- Email: [email protected]
Emergency medical services: Brazil
Resuscitation (2006) 70, 356—359
INTERNATIONAL EMS SYSTEMS
Emergency medical services: Brazil夽 Sergio Timerman a, Maria M.C. Gonzalez a,∗, Ana C. Zaroni a, Jose A.F. Ramires b a
Laboratory of Training and Simulation in Cardiovascular Emergencies, Heart Institute (InCor), University of S˜ ao Paulo Medical School, Brazil b Clinical Division, Heart Institute (InCor), University of S˜ ao Paulo Medical School, Brazil Received 25 May 2006 ; received in revised form 25 May 2006; accepted 25 May 2006 KEYWORDS Emergency medicine; EMS; Emergency department; Brazil
Summary Emergency medical services in Brazil have been created to offer first aid, primary medical treatment, basic life support, stabilization and rapid transfer to the closest appropriate hospital and advanced life support. Pre-hospital emergency care in Brazil is divided into permanent and mobile services. Permanent care is provided by the pre-hospital network (basic health units, family health program, specialized clinics, diagnosis and therapy services, non-hospital emergency care units). The mobile medical services include: mobile emergency care service, fire department and private services. Emergency hospital care units (emergency departments) are classified into general and reference units. Details of these services are described. © 2006 Elsevier Ireland Ltd. All rights reserved.
Introduction Brazil is a large country located in the eastern portion of South America. It occupies 47% of South America and 21% of the entire North, Central, and South American continents. As the fifth largest country in the world, it has an area of 8,547,403 km2 , a total perimeter of 23,086 km, 7367 km of which are the Atlantic Ocean coast-
夽
A Spanish translated version of the summary of this article appears as Appendix in the online version at doi:10.1016/j.resuscitation.2006.05.010 ∗ Corresponding author at: Avenida Doutor En´ eas Carvalho Aguiar 44, S˜ ao Paulo 05403 900, Brazil. Tel.: +55 11 3069 5926; fax: +55 11 3069 5337. E-mail address: [email protected] (M.M.C. Gonzalez).
line. The Brazilian regions are divided in two ways: through the five regions of the Brazilian Institute of Geography and Statistics (North, Northeast, Center-West, Southeast, and South) or from three large geo-economic regions: Amazon, Northeast, and Center-South. The country is divided into 26 states and 1 Federal District, which is the seat of the Federal Government.1 The current population is around 185 million. The population density is approximately 22 inhabitants/km2 , but the demographic distribution is very heterogeneous. The north of the country includes seven states (45% of the national territory) that are dominated by the Brazilian Amazon and have a population density of only 4 inhabitants/km2 . At the other extreme, the southeast region, which has the biggest population density, is the most developed economically and
0300-9572/$ — see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2006.05.010
Emergency medical services: Brazil occupies 11% of the national territory with a population density of 85 inhabitants/km2 . About 81% of the population lives in urban areas. Life expectancy, in 2003, was estimated at 73 years for females and 65 years for males. There is on average of 1 physician for each 622 inhabitants. The whole population is entitled to public medical assistance, and only 24.4% of the population pay for full private medical assistance. The state medical service is managed by the Ministry of Health, and each state has a Regional Health Council.1
357
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•
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Pre-hospital care Pre-hospital emergency care in Brazil is divided into permanent locations and mobile units. Care in the permanent locations is performed by a network of outside hospitals (basic health units, family health programme, specialized clinics, diagnosis and therapy services, non-hospital emergency care units). Mobile medical care arrives as soon as possible after a patient has a serious illness or injury, and also gives psychiatric emergency assistance. The services that deliver care at the scene of an incident are the following: (1) mobile emergency care service (in Portuguese: Servic¸o de Atendimento M´ ovel de Urgˆ encia, SAMU); (2) mobile services of private hospitals; (3) the fire department (rescue).2 SAMU follows the French pre-hospital care model3 that provides on-scene care for patients and not just transport to the hospital. Launched in September 2003 by the Federal Government, SAMU is available 24 h a day and consists of teams of health professional that include physicians, nurses, nursing assistants, and rescuers who respond to a wide range of emergencies including trauma, medical, pediatric, surgical, gynaecology, obstetrics and mental health. The system provides an ambulance equipped with standard basic life support for every 100,000—150,000 inhabitants and an advanced life support vehicle for every 400,000—450,000 inhabitants. In the pre-hospital care system, ambulances are classified as: • Type A: transport ambulance. A vehicle to provide transport of patients in the supine position who have non-life-threatening problems. Also used for elective transport. • Type B: basic life support ambulance. A vehicle to provide transportation of patients with potentially life-threatening problems and those with undiagnosed problems. It can provide some med-
•
ical interventions at the scene of an incident and during transportation to the hospital. Type C: rescue ambulance. A vehicle that can provide pre-hospital care for the victims of accidents or those in situations with difficult access (e.g., rough terrain, water, and heights). Type D: advanced life support ambulance. A vehicle designed to provide care and transport for high-risk patients in pre-hospital emergencies and inter hospital transfer. Type E: aeromedical transport. Aircraft with fixed or rotary wings used to attend and transport patients to and between hospitals. These aircraft are equipped for treatment, transport, and rescue. Type F: medical transport vessel. Medically equipped boats used to carry victims through maritime or fluvial routes.
