- Email: [email protected]
Emergency health services in Bulgaria
Emergency Health Services in Bulgaria OLIVER W. HAYES, DO, MHSA AND HARITON NOVKOV, MD, PHD The emergency care system in Bulgaria is evolving as a hybrid of the former “Soviet-style” health service and western-style emergency medicine. Bulgaria like other “Eastern bloc” Communist nations has undergone a sweeping socioeconomic transformation during the past 10 years. These changes have had profound consequences including the development of emergency services and the recognition of emergency medicine as a specialty in Bulgaria. (Am J Emerg Med 2002;20:122-125. Copyright 2002, Elsevier Science (USA). All rights reserved.)
The Republic of Bulgaria is a central European nation bordering the Black Sea, Turkey, Greece, Macedonia, Serbia, and Romania. Modern Bulgaria emerged in the wake of the last Russian invasion of the Ottoman Empire in (1877) with the Treaty of San Stefano.1 Bulgaria’s strategic location in the Balkan Peninsula has served as a crossroads for Eastern and Western cultures in that the land route from Europe to the Asia runs through its territories. For most of its contemporary history, Bulgaria, typical of Balkan nations, has been challenged by the rivalry and hostility of neighboring empires. However, uncharacteristic of the Balkans, Bulgaria has been relatively free of ethnic hatreds and violence. Approximately the size of Tennessee, Bulgaria has a surface area of 110,901 square kilometers with a total population of 8,230,371 (male 48.8%, female 51.2%). The major ethnic groups inhabiting Bulgaria are: (1) Bulgar, 85.3%; (2) Turk, 8.5%; (3) Roma (Gypsy), 2.6%; (4) Macedonian, 1.5%; and (5) Jewish, 1% (Bulgaria’s Jewish population was spared from the Holocaust).2 Interestingly, the population has become static (population growth rate: ⫺0.63%) with excess of deaths (death rate 14.3 per thousand) over births (birth rate of 7.9 per thousand) influenced by periodic, limited emigration. This negative growth rate needs to be understood in terms of pregnancy terminations, which have outnumbered births since 1980. Approximately two-thirds of the total population resides in urban settings and nearly all adults are literate.1,3 In 1989, Bulgaria experienced significant socioeconomic transformation with the collapse of the Communist one-
From the Section of Emergency Medicine, Michigan State University, East Lansing, MI and the Pediatric Orthopaedic Trauma Department, Pirogov Emergency Medical Institute, Sofia, Bulgaria. The United States Agency for International Development (USAID) has employed the authors as consultants in Bulgaria. Statements or opinions express in this article are those of the authors and not the United States Agency for International Development or the Ministry of Health, Republic of Bulgaria. Manuscript received and accepted August 29, 2001. Address reprint requests to Oliver W. Hayes, DO, MHSA, Section of Emergency Medicine, B-305 West Fee Hall, Michigan State University, East Lansing, MI 48824.E-mail: [email protected] Key Words: Bulgaria, emergency services. Copyright 2002, Elsevier Science (USA). All rights reserved. 0735-6757/02/2002-0015$35.00/0 doi:10.1053/ajem.2002.31147 122
party state.1 A fragile multiparty democracy emerged with a market-oriented economy. This transition although nonviolent and free of ethnic nationalism found in other Balkan countries proved challenging. Anticipated economic improvement accompanying the favorable political changes did not occur.4,5 Rather, laggard advancement on trade and industry reforms pitched the economy into crisis in 1991; marked by turmoil in the banking system, depreciation of currency, high inflation and contraction of domestic production and foreign trade.6 Until most recently the Bulgarian economy has had slow growth coupled with high inflation. Knowledge of the country’s history, heath care system, and economic conditions is essential in understanding changes in emergency services. HEALTH STATUS OF THE BULGARIAN POPULATION In many respects, the health status achievements in Bulgaria have been impressive until lately when progress became sluggish. Infant mortality rate, overall life expectancy and level of health care services are good by international standards. However, life expectancy (71.6 years) has shown little improvement in the past decade and in recent years there has been a decline in life expectancy for men.3 Mortality caused by cardiovascular disease represents the leading cause of adult deaths. Factors relevant to the prevalence of cardiovascular disease include: (1) a daily per capita caloric intake that is 147% of the daily requirement (the second highest in the world according to UNICEF data); (2) unusually high rates of tobacco use, and (3) high fat and dietary salt consumption.3 Malignancies (13.3% of deaths) and unintentional injuries (4.2% of deaths) are the second and third leading causes of adult death, respectively. Infant mortality rate (13.2 deaths/1,000 births) showed substantial improvement until 1980, but then the rate improved.3 Respiratory illnesses are the most prevalent cause of morbidity (accounting for 39.0% of all patient visits), followed by cardiovascular disease (12.1%), neurologic disease (9.8%), and trauma (7.4%).3 Other factors affecting health of the Bulgarian population include alcohol consumption, environmental pollution, and intentional injury. Per capita alcohol consumption and abuse is high in comparison with other European nations.3 Important environmental pollutants include: air pollution from automobile and industrial emissions; water contamination from raw sewage, heavy metals, and detergents; and soil contamination from heavy metals and industrial wastes.4 Intentional injury has emerged as a significant health concern with the development of organized crime and an increasingly violent society. PROFILE OF THE HEALTH CARE SYSTEM Bulgarian health service organization is evolving from a centrally administered system to a much less formalized,
