- Email: [email protected]
Emergency medicine in Southern Brazil
INTERNATIONAL REPORT
Emergency Medicine in Southern Brazil From the Section of Emergency Medicine, Provena St. Joseph Medical Center, Joliet, IL, and the Department of Emergency Medicine, University of Illinois College of Medicine, Chicago, IL*; the Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, CA‡; General Secretary of the Brazilian Network of Emergency Cooperation, Planning Department, Hospital Municipal de Pronto Socorro,§ and Universidade Federal do Rio Grande do Sul,II Porto Alegre, Brazil.
Ross D. Tannebaum, MD* Jeffrey L. Arnold, MD‡ Armando De Negri Filho, MD§ Viviane S. SpadoniII
Received for publication August 6, 1999. Revisions received March 24, 2000, June 21, 2000, and September 21, 2000. Accepted for publication October 4, 2000. Presented at the 8th International Conference in Emergency Medicine, Boston, MA, May 2000. Address for reprints: Ross Tannebaum, MD, Section of Emergency Medicine, Provena St. Joseph Medical Center, 333 North Madison Street, Joliet, IL 60435; fax 815-741-7660; E-mail [email protected]. Copyright © 2001 by the American College of Emergency Physicians. 0196-0644/2001/$35.00 + 0 47/1/112252 doi:10.1067/mem.2001.112252
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Emergency medicine is developing rapidly in southern Brazil, where elements of both the Franco-German and the AngloAmerican models of emergency care are in place, creating a uniquely Brazilian approach to emergency care. Although emergency medical services (EMS) in Brazil have been directly influenced by the French mobile EMS (SAMU) system, with physicians dispatched by ambulances to the scenes of medical emergencies, the first American-style emergency medicine residency training program in Brazil was recently established at the Hospital de Pronto Socorro (HPS) in Porto Alegre. Emergency trauma care appears to be particularly developed in southern Brazil, where advanced trauma life support is widely taught and SAMU delivers sophisticated trauma care en route to trauma centers designated by the state. [Tannebaum RD, Arnold JL, de Negri Filho A, Spadoni VS. Emergency medicine in southern Brazil. Ann Emerg Med. February 2001;37:223-228.] INTRODUCTION
The Federal Republic of Brazil covers 3.3 million square miles, encompassing almost 50% of the entire continent of South America.1 Brazil is also one of the world’s most populous countries, with 165 million people in 1998.2 Although the Brazilian government incorporates 26 states and the Federal District of Brasilia,1 the country itself can be divided into 5 distinct geographic and cultural regions: (1) the south, with the city Porto Alegre; (2) the southeast, with São Paulo and Rio de Janeiro; (3) the northeast, with Salvador and Recife; (4) the central, with Brasília; and (5) the north, which includes the Amazon region. Brazil is a nation of great economic contrast. With recent annual economic growth of 3% lifting the average per capita gross domestic product (GDP) to $6,300, the Brazilian economy now ranks among the top 10 economies in the world ($1.04 trillion GDP in 1997).1 Nevertheless,
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vast areas of Brazil still reflect third world conditions, including much of the north and northeast and the peripheries of major cities, where people live in slums or favelas that rank among the poorest places on earth. This report focuses on the emergency care system in Porto Alegre, as representative of the wealthier southern region of Brazil. Porto Alegre, with 1.5 million inhabitants, is the capital city of the southernmost state of Rio Grande do Sul. Most inhabitants of this region descend from Italians and Germans who immigrated there during the 19th century. Porto Alegre prospers from the largest middle class in Brazil. Although favelas exist (30% of the population lives below the poverty line), they are less common in Porto Alegre than in São Paulo or Rio de Janeiro. MEDICAL ENVIRONMENT
The major cause of death in Brazil today is cardiovascular disease, followed by cancer, respiratory disease, and trauma.3 In general, patients in urban areas of southern Brazil have diseases of lifestyle similar to those in developed countries. Trauma, from motor vehicle crashes and interpersonal violence, is a major problem in southern Brazil and the leading cause of death from age 15 to 60 years.3 Much penetrating trauma stems from the drug trade in the poorly policed and impoverished favelas. Substance abuse is an increasing concern in the favelas, where crack cocaine abuse is growing and alcohol abuse, petroleum solvent sniffing, and other drug abuse are prevalent. Several tropical diseases are endemic in different regions of Brazil. Even physicians in urban Brazil must be familiar with tropical medicine, because they occasionally see patients from rural areas presenting with cardiac or colonic complications of Chagas disease, portal hypertension from schistosomiasis, malaria contracted in the Amazon, dengue fever, and occasional snake or scorpion envenomations.3 H E A LT H C A R E E C O N O M I C S
