Paramedics in prehospital emergency medical systems across Europe

Health system in Europe

The organization and means of prehospital EMS depends, in part, on the health system. Throughout Europe, there are a combination of different cultures and influences, as well as economic systems and health policies that also vary between regions. It is difficult to compare the health care system because few global health indicators provide good summary measures of overall population health.

Despite the harmonization of health policy in Europe, some differences persist. The data chosen for this overview to illustrate the health care system in Europe is shown in Table 1. Such data displays a part of the health system and population health in the European region, which helps explain some differences in the organization and means of prehospital EMS.

Anglo-American model

This model is paramedic-led, with the care on scene performed by skilled practitioners, who ensure arrival to hospital is as prompt and safe as possible; this is a ‘scoop and run’ approach. In this model, it is rare to find a physician in the prehospital setting, although they may be used for complex situations; for untransportable critically ill patients; for trapped patients, or when non-physician protocols are insufficient (Dick, 2003; Fleischmann and Fulde, 2006). In Europe, only Finland, Ireland, the Netherlands and UK apply this model.

Franco-German model

The model is physician-led, with doctors sent on all major emergencies; on-scene care is highly developed and the patient is stabilized before being transported; this is a ‘stay and care’ approach (Dick, 2003; Fleischmann and Fulde, 2007). This is the most common model in Europe. Two different systems are used to transport the physician on-scene: the stationary system and the ‘rendezvous’ system. In the first, the physician travels with the ALS-unit. In the second, the physician arrives in a rapid response car with all necessary equipment, but no facilities for patient transport.

The stationary system has the advantage that only one vehicle has to be sent, but the ‘rendezvous’ system is more flexible—if the patient does not need to be escorted by the physician, he/she is available for the next call much earlier (Dick, 2003). Another advantage is that the physician can evaluate, treat, and discharge the patient in the field without transporting the patient to the hospital (Dick, 2003).

Ambulance driver (AD)

An ambulance driver (AD) drives the staff on scenes and performs patient transport duties (which can include stretcher or wheelchair cases); AD can only assist physicians and nurses, but does not have legal permission for independent emergency care. Usually, the AD has first-aid skills only, such as cardiopulmonary resuscitation (CPR) and can use automated external defibrillators (AED), but AD is also trained in radio-communications, ambulance operations and emergency response driving skills. AD receives between 12–60 hours of training, often characterized as minimal; except in two countries (Estonia and France) where AD receives between 400–500 hours of training, but with the same legal restrictions than other countries—thus with additional skills not exploited.

Basic emergency medical technician (EMT-B)

A basic emergency medical technician (EMT-B) is usually capable of performing a wide range of emergency care skills independently, such as BLS (CPR and AED); basic airway management; haemorrhage control and wound care, immobilization of fracture including the spine; management of burns; uncomplicated and unplanned obstetric delivery, and providing safe transport. EMT-B can also perform an assessment of the critically ill patient and a first triage. However, EMT-B cannot perform invasive procedures (intravenous (IV) cannulation, endotracheal intubation and administration of pharmacotherapy). EMT-B usually receives 110 to 560 hours of training, except for four countries (Finland, Hungary, Sweden and UK) where he receives between 1080–2800 hours. The European median (SD) for EMT-B training is 408 hours (±885).

Paramedic (EMT-P)

A paramedic is a type of emergency medical technician, and performs all of the skills performed by an EMT-B, but has a higher level of medical training. Paramedics are trained to deal with a broad range of emergency medical or traumatic situations. These include management of cardiac, respiratory, orthopaedic, obstetric, paediatric, metabolic, trauma emergencies, and psychological and mental health emergencies. Paramedics are also trained in communications, vehicle extrication, IV or intraosseous line placement, fluid administration, intravenous therapy and pharmacotherapy, with the administration of a wide range of medications such as epinephrine, nitroglycerine, inhaled ß2-adrenergic drugs and benzodiazepines such as lorazepam and dextrose.

Sometimes, paramedics are trained in tracheal intubation, but almost always without muscle relaxants or anaesthetic agents and exclusively for cardiac arrests. They are also trained in advanced cardiac life support, including cardiac monitoring; 12-lead ECG interpretation; synchronized cardioversion and transcutaneous cardiac pacing; paediatric advanced life support, and needle chest decompression.