HAYES AND NOVKOV ■ EMERGENCY HEALTH SERVICES IN BULGARIA
divisionalized structure. The previous multitiered health system (see Fig 1) was modeled after that of the former Soviet Union (Bulgaria was a close ally of the former Soviet Union from 1945-1989). An extensive network of primary health clinics formed the base of this health care system. Groups of primary health clinics were served by multispecialty district polyclinics. Community and regional hospitals provided in-patient services for routine medical problems originating from the polyclinics. Provincial hospitals at the next level of care were 400- to 500-bed institutions where most medical specialties are represented. Often at the provincial level, separate hospital facilities existed for tuberculosis, psychiatric conditions, the elderly and other categorical conditions or illnesses. At the apex of the health care pyramid were university medical centers and national specialty hospitals for referral, rehabilitation, and special conditions. An example of such a national specialty hospital is the Pirogov Emergency Medical Institute (PEMI) that has evolved as Bulgaria’s leading trauma center. Currently, PEMI has a well-equipped and busy emergency treatment ward supervised by physicians from the Department of Anesthesiology. Substantial elements of the multitiered health services system remain (especially in rural settings) but institutional consolidation, closure, and system evolution has markedly affected this structure. This network of health care facilities continues to be administered through the Ministry of Health, although control is evolving to local health councils. Most nonemergent health services are obtained from primary health clinics, regional polyclinics, and general or community hospitals. Until recently, it was not possible for patients to be routinely admitted to a hospital without obtaining consent and documentation from a regional polyclinic. Exceptions were made for the severely ill or injured patients who could be directly admitted to the triage area (somewhat equivalent to an ED) of a hospital. Although the number of hospital beds is more than adequate at 98 beds per 10,000 population (a rate similar to that of Italy), basic equipment and support services are lacking in most hospitals. Of the existing 193 hospitals, 125 facilities have some type of emergency treatment area. Annually (in 1998) there were a total of 1,331,831 hospital discharges
123
with a death rate of hospitalized patients of 1.2%.3 Health care expenditures represent 7.3% of the total governmental budget.3 In broad terms, Bulgaria has ample numbers of medical personnel with physician to population rates similar to those in Western European nations (34.6 physicians per 10,000 population).3 Bulgarians enter medical university directly from high school and medical education is 6 years in length. After the completion of medical school, graduates complete 5 obligatory national examinations and enter residency education includes 4 years of training in a tertiary hospital after completion of an internship. Currently, there are 15 teaching hospitals in the country. Although Bulgaria has ample supply of medical personnel, the specialty distribution of physicians is skewed towards specialization. The availability of all levels of medical practitioners shows regional variation, but not such as to cause significant local physician shortages. In 1998, the Bulgarian Parliament approved a system for global health insurance for the entire population. This system is based on a German social model “Krankenkasse” (centralized obligatory national health insurance) and began July 1, 2000. Funding for this health insurance system is based on income taxes (3% of monthly income) with matching funds from employers. Included for the first time in this health care financing system is funding for emergency care. Although socialized health care is the norm, modest private health insurance by small private insurance companies is beginning. STATUS OF EMERGENCY HEALTH SERVICES Until the most recent decade, the concept of emergency care in Bulgaria was similar to the approach found in other Eastern European nations that functioned without true emergency care specialists or EDs, rather various specialty physicians would serve patients in a triage receiving area based on chief complaint. Even today, in some hospitals emergency care continues to be structured in a triage mode where patients are examined in a small receiving area before referral to a specialty service or to an outpatient facility. For example, for a patient presenting with chest pain, a cardiologist or internist would be summoned to examine the patient before transfer to a cardiac care unit for care. In the majority of Bulgarian hospitals limited equipment and facilities exist in these triage areas for the purposes of provision of emergency health care. Critically ill or injured patients are triaged to the intensive care unit and stabilized by a critical care specialist (“reanimatist”) usually an anesthesiologist. From the standpoint of our health care system, these critical care physicians most resemble emergency physicians or hospitalists. In 1994, emergency medicine was officially recognized as a specialty and modest governmental funds were made available to develop emergency health services as described later.7 PREHOSPITAL CARE
FIGURE 1.