Both the public and the private sectors finance health care in Brazil. The federal government funds universal medical care through the Sistema Único de Saúde (SUS) program, which was passed into constitutional law in 1988.3,4 SUS funds public hospitals in Brazil and contracts for medical care at individual private hospitals. Because Brazilians are not required to qualify or register for SUS, any person in Brazil can receive free medical care at any hospital with an
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SUS contract. Although the federal constitution guarantees universal health care to all Brazilians through SUS, the actual delivery of this care is limited by insufficient government funding. Brazilian health care is also funded by private medical insurance, which both complements, and in some cases, competes with SUS.4-6 Certain national corporations and government entities also provide employees with medical insurance, which is only valid at specified hospitals. H E A LT H C A R E S Y S T E M
The health care system in Brazil is also divided into public and private sectors, operating in parallel. Accordingly, Brazil has both public and private medical schools, hospitals, and out-of-hospital care services.4,6 Even private hospitals with SUS contracts often divide their emergency departments into separate areas for patients with private medical insurance and patients with SUS, creating an often jarring disparity between modern, well-equipped sides for the insured and often overcrowded, third world– appearing sides for patients with SUS. Brazilian hospitals tend to specialize in specific areas of medicine, such as trauma or cardiology. For example, trauma hospitals provide care for patients with virtually any type of trauma, including orthopedic or hand injuries, but will refuse to admit patients with medical disease. Hospitals specializing in internal medical care, such as the Hospital de Clínica in Porto Alegre, will transfer a patient with even a simple shoulder fracture. Hospitals specializing in cardiology, such as the Instituto de Cardiologia in Porto Alegre, may even have cardiac EDs, but only for patients with cardiac emergencies. Major centers offer the same state-of-the-art medical technology available in more developed countries. Physicians are more widely specialized in Brazil, with 63 officially recognized medical specialties compared with 24 specialty boards in the United States.7,8 Emergency medicine per se is not yet an officially recognized medical specialty in Brazil. The recent trend of reducing the number of medical specialties in Brazil poses a major obstacle to the future recognition of emergency medicine as an independent medical specialty. Although the health care system in different regions of Brazil is based on similar law and organizational framework, facilities in the less-populated northern and Amazon regions are usually less well-equipped and physicians tend to be less well-trained. As in the United States, there is a maldistribution of physicians with an overabundance
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of physicians in the metropolitan areas, and a shortage of physicians, especially specialists, in the poorer rural areas.3,4,6 MEDICAL SCHOOL AND RESIDENCY TRAINING
Students enter medical school in Brazil immediately after graduation from high school and after passing a competitive qualifying state examination. Medical school lasts 6 years. Emergency medicine is included in the curricula at the 4 medical schools in Porto Alegre. Brazil offers residency training in most medical specialties. Training in either internal medicine or general surgery generally takes 2 years. Training in medical subspecialty areas consists of an additional 1 to 3 years after 1 to 2 years of internal medicine residency, whereas training in surgical subspecialties begins after 1 to 2 years in general surgery. On completing postgraduate training, many Brazilian subspecialists take a qualifying examination, although it is not necessary to pass this examination to practice a subspecialty. Recently, residency training in emergency medicine was established at the Hospital de Pronto Socorro (HPS) in Porto Alegre. EMERGENCY MEDICAL SERVICES