Paramedics receive from 1000–5508 hours of training, except for Austria where they receive 480 hours. The European median (SD) for EMT-P training is 2000 hours (±2053).

In the countries with Anglo-American model (UK, Finland and The Netherlands), the paramedic training is 4 years, except in Ireland where the training is 1009 hours.

For the other European countries with FrancoGerman model and paramedics, the training median (SD) is 1795 hours (±966), corresponding to a little over a year of training. This difference is explained by the great skills of paramedics in the Anglo-American model.

Registered nurse (RN)

The use of registered nurses (RNs) in the prehospital setting is more common in countries that do not have paramedics (except in Finland). The nurses can provide ALS services, perform practically all emergency procedures, and administer medicines prehospital settings in the same way as physicians. These RNs may work under the direct supervision of a physician, or, in rare cases, independently. Sometimes jurisdiction permits specially trained nurses for medical inter-hospital transport work.

In Europe, the most common use of RNs is in the ALS-unit with a physician, but in some countries the ambulance nurse leads the team (Finland, Netherlands). Nurses used in a prehospital setting have all completed the full training required to be a RN in Europe, between 3–4 years, followed by additional training and certification in intensive care; prehospital care; cardiac care; anaesthesia or operating room. However, the duration of additional training varies a great deal in each country, and ranges from 40 hours to 2 years.

Physicians

On scene, the physician can provide all necessary interventions. Examples include post-resuscitation care, prehospital thrombolysis, chemical or electrical cardioversion, transcutaneous or transvenous cardiac pacing, non-invasive ventilation, chest drainage, central venous access and prehospital sonography.

In Europe, there are a wide number of specialities that staff the ALS units, mostly anaesthesiologists and emergency physicians but sometimes surgeons, internists, cardiologists, and other specialists. Usually they receive additional training in prehospital emergency medicine to be able to carry out all necessary emergency procedures, between 400 hours and 1 year.

They are capable of performing certain interventions and procedures safely as a result of their clinical expertise which allows them to establish a medical diagnosis, especially in less common conditions such as subarachnoid haemorrhage where the patient can be referred directly to the appropriate hospital for prompt specific treatment. Equally, minor cases can be dealt with on scene, avoiding unnecessary hospital admissions.

For the management of major incidents with mass casualties, every country is required to have an on-call lead emergency physician to coordinate the EMS response. The medical director of an EMS is responsible for supervision, resource planning, quality management and audits as well as continuing education of EMS personnel. The director also represents the EMS on external bodies and coordinates the activities of the EMS with other institutions (e.g. police, fire brigade, hospitals).

Response time

Response time is a very important factor in determining the quality of prehospital EMS, and rapid access to care is fundamental, especially for the trauma emergencies. In European countries, in urban areas, BLS-unit average response times vary from 4 to 10 minutes; the European median (SD) response time is 6 min (±2.28). ALS-unit average response times vary from 5 to 13 minutes; the European median (SD) response time is 8 min (±1.96).

The response time is obviously longer in rural areas, between 15 and 30 min, and as a function of the geographical conditions of each country.

Ambulance or rapid emergency car

Ground ambulance is mostly used. Many vehicles can be adapted to fill the role of a ground ambulance; all countries have to respect European standards (EN 1789: 2007+A1: 2010). It needs safety features for patients and personnel, a modular structure that allows for local and regional flexibility in stocking equipment and supplies, and a place for basic immobilization tools.

Motorcycle

In seven countries (Greece, Hungary, Netherlands, Poland, Portugal, UK, and Slovenia), 12–20 motorcycles staffed with either a paramedic or one physician and one paramedic are used to improve the response time for emergency medical care. They are used in particular in metropolitan areas where traffic congestions are common, but further safety and efficiency studies are necessary.

Helicopter

Helicopter emergency medical service (HEMS) is available in many countries across Europe (except for Bulgaria and Lithuania, and the information is not available for 5 countries). The use of a helicopter allows for faster response times as well as safe and fast transportation over large distances (Wigman et al, 2010).

HEMS are predominately used in rural areas, especially in mountain regions where transportation on the ground is difficult or even impossible. A helicopter is sent if this is the fastest way of getting a medical team on scene. In many countries, the indications do not differ from those for a ground ALS-unit. They are used in primary as well as secondary (inter-hospital) transport of critically ill or seriously injured patients. Serious injuries, followed by neurological diseases, are the most common reasons for HEMS operations (Wigman et al, 2010).