Structure of Bulgaria’s health care system.
The emergency ambulance service (“EAS” as prehospital care is known in Bulgaria) consists of a regional dispatch center (separate from police, fire department, or the hospital system), ambulance transport vehicles, and personnel in-
124
AMERICAN JOURNAL OF EMERGENCY MEDICINE ■ Volume 20, Number 2 ■ March 2002
cluding physicians. This service answers emergency calls, initiates responses, and transports patients to polyclinics or regional hospitals for initial evaluation. The ambulance transport vehicles typically have a physician on board but are not equipped with monitoring and resuscitation equipment. In 1997, a national program for training and certification of nonphysician providers for the EAS was implemented. This program included training in first aid, basic cardiac life support, and basic trauma life support. During the first course, nurses, fire fighters and police personnel took part in the training. As governmental funds have been allocated for emergency services, a modest number of better-equipped ambulances with nonphysician providers have been brought on line in larger cities. Although ambulances are now better equipped, communication systems between prehospital personnel and receiving hospitals remain at a rudimentary level. Over the past 5 years prehospital care gradually changed from the centrally based, physician-staffed ambulance service to nonphysician-staffed ambulances linked to hospitals. However, even in Sofia (Bulgaria’s capital and largest city) nearly half of the critically ill or injured patients arrive at the emergency care center of PEMI by private vehicle. In 1998, the EAS system managed 1,491,756 emergency calls involving ambulance dispatches for 1,244,245 patients. Of these services, 624,773 emergency calls involved accidents or injuries, 624,091 involved medical problems and 242,892 were for transportation only. The reported mortality rate (1998) during EAS transport was 1.2%7. Currently there are no helicopters devoted to emergency transport of critically injured or ill patients from more remote areas however there are 2 available jet aircraft equipped with resuscitative equipment and supplies. Mountainous terrain and available airports severely limit use of these rescue aircraft. However, there is no coordinated EAS system to transport ill or injured patients from rural areas to urban centers. EMERGENCY CARE OF PATIENTS Emergency care in Bulgaria has been organized with initial prehospital care (described earlier) followed by some care in triage areas of hospitals and definitive care on in-patient services (operating room, intensive care unit, or hospital ward). Initial hospital emergency services were generally provided in small triage areas with minimal capability for patient stabilization and care. However, with the slow but continued growth of the specialty of emergency medicine more care is being rendered in the triage area and some modern emergency care facilities are evolving. These emergency care facilities (similar to EDs in the United States) exist in specialized hospitals and university centers. Physician staffing of emergency care facilities consists of a team of doctors headed by either a general surgeon or anesthesiologist. Unfortunately, national statistics regarding emergency health services are not uniformly reported. The best available data on emergency care visits from 1998 (Ministry of Health statistics) are summarized in Table 1. These data are derived primarily from larger specialized and/or University hospitals found in the major urban population centers.
TABLE 1. Utilization of Emergency Services in Bulgaria (1998 Data) 1.
Trauma Nonintentional injuries Motor vehicle accidents Other injuries (not classified) Industrial accidents Sport-related injuries
2.