SAMU performs emergency medical care anywhere: residences, work sites, and public locations. Dispatch is made after dialing a common singleaccess number (192), which is a free call. The telephone call is answered by dispatchers in the Regulation Center, who identify the type of emergency and immediately transfer the call to the dispatching physician. The physician determines the appropriate medical resource to provide to the patient: he/she can guide the caller to a public health center; mobilize a basic life support ambulance-BLS (type B), staffed by a nurse assistant and rescuer for local care; or if serious send a mobile ICU-ALS (type D) staffed by a physician and nurse. The dispatching physician communicates with the public hospital and keeps track of bed availability.2 Currently, 70 SAMU are established and operating in Brazil. Altogether, 320 towns in 22 states have SAMU assistance with a population of 68 million. Among Brazilian capitals, SAMU acts in S˜ ao Paulo, Recife, Natal, Fortaleza, Bel´ em, Curitiba, Porto Alegre, Belo Horizonte, Aracaju, Jo˜ ao Pessoa, Goiˆ ania, Macei´ o, S˜ ao Luis, Teresina, and Palmas. Up to August 2005, 174,791 services were performed, 127,734 services by ambulances, divided into clinical (65.23%), trauma (24.48%), obstetric (5.95%), and psychiatric (4.33%) emergencies.4 Ministry of Health policy (through the national policy on attending emergencies) aims to establish SAMU service in all Brazilian towns, respecting the jurisdiction of the three administrative spheres (federal, state, and municipal government). It is expected that in 2006 the service will be established in 1215 towns, serving a population of 97 million. There are well-established multi-agency responses to complex emergencies that may
358 include the military, fire department, police, highway patrol, and others working with the medical resources to rescue and treat victims. The fire department is accessed via the telephone number 193. They rescue fire victims and provide rescue and first aid to victims of drowning, flooding, collapse, and catastrophes. Their actions include the identification and management of hazards at the scene to protect victims and rescuers. They rescue victims in places or situations where the health team cannot reach. Where medical assistance is not directly available, they can perform basic life support (with no advanced interventions) with direct or remote medical supervision. When EMS contact is made through the fire department, the medical dispatch center is immediately contacted to provide assistance. Mobile services from private hospitals are scarce, but they are present in the developed urban centers.
Emergency hospital care units Emergency hospital units are classified into general units (types I and II) and reference units.
Emergency general hospital units • Type I are those units located in small general hospitals able to provide emergency care corresponding to first-level care of only minor complexity. • Type II are those located in medium-size hospitals able to provide emergency care of medium complexity. These units work 24 h a day and must have a basic infrastructure, technological and human resources, appropriate to give a second level of emergency. These general hospitals must have surgical and obstetric facilities, and physicians specialised in general medicine, paediatrics, gynaecology, obstetrics, general surgery, orthopaedics, and anaesthesia.
Emergency reference hospital units Emergency reference hospital units are located in general or specialized hospitals and are able to provide emergency care at high levels of complexity. These units are equipped and funded on the basis of the numbers and complexity of attending patients. To be part of the state hospital reference system on emergency care, a hospital must have the appropriate physical infrastructure and technological and human resources.
