pre-hospital time, for example when ambulating the patient may be difficult and transport to hospital delayed. In this case, the presence of a physician significantly improves survival rates. A large group of studies has demonstrated that the benefit of helicopter emergency medical service (HEMS) is not to be attributed to faster transportation, but rather to the presence of a physician.
Expertise and skill
The length of EMT and paramedic training programs ranges from a few months to two years depending on the policy of the country and the specific degree. EMTs are required to follow standard operating procedures, whereas physicians may, in certain circumstances, act autonomously. There is an ongoing debate on skills which paramedics should or should not be allowed to utilize. It has been found that there is a relatively high rate of misplaced endotracheal tubes in patients intubated by paramedics. Even with adequate training, skills deteriorate over time, as is the case with paramedics who mostly attend minor cases and do not regularly utilize practical skills such as endotracheal intubation, and intravenous drug administration. Physicians usually practice these skills in their hospital settings as well as in pre-hospital environment, allowing them more of a chance to practice their skills. In addition, specialists are more qualified to perform such skills in non-standard conditions.
Quality of care
Skills and expertise of EMTs and physicians reflect in quality of care. A large number of studies show a significantly better first hour and first day survival rate, a better functional outcome, as well as less time spent in intensive care unit in trauma patients; as well as survival of patients with acute myocardial infarction and respiratory diseases when treated by physicians. These results may reflect the higher level of expertise and the more profound knowledge of the physicians, as well as their ability to make clinical decisions and use aggressive treatment on scene. Studies have, however, found a difference in survival even when standard procedures were followed by both physicians and EMTs, such as in cases of cardiac arrest. Physicians administer a higher number of drug dosages per minute, they have shorter hands-off intervals and pre-shock pauses, and intubate a greater proportion of patients.
Issues
One of the biggest problems of maintaining a physician-based EMS is the financial “loss”. Is it worth overcrowding the Accident and Emergency (A&E) waiting rooms with myriads of “minor” patients who EMTs have to bring in, rather than clearing the A&E departments and allowing the staff to treat the more serious cases requiring advanced hospital equipment? Looking at the larger picture, survival of patients after CPR may be less costly in the Franco-German model than in the Anglo-American model. A study showed the expense of 0.7 euro per patient after CPR in Birmingham, compared to 0.17 euro in Bonn. Another problem, arguably more evident in the Americas than in the Europe is the litigious concerns. Many physicians who volunteer or work in ambulance services in the USA have malpractice insurance, which only covers their practice at their respective facilities, not in the pre-hospital environment, making them vulnerable to malpractice law suits. Some hospitals have overcome this problem by rewriting their insurance policies to include pre-hospital coverage for physicians working in those capacities.
While I support the involvement of physicians in pre-hospital emergency care, there remains a question of which physicians should be sent on the scene. Not all countries have enough physicians or adequate finances to allow all ambulances to be manned by anesthesiology or emergency medicine specialists, and instead send out newly qualified doctors with little experience. The right answer may lie between the two extremes: the use of both physicians and EMTs. For example, in Portugal dispatchers communicate with patients and decide whether to dispatch an emergency vehicle, as well as whether to man the vehicle with a physician and a nurse, or two EMTs.
Sources:
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Featured images courtesy of Dr. Gregor Prosen