Medical Conditions Cardiovascular disorders Infectious disorders Neurologic disorders Gastrointestinal disorders Intoxications
3.
4.
5.
Surgical Conditions Appendicitis Cholecystitis Bowel obstructions Hernias Nephrolithiasis Obstetrical Conditions Spontaneous abortions Ectopic pregnancy Other conditions (unclassified) TOTAL NO. VISITS:
No. visits 81,009 16,346 9,173 6,542 3,799 TOTAL 116,869 294,755 53,496 41,062 21,639 16,503 TOTAL 427,455 14,494 7,655 3,529 3,749 3,200 TOTAL 32,627 7,306 3,605 TOTAL 10,911 598,233 1,186 095
Data from Ministry of Health, Republic of Bulgaria, 1998. (Personal communication from U Petrov, H Novkov).
EMERGENCY MEDICINE AS A SPECIALTY With the collapse of the Communist state in 1989, the Bulgarian society was exposed to western developments including the discipline of emergency medicine. Programming sponsored by American hospitals, United States Agency for International Development, and European Union assisted in the development of a trauma center (PEMI), teaching of Advanced Cardiac Life Support (ACLS) to Bulgarian physicians and nurses in the development of a prehospital care system. Several Western organizations have worked with the medical community in Bulgaria to promote developments in emergency care including Children’s Hospital of Philadelphia (an institutional partner of PEMI), Michigan State University (an institutional partner of St. Ekaternina Hospital) and mutual aid societies from Germany providing prehospital equipment and training. Because of such efforts and evolution of Bulgarian medical establishment, the discipline of emergency medicine has been officially recognized as a specialty. Moreover, in 1996 the first cohort of 80 physicians began a 5-year residency to become the first trained Bulgarian specialists in emergency medicine. The physicians selected for this training consisted of those who had already completed residency (anesthesiologists, family practitioners, internists, and surgeons) and recent graduates of medical school. The 5-year training period consists of 3-month block rotations on anesthesia, surgery, obstetrics/gynecology, trauma, cardiology, toxicology, pediatrics, neurosurgery and neurology, orthopedics, urology, and intensive care medicine. On com-
HAYES AND NOVKOV ■ EMERGENCY HEALTH SERVICES IN BULGARIA
pletion of training it is expected that these specialists will be distributed throughout the country. Other changes involving emergency services include: 1. Offerings of postgraduate emergency medicine courses (the concept of continuing medical education is not well established) such as ACLS, Advanced Trauma Life Support, and Pediatric Advanced Life Support has been offered in collaboration with western agencies. 2. In 1993, the Bulgarian Journal of Emergency Medicine was introduced and has continued publication. 3. Bulgarian physicians who practice emergency medicine at PEMI published the first textbook of emergency medicine that is now used extensively in Bulgaria. 4. The Bulgarian medical school curriculum has been modified to include topics on the emergency care of patients. CONCLUSION Emergency health care services are developing in Bulgaria as the system evolves. Momentous institutional change has allowed exposure to American and European systems of health care and increased citizens’ expectations for improved emergency services. However, economic downswings accompanying trade and industry changes have
125
limited governmental funding for health care in general and emergency services in particular. Despite this conditions emergency services are improving (particularly in the major cities), emergency medicine has successfully become recognized as a specialty and physicians are now actively training in residency programs. Although it is unlikely that Bulgaria will attempt to duplicate an emergency care system on existing Western models, there is keen interest in using knowledge gained from linkages to institutions in the United States and Europe. It is in this evolving environment that the emergency care strategy for Bulgaria will emerge. REFERENCES 1. Mazower M: The Balkans: A Short History. New York, NY, Modern Library Chronicles, 2000, pp 94-96, 261-262 2. Bar-Zohar M: Beyond Hitler’s Grasp: The Heroic Rescue of Bulgaria’s Jews. Holbrook, MA, Adams Media Corporation, 1988, pp 260-2611 3. The 1998 World Factbook: Country Listing: Bulgaria. Published by the Central Intelligence Agency. Available at http:// www.odic.gov/cia/factbook/bu/ht. Accessed November 26, 2001 4. Bell JD: “Post-Communist” Bulgaria. Current History 1990;89: 417-420 5. Troxel L: Bulgaria: Stable ground in the Balkans? Current History 1993;92:386-389 6. Amanpour A: Bulgaria suffers winter of economic pain. CNN World News Available at http://www.cnn.com/9701/13/bulgaria/index.html. Accessed January 13, 1997 7. Novkov HV: Pediatric emergency care in Bulgaria: General outline and two illustrative cases. Pediatric Emergency Care 1997; 13:54-57