The emergency medical services (EMS) system in Porto Alegre is similar to EMS in other metropolitan areas of Brazil. It is relatively well developed and involves a number of often overlapping services. In the country’s north, ambulances are less well equipped and the organizational structure is looser. In the Amazon region east of Manaus, EMS may be nonexistent. The various services that comprise EMS in Porto Alegre can be grouped into 3 categories: (1) the public service represented by the Servic¸ o de Atendímento Médico de Urg eˆ ncia (SAMU) and the fire department, (2) privatized highway services, and (3) fully privatized (nonhighway) ambulance services. There has been a recent trend to regulate and coordinate all of these diverse EMS services by Brazilian federal and state governments. In the 1990s, the Federal Council of Medicine and the Ministry of Health established out-of-hospital care standards for EMS systems. The Franco-German model of emergency medicine has influenced all of these systems, with physicians frequently riding in ambulances. Paramedics do not exist in Brazil because Brazilian law precludes nonphysicians from performing intubation, defibrillation, and other advanced life support (ALS) procedures. Brazilian law
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also recognizes the public SAMU service as having the authority to set additional standards and to coordinate all public and private services. There are no standards governing qualifications of EMS physicians, except that they must hold a valid state license to practice medicine. SAMU is the major provider of out-of-hospital trauma care in Porto Alegre. It also currently provides about half of the nontrauma EMS care in the city. SAMU is free to all citizens and is supported by SUS, mostly through municipal funds. SAMU was established in 1995 after an agreement between Brazil and France to exchange technical information. A major characteristic of the SAMU system is the evaluation or screening of emergency calls (medical regulation) by a physician at the communication or dispatch center. Medical regulation may result in medical advice to the caller, basic life support (BLS) ambulance dispatch, or ALS ambulance dispatch. Importantly, not every call to SAMU results in an ambulance dispatch. The management tool of medical regulation was sanctioned by the Federal Council of Medicine in 1998 and was more recently made official by the Ministry of Health. One physician works with the team of communication operators to screen cases. Two other physicians are available to be sent to the scene of medical emergencies. SAMU ambulances are dispatched from 5 bases throughout Porto Alegre. The public accesses SAMU by calling 192. The current SAMU director is attempting to popularize this number for all medical emergency calls. At the dispatch center, 5 to 6 communication operators act as medical regulation assistants, answering about 2,000 calls per day, with most callers simply requesting information. SAMU dispatches approximately 1,800 ambulance runs per month. Similar to US advanced cardiac life support (ACLS) ambulances, SAMU ambulances are well equipped with oxygen, airway equipment, intravenous equipment, cardiac monitors/defibrillators, standard ACLS medications, and even respirators. Because 45% of SAMU dispatches are presently for trauma, most patients are brought to 1 of Porto Alegre’s 2 trauma centers. The fire department and military police each have their own ambulance system and public access numbers. Both systems are currently being absorbed into SAMU, and most calls are now routed to the dispatch center in Porto Alegre. In regions where the highway system is privatized, an EMS system exists with BLS ambulances placed 30 km apart on private roads. This system also provides ALS ambulances staffed by relatively well-compensated physicians ($25 to $30 per hour). The guiding philosophy of this service is to transport patients as rapidly as possible to
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previously selected hospitals, including the 2 trauma centers in Porto Alegre.9,10 This service is paid from money generated by tolls. As with the SUS-supported SAMU service, patients are not charged directly for these services. Several private ambulance services operate in Porto Alegre. Patients pay a monthly insurance premium for private ambulance service (approximately $10 to $15). Uninsured patients may also access private ambulances, but must pay at a higher rate of $100 to $150 per transport. The physicians who provide care in these ambulances are usually moonlighting residents or other physicians with no training in emergency care. Many emergency physicians believe that an inappropriate number of seriously ill medical patients are brought to EDs by taxi or private vehicle. Some reasons suggested for this are that the public is generally unaware that SAMU can be accessed for conditions other than trauma, and that private ambulances are expensive for uninsured