S. Timerman et al. Medical staff in the emergency department Emergency department physicians vary from one hospital to another, depending on the level of care provided and whether it is a teaching or private hospital. In general, the teaching hospitals are staffed by residents from different specialties, under the supervision of a specialist physician or assistant. They are available 24 h per day. The shifts are usually 12 h. Residents and assistant physicians work 4—6 shifts of 12 h per month. Care organization When a patient arrives in the emergency department, the first step is triage, which is usually performed by one of the physicians on duty (resident or assistant). The subsequent patient pathway is determined by initial triage. All emergency departments have facilities for cardiopulmonary resuscitation and all physicians who work in emergency departments are required to attend advanced cardiac life support courses (of the American Heart Association). Medical training In Brazil, medical schools can be public or private. The length of medical education is 6 years and subsequent specialization varies from 3 to 5 years. Emergency medicine is not yet recognized as a stand-alone specialty. We are trying to establish its recognition as a specialty.
The future of emergency care in Brazil The priorities for the future are: • To expand the geographical coverage of SAMU. • To decrease the response times between the access call and SAMU arrival at the scene of the incident. • To prioritize education programmes on emergency medicine and recognize emergency medicine as a stand-alone speciality. • To make available and increase emergency courses for physicians, nurses, and health technicians (e.g., basic life support and advanced cardiac life support, advanced trauma life support, basic and advanced paediatric life support). • To provide widespread public access to defibrillation programmes. • To encourage research in emergency care to improve effective assistance through new techniques and therapeutics.
Emergency medical services: Brazil
Conflict of interest statement None.
References 1. Brazilian Institute of Geography and Statistics, available at http://www.ibge.gov.br, December 2005.
359 2. Emergency System in Brazil. Technical Regulation, available at http://www.aph.com.br, December 2005. 3. Adnet F, Lapostolle F. International EMS systems: France. Resuscitation 2004;63:7—9. 4. SAMU database, available at http://www.saude.gov.br/samu, December 2005.
INTERNATIONAL EMS SYSTEMS
Emergency medical services: Brazil夽 Sergio Timerman a, Maria M.C. Gonzalez a,∗, Ana C. Zaroni a, Jose A.F. Ramires b a
Laboratory of Training and Simulation in Cardiovascular Emergencies, Heart Institute (InCor), University of S˜ ao Paulo Medical School, Brazil b Clinical Division, Heart Institute (InCor), University of S˜ ao Paulo Medical School, Brazil Received 25 May 2006 ; received in revised form 25 May 2006; accepted 25 May 2006 KEYWORDS Emergency medicine; EMS; Emergency department; Brazil
Summary Emergency medical services in Brazil have been created to offer first aid, primary medical treatment, basic life support, stabilization and rapid transfer to the closest appropriate hospital and advanced life support. Pre-hospital emergency care in Brazil is divided into permanent and mobile services. Permanent care is provided by the pre-hospital network (basic health units, family health program, specialized clinics, diagnosis and therapy services, non-hospital emergency care units). The mobile medical services include: mobile emergency care service, fire department and private services. Emergency hospital care units (emergency departments) are classified into general and reference units. Details of these services are described. © 2006 Elsevier Ireland Ltd. All rights reserved.
Introduction Brazil is a large country located in the eastern portion of South America. It occupies 47% of South America and 21% of the entire North, Central, and South American continents. As the fifth largest country in the world, it has an area of 8,547,403 km2 , a total perimeter of 23,086 km, 7367 km of which are the Atlantic Ocean coast-
夽
A Spanish translated version of the summary of this article appears as Appendix in the online version at doi:10.1016/j.resuscitation.2006.05.010 ∗ Corresponding author at: Avenida Doutor En´ eas Carvalho Aguiar 44, S˜ ao Paulo 05403 900, Brazil. Tel.: +55 11 3069 5926; fax: +55 11 3069 5337. E-mail address: [email protected] (M.M.C. Gonzalez).