The Republic of Bulgaria is a central European nation bordering the Black Sea, Turkey, Greece, Macedonia, Serbia, and Romania. Modern Bulgaria emerged in the wake of the last Russian invasion of the Ottoman Empire in (1877) with the Treaty of San Stefano.1 Bulgaria’s strategic location in the Balkan Peninsula has served as a crossroads for Eastern and Western cultures in that the land route from Europe to the Asia runs through its territories. For most of its contemporary history, Bulgaria, typical of Balkan nations, has been challenged by the rivalry and hostility of neighboring empires. However, uncharacteristic of the Balkans, Bulgaria has been relatively free of ethnic hatreds and violence. Approximately the size of Tennessee, Bulgaria has a surface area of 110,901 square kilometers with a total population of 8,230,371 (male 48.8%, female 51.2%). The major ethnic groups inhabiting Bulgaria are: (1) Bulgar, 85.3%; (2) Turk, 8.5%; (3) Roma (Gypsy), 2.6%; (4) Macedonian, 1.5%; and (5) Jewish, 1% (Bulgaria’s Jewish population was spared from the Holocaust).2 Interestingly, the population has become static (population growth rate: ⫺0.63%) with excess of deaths (death rate 14.3 per thousand) over births (birth rate of 7.9 per thousand) influenced by periodic, limited emigration. This negative growth rate needs to be understood in terms of pregnancy terminations, which have outnumbered births since 1980. Approximately two-thirds of the total population resides in urban settings and nearly all adults are literate.1,3 In 1989, Bulgaria experienced significant socioeconomic transformation with the collapse of the Communist one-
From the Section of Emergency Medicine, Michigan State University, East Lansing, MI and the Pediatric Orthopaedic Trauma Department, Pirogov Emergency Medical Institute, Sofia, Bulgaria. The United States Agency for International Development (USAID) has employed the authors as consultants in Bulgaria. Statements or opinions express in this article are those of the authors and not the United States Agency for International Development or the Ministry of Health, Republic of Bulgaria. Manuscript received and accepted August 29, 2001. Address reprint requests to Oliver W. Hayes, DO, MHSA, Section of Emergency Medicine, B-305 West Fee Hall, Michigan State University, East Lansing, MI 48824.E-mail: [email protected] Key Words: Bulgaria, emergency services. Copyright 2002, Elsevier Science (USA). All rights reserved. 0735-6757/02/2002-0015$35.00/0 doi:10.1053/ajem.2002.31147 122
party state.1 A fragile multiparty democracy emerged with a market-oriented economy. This transition although nonviolent and free of ethnic nationalism found in other Balkan countries proved challenging. Anticipated economic improvement accompanying the favorable political changes did not occur.4,5 Rather, laggard advancement on trade and industry reforms pitched the economy into crisis in 1991; marked by turmoil in the banking system, depreciation of currency, high inflation and contraction of domestic production and foreign trade.6 Until most recently the Bulgarian economy has had slow growth coupled with high inflation. Knowledge of the country’s history, heath care system, and economic conditions is essential in understanding changes in emergency services. HEALTH STATUS OF THE BULGARIAN POPULATION In many respects, the health status achievements in Bulgaria have been impressive until lately when progress became sluggish. Infant mortality rate, overall life expectancy and level of health care services are good by international standards. However, life expectancy (71.6 years) has shown little improvement in the past decade and in recent years there has been a decline in life expectancy for men.3 Mortality caused by cardiovascular disease represents the leading cause of adult deaths. Factors relevant to the prevalence of cardiovascular disease include: (1) a daily per capita caloric intake that is 147% of the daily requirement (the second highest in the world according to UNICEF data); (2) unusually high rates of tobacco use, and (3) high fat and dietary salt consumption.3 Malignancies (13.3% of deaths) and unintentional injuries (4.2% of deaths) are the second and third leading causes of adult death, respectively. Infant mortality rate (13.2 deaths/1,000 births) showed substantial improvement until 1980, but then the rate improved.3 Respiratory illnesses are the most prevalent cause of morbidity (accounting for 39.0% of all patient visits), followed by cardiovascular disease (12.1%), neurologic disease (9.8%), and trauma (7.4%).3 Other factors affecting health of the Bulgarian population include alcohol consumption, environmental pollution, and intentional injury. Per capita alcohol consumption and abuse is high in comparison with other European nations.3 Important environmental pollutants include: air pollution from automobile and industrial emissions; water contamination from raw sewage, heavy metals, and detergents; and soil contamination from heavy metals and industrial wastes.4 Intentional injury has emerged as a significant health concern with the development of organized crime and an increasingly violent society. PROFILE OF THE HEALTH CARE SYSTEM Bulgarian health service organization is evolving from a centrally administered system to a much less formalized,
HAYES AND NOVKOV ■ EMERGENCY HEALTH SERVICES IN BULGARIA
divisionalized structure. The previous multitiered health system (see Fig 1) was modeled after that of the former Soviet Union (Bulgaria was a close ally of the former Soviet Union from 1945-1989). An extensive network of primary health clinics formed the base of this health care system. Groups of primary health clinics were served by multispecialty district polyclinics. Community and regional hospitals provided in-patient services for routine medical problems originating from the polyclinics. Provincial hospitals at the next level of care were 400- to 500-bed institutions where most medical specialties are represented. Often at the provincial level, separate hospital facilities existed for tuberculosis, psychiatric conditions, the elderly and other categorical conditions or illnesses. At the apex of the health care pyramid were university medical centers and national specialty hospitals for referral, rehabilitation, and special conditions. An example of such a national specialty hospital is the Pirogov Emergency Medical Institute (PEMI) that has evolved as Bulgaria’s leading trauma center. Currently, PEMI has a well-equipped and busy emergency treatment ward supervised by physicians from the Department of Anesthesiology. Substantial elements of the multitiered health services system remain (especially in rural settings) but institutional consolidation, closure, and system evolution has markedly affected this structure. This network of health care facilities continues to be administered through the Ministry of Health, although control is evolving to local health councils. Most nonemergent health services are obtained from primary health clinics, regional polyclinics, and general or community hospitals. Until recently, it was not possible for patients to be routinely admitted to a hospital without obtaining consent and documentation from a regional polyclinic. Exceptions were made for the severely ill or injured patients who could be directly admitted to the triage area (somewhat equivalent to an ED) of a hospital. Although the number of hospital beds is more than adequate at 98 beds per 10,000 population (a rate similar to that of Italy), basic equipment and support services are lacking in most hospitals. Of the existing 193 hospitals, 125 facilities have some type of emergency treatment area. Annually (in 1998) there were a total of 1,331,831 hospital discharges
123
with a death rate of hospitalized patients of 1.2%.3 Health care expenditures represent 7.3% of the total governmental budget.3 In broad terms, Bulgaria has ample numbers of medical personnel with physician to population rates similar to those in Western European nations (34.6 physicians per 10,000 population).3 Bulgarians enter medical university directly from high school and medical education is 6 years in length. After the completion of medical school, graduates complete 5 obligatory national examinations and enter residency education includes 4 years of training in a tertiary hospital after completion of an internship. Currently, there are 15 teaching hospitals in the country. Although Bulgaria has ample supply of medical personnel, the specialty distribution of physicians is skewed towards specialization. The availability of all levels of medical practitioners shows regional variation, but not such as to cause significant local physician shortages. In 1998, the Bulgarian Parliament approved a system for global health insurance for the entire population. This system is based on a German social model “Krankenkasse” (centralized obligatory national health insurance) and began July 1, 2000. Funding for this health insurance system is based on income taxes (3% of monthly income) with matching funds from employers. Included for the first time in this health care financing system is funding for emergency care. Although socialized health care is the norm, modest private health insurance by small private insurance companies is beginning. STATUS OF EMERGENCY HEALTH SERVICES Until the most recent decade, the concept of emergency care in Bulgaria was similar to the approach found in other Eastern European nations that functioned without true emergency care specialists or EDs, rather various specialty physicians would serve patients in a triage receiving area based on chief complaint. Even today, in some hospitals emergency care continues to be structured in a triage mode where patients are examined in a small receiving area before referral to a specialty service or to an outpatient facility. For example, for a patient presenting with chest pain, a cardiologist or internist would be summoned to examine the patient before transfer to a cardiac care unit for care. In the majority of Bulgarian hospitals limited equipment and facilities exist in these triage areas for the purposes of provision of emergency health care. Critically ill or injured patients are triaged to the intensive care unit and stabilized by a critical care specialist (“reanimatist”) usually an anesthesiologist. From the standpoint of our health care system, these critical care physicians most resemble emergency physicians or hospitalists. In 1994, emergency medicine was officially recognized as a specialty and modest governmental funds were made available to develop emergency health services as described later.7 PREHOSPITAL CARE
FIGURE 1.