line. The Brazilian regions are divided in two ways: through the five regions of the Brazilian Institute of Geography and Statistics (North, Northeast, Center-West, Southeast, and South) or from three large geo-economic regions: Amazon, Northeast, and Center-South. The country is divided into 26 states and 1 Federal District, which is the seat of the Federal Government.1 The current population is around 185 million. The population density is approximately 22 inhabitants/km2 , but the demographic distribution is very heterogeneous. The north of the country includes seven states (45% of the national territory) that are dominated by the Brazilian Amazon and have a population density of only 4 inhabitants/km2 . At the other extreme, the southeast region, which has the biggest population density, is the most developed economically and
0300-9572/$ — see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2006.05.010
Emergency medical services: Brazil occupies 11% of the national territory with a population density of 85 inhabitants/km2 . About 81% of the population lives in urban areas. Life expectancy, in 2003, was estimated at 73 years for females and 65 years for males. There is on average of 1 physician for each 622 inhabitants. The whole population is entitled to public medical assistance, and only 24.4% of the population pay for full private medical assistance. The state medical service is managed by the Ministry of Health, and each state has a Regional Health Council.1
357
•
•
•
Pre-hospital care Pre-hospital emergency care in Brazil is divided into permanent locations and mobile units. Care in the permanent locations is performed by a network of outside hospitals (basic health units, family health programme, specialized clinics, diagnosis and therapy services, non-hospital emergency care units). Mobile medical care arrives as soon as possible after a patient has a serious illness or injury, and also gives psychiatric emergency assistance. The services that deliver care at the scene of an incident are the following: (1) mobile emergency care service (in Portuguese: Servic¸o de Atendimento M´ ovel de Urgˆ encia, SAMU); (2) mobile services of private hospitals; (3) the fire department (rescue).2 SAMU follows the French pre-hospital care model3 that provides on-scene care for patients and not just transport to the hospital. Launched in September 2003 by the Federal Government, SAMU is available 24 h a day and consists of teams of health professional that include physicians, nurses, nursing assistants, and rescuers who respond to a wide range of emergencies including trauma, medical, pediatric, surgical, gynaecology, obstetrics and mental health. The system provides an ambulance equipped with standard basic life support for every 100,000—150,000 inhabitants and an advanced life support vehicle for every 400,000—450,000 inhabitants. In the pre-hospital care system, ambulances are classified as: • Type A: transport ambulance. A vehicle to provide transport of patients in the supine position who have non-life-threatening problems. Also used for elective transport. • Type B: basic life support ambulance. A vehicle to provide transportation of patients with potentially life-threatening problems and those with undiagnosed problems. It can provide some med-
•
ical interventions at the scene of an incident and during transportation to the hospital. Type C: rescue ambulance. A vehicle that can provide pre-hospital care for the victims of accidents or those in situations with difficult access (e.g., rough terrain, water, and heights). Type D: advanced life support ambulance. A vehicle designed to provide care and transport for high-risk patients in pre-hospital emergencies and inter hospital transfer. Type E: aeromedical transport. Aircraft with fixed or rotary wings used to attend and transport patients to and between hospitals. These aircraft are equipped for treatment, transport, and rescue. Type F: medical transport vessel. Medically equipped boats used to carry victims through maritime or fluvial routes.