Structure of Bulgaria’s health care system.
The emergency ambulance service (“EAS” as prehospital care is known in Bulgaria) consists of a regional dispatch center (separate from police, fire department, or the hospital system), ambulance transport vehicles, and personnel in-
124
AMERICAN JOURNAL OF EMERGENCY MEDICINE ■ Volume 20, Number 2 ■ March 2002
cluding physicians. This service answers emergency calls, initiates responses, and transports patients to polyclinics or regional hospitals for initial evaluation. The ambulance transport vehicles typically have a physician on board but are not equipped with monitoring and resuscitation equipment. In 1997, a national program for training and certification of nonphysician providers for the EAS was implemented. This program included training in first aid, basic cardiac life support, and basic trauma life support. During the first course, nurses, fire fighters and police personnel took part in the training. As governmental funds have been allocated for emergency services, a modest number of better-equipped ambulances with nonphysician providers have been brought on line in larger cities. Although ambulances are now better equipped, communication systems between prehospital personnel and receiving hospitals remain at a rudimentary level. Over the past 5 years prehospital care gradually changed from the centrally based, physician-staffed ambulance service to nonphysician-staffed ambulances linked to hospitals. However, even in Sofia (Bulgaria’s capital and largest city) nearly half of the critically ill or injured patients arrive at the emergency care center of PEMI by private vehicle. In 1998, the EAS system managed 1,491,756 emergency calls involving ambulance dispatches for 1,244,245 patients. Of these services, 624,773 emergency calls involved accidents or injuries, 624,091 involved medical problems and 242,892 were for transportation only. The reported mortality rate (1998) during EAS transport was 1.2%7. Currently there are no helicopters devoted to emergency transport of critically injured or ill patients from more remote areas however there are 2 available jet aircraft equipped with resuscitative equipment and supplies. Mountainous terrain and available airports severely limit use of these rescue aircraft. However, there is no coordinated EAS system to transport ill or injured patients from rural areas to urban centers. EMERGENCY CARE OF PATIENTS Emergency care in Bulgaria has been organized with initial prehospital care (described earlier) followed by some care in triage areas of hospitals and definitive care on in-patient services (operating room, intensive care unit, or hospital ward). Initial hospital emergency services were generally provided in small triage areas with minimal capability for patient stabilization and care. However, with the slow but continued growth of the specialty of emergency medicine more care is being rendered in the triage area and some modern emergency care facilities are evolving. These emergency care facilities (similar to EDs in the United States) exist in specialized hospitals and university centers. Physician staffing of emergency care facilities consists of a team of doctors headed by either a general surgeon or anesthesiologist. Unfortunately, national statistics regarding emergency health services are not uniformly reported. The best available data on emergency care visits from 1998 (Ministry of Health statistics) are summarized in Table 1. These data are derived primarily from larger specialized and/or University hospitals found in the major urban population centers.
TABLE 1. Utilization of Emergency Services in Bulgaria (1998 Data) 1.
Trauma Nonintentional injuries Motor vehicle accidents Other injuries (not classified) Industrial accidents Sport-related injuries
2.
Medical Conditions Cardiovascular disorders Infectious disorders Neurologic disorders Gastrointestinal disorders Intoxications
3.
4.
5.