SAMU performs emergency medical care anywhere: residences, work sites, and public locations. Dispatch is made after dialing a common singleaccess number (192), which is a free call. The telephone call is answered by dispatchers in the Regulation Center, who identify the type of emergency and immediately transfer the call to the dispatching physician. The physician determines the appropriate medical resource to provide to the patient: he/she can guide the caller to a public health center; mobilize a basic life support ambulance-BLS (type B), staffed by a nurse assistant and rescuer for local care; or if serious send a mobile ICU-ALS (type D) staffed by a physician and nurse. The dispatching physician communicates with the public hospital and keeps track of bed availability.2 Currently, 70 SAMU are established and operating in Brazil. Altogether, 320 towns in 22 states have SAMU assistance with a population of 68 million. Among Brazilian capitals, SAMU acts in S˜ ao Paulo, Recife, Natal, Fortaleza, Bel´ em, Curitiba, Porto Alegre, Belo Horizonte, Aracaju, Jo˜ ao Pessoa, Goiˆ ania, Macei´ o, S˜ ao Luis, Teresina, and Palmas. Up to August 2005, 174,791 services were performed, 127,734 services by ambulances, divided into clinical (65.23%), trauma (24.48%), obstetric (5.95%), and psychiatric (4.33%) emergencies.4 Ministry of Health policy (through the national policy on attending emergencies) aims to establish SAMU service in all Brazilian towns, respecting the jurisdiction of the three administrative spheres (federal, state, and municipal government). It is expected that in 2006 the service will be established in 1215 towns, serving a population of 97 million. There are well-established multi-agency responses to complex emergencies that may
358 include the military, fire department, police, highway patrol, and others working with the medical resources to rescue and treat victims. The fire department is accessed via the telephone number 193. They rescue fire victims and provide rescue and first aid to victims of drowning, flooding, collapse, and catastrophes. Their actions include the identification and management of hazards at the scene to protect victims and rescuers. They rescue victims in places or situations where the health team cannot reach. Where medical assistance is not directly available, they can perform basic life support (with no advanced interventions) with direct or remote medical supervision. When EMS contact is made through the fire department, the medical dispatch center is immediately contacted to provide assistance. Mobile services from private hospitals are scarce, but they are present in the developed urban centers.
Emergency hospital care units Emergency hospital units are classified into general units (types I and II) and reference units.
Emergency general hospital units • Type I are those units located in small general hospitals able to provide emergency care corresponding to first-level care of only minor complexity. • Type II are those located in medium-size hospitals able to provide emergency care of medium complexity. These units work 24 h a day and must have a basic infrastructure, technological and human resources, appropriate to give a second level of emergency. These general hospitals must have surgical and obstetric facilities, and physicians specialised in general medicine, paediatrics, gynaecology, obstetrics, general surgery, orthopaedics, and anaesthesia.
Emergency reference hospital units Emergency reference hospital units are located in general or specialized hospitals and are able to provide emergency care at high levels of complexity. These units are equipped and funded on the basis of the numbers and complexity of attending patients. To be part of the state hospital reference system on emergency care, a hospital must have the appropriate physical infrastructure and technological and human resources.
S. Timerman et al. Medical staff in the emergency department Emergency department physicians vary from one hospital to another, depending on the level of care provided and whether it is a teaching or private hospital. In general, the teaching hospitals are staffed by residents from different specialties, under the supervision of a specialist physician or assistant. They are available 24 h per day. The shifts are usually 12 h. Residents and assistant physicians work 4—6 shifts of 12 h per month. Care organization When a patient arrives in the emergency department, the first step is triage, which is usually performed by one of the physicians on duty (resident or assistant). The subsequent patient pathway is determined by initial triage. All emergency departments have facilities for cardiopulmonary resuscitation and all physicians who work in emergency departments are required to attend advanced cardiac life support courses (of the American Heart Association). Medical training In Brazil, medical schools can be public or private. The length of medical education is 6 years and subsequent specialization varies from 3 to 5 years. Emergency medicine is not yet recognized as a stand-alone specialty. We are trying to establish its recognition as a specialty.
The future of emergency care in Brazil The priorities for the future are: • To expand the geographical coverage of SAMU. • To decrease the response times between the access call and SAMU arrival at the scene of the incident. • To prioritize education programmes on emergency medicine and recognize emergency medicine as a stand-alone speciality. • To make available and increase emergency courses for physicians, nurses, and health technicians (e.g., basic life support and advanced cardiac life support, advanced trauma life support, basic and advanced paediatric life support). • To provide widespread public access to defibrillation programmes. • To encourage research in emergency care to improve effective assistance through new techniques and therapeutics.
Emergency medical services: Brazil
Conflict of interest statement None.
References 1. Brazilian Institute of Geography and Statistics, available at http://www.ibge.gov.br, December 2005.
359 2. Emergency System in Brazil. Technical Regulation, available at http://www.aph.com.br, December 2005. 3. Adnet F, Lapostolle F. International EMS systems: France. Resuscitation 2004;63:7—9. 4. SAMU database, available at http://www.saude.gov.br/samu, December 2005.