Surgical Conditions Appendicitis Cholecystitis Bowel obstructions Hernias Nephrolithiasis Obstetrical Conditions Spontaneous abortions Ectopic pregnancy Other conditions (unclassified) TOTAL NO. VISITS:
No. visits 81,009 16,346 9,173 6,542 3,799 TOTAL 116,869 294,755 53,496 41,062 21,639 16,503 TOTAL 427,455 14,494 7,655 3,529 3,749 3,200 TOTAL 32,627 7,306 3,605 TOTAL 10,911 598,233 1,186 095
Data from Ministry of Health, Republic of Bulgaria, 1998. (Personal communication from U Petrov, H Novkov).
EMERGENCY MEDICINE AS A SPECIALTY With the collapse of the Communist state in 1989, the Bulgarian society was exposed to western developments including the discipline of emergency medicine. Programming sponsored by American hospitals, United States Agency for International Development, and European Union assisted in the development of a trauma center (PEMI), teaching of Advanced Cardiac Life Support (ACLS) to Bulgarian physicians and nurses in the development of a prehospital care system. Several Western organizations have worked with the medical community in Bulgaria to promote developments in emergency care including Children’s Hospital of Philadelphia (an institutional partner of PEMI), Michigan State University (an institutional partner of St. Ekaternina Hospital) and mutual aid societies from Germany providing prehospital equipment and training. Because of such efforts and evolution of Bulgarian medical establishment, the discipline of emergency medicine has been officially recognized as a specialty. Moreover, in 1996 the first cohort of 80 physicians began a 5-year residency to become the first trained Bulgarian specialists in emergency medicine. The physicians selected for this training consisted of those who had already completed residency (anesthesiologists, family practitioners, internists, and surgeons) and recent graduates of medical school. The 5-year training period consists of 3-month block rotations on anesthesia, surgery, obstetrics/gynecology, trauma, cardiology, toxicology, pediatrics, neurosurgery and neurology, orthopedics, urology, and intensive care medicine. On com-
HAYES AND NOVKOV ■ EMERGENCY HEALTH SERVICES IN BULGARIA
pletion of training it is expected that these specialists will be distributed throughout the country. Other changes involving emergency services include: 1. Offerings of postgraduate emergency medicine courses (the concept of continuing medical education is not well established) such as ACLS, Advanced Trauma Life Support, and Pediatric Advanced Life Support has been offered in collaboration with western agencies. 2. In 1993, the Bulgarian Journal of Emergency Medicine was introduced and has continued publication. 3. Bulgarian physicians who practice emergency medicine at PEMI published the first textbook of emergency medicine that is now used extensively in Bulgaria. 4. The Bulgarian medical school curriculum has been modified to include topics on the emergency care of patients. CONCLUSION Emergency health care services are developing in Bulgaria as the system evolves. Momentous institutional change has allowed exposure to American and European systems of health care and increased citizens’ expectations for improved emergency services. However, economic downswings accompanying trade and industry changes have
125
limited governmental funding for health care in general and emergency services in particular. Despite this conditions emergency services are improving (particularly in the major cities), emergency medicine has successfully become recognized as a specialty and physicians are now actively training in residency programs. Although it is unlikely that Bulgaria will attempt to duplicate an emergency care system on existing Western models, there is keen interest in using knowledge gained from linkages to institutions in the United States and Europe. It is in this evolving environment that the emergency care strategy for Bulgaria will emerge. REFERENCES 1. Mazower M: The Balkans: A Short History. New York, NY, Modern Library Chronicles, 2000, pp 94-96, 261-262 2. Bar-Zohar M: Beyond Hitler’s Grasp: The Heroic Rescue of Bulgaria’s Jews. Holbrook, MA, Adams Media Corporation, 1988, pp 260-2611 3. The 1998 World Factbook: Country Listing: Bulgaria. Published by the Central Intelligence Agency. Available at http:// www.odic.gov/cia/factbook/bu/ht. Accessed November 26, 2001 4. Bell JD: “Post-Communist” Bulgaria. Current History 1990;89: 417-420 5. Troxel L: Bulgaria: Stable ground in the Balkans? Current History 1993;92:386-389 6. Amanpour A: Bulgaria suffers winter of economic pain. CNN World News Available at http://www.cnn.com/9701/13/bulgaria/index.html. Accessed January 13, 1997 7. Novkov HV: Pediatric emergency care in Bulgaria: General outline and two illustrative cases. Pediatric Emergency Care 1997; 13:54-57