patients. Because emergency medicine does not yet exist as a specialty in Brazil, an emergency physician may be any physician with a license to practice medicine. In the large urban academic medical centers, teams of internists, general surgeons, and occasionally orthopedists see adult emergency patients. These teams may also include residents and medical students. Residents and young physicians building their private practices frequently moonlight in smaller EDs. Pediatricians see children in the EDs of pediatric hospitals. Emergency physicians are not well compensated in Brazil. In Porto Alegre, physicians working in EDs earn approximately $10 to $20 per hour. EDs at both public and private hospitals serve the people of Porto Alegre. The largest public ED in Porto Alegre is at the Hospital Nossa Senhora Conce¸cão complex, providing care to a reported 360,000 patients per year. Comprised of 4 hospitals and 1,100 beds, this complex is the largest in Porto Alegre and includes the 300-bed Hospital Cristo Redentor, which specializes in trauma. Consequently, the ED is flooded with indigent patients, many who arrive by bus from throughout the state seeking care for chronic medical problems. During the day, 6 internists, 2 surgeons, 1 gynecologist, 4 dentists, and 6 medical residents staff this ED. During the night, even fewer physicians and residents are on duty. The ED at the public Hospital de Clínica de Porto Alegre sees about 70,000 patients per year and is staffed by internists, surgeons, pediatricians, and residents in internal medicine, surgery, and pediatrics. This hospital is the main teaching facility for the Universidade Federal do Rio Grande do Sul medical school.
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The ED for the private Hospital da Santa Casa complex actually consists of 2 separately staffed departments located on opposite sides of the main hospital. The private side is staffed by 2 internists during the daytime and the indigent side is staffed by 1 internist. These departments see a combined 77,000 patients per year. The hospital complex is composed of 5 separate hospitals, including hospitals specializing in cardiology, neurology, and pulmonary medicine and serves as the main teaching facility for another medical school. The ED at the private Pontificia Universidade Catolica (PUC) Hospital São Lucas consists of 6 separately staffed emergency care units, 3 for adults and 3 for children. For adults, there are separate public and private general EDs and a combined critical care ED for critically ill patients regardless of insurance. These 3 units provide emergency care to an estimated 120,000 adult patients per year. During the day, 2 internists staff the privately insured adult unit and 1 internist, 1 resident, and 1 student staff the indigent unit. Two internists, 1 resident, and 1 student also staff the adult critical care unit. The 3 pediatric emergency units are also separated into areas for the privately insured, indigent, and critically ill and follow the same pattern of staffing. Although the PUC hospital is considered private, it has contracted with SUS to provide 70% of its inpatient beds to SUS patients. Approximately 70% of its emergency patients are also funded by SUS. This modern hospital also serves as the main teaching hospital for the PUC medical school. These ED volumes may be inflated because the total number of ED visits tends to include the total number of hospital admissions or outpatient clinic visits. In addition, SUS patients often seek care in the public hospital EDs for all of their medical needs, including primary care for chronic medical problems. The volumes reported by private hospitals may be skewed because hospital admissions are often routed from private physician offices through the ED. Porto Alegre also has many private clinics advertising themselves as emergency hospitals, but which are actually the equivalents of US walk-in centers. These freestanding clinics are not usually affiliated with hospitals, making diagnostic evaluations and arrangements for inpatient care problematic. EDs in southern Brazil stock the same drugs and equipment available in more developed countries, although there is often a 3- to 5-year delay before new drugs become available. Other standard ACLS medications are typically in supply. Defibrillators, intubation equipment, and ventilators are standard equipment in southern Brazilian
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EDs. Although emergency physicians perform thrombolysis with streptokinase, conscious sedation and rapid sequence intubation are rarely performed (usually only by anesthesiologists). Angiography and computed tomography (CT; often on older-generation imaging equipment) are available in most hospitals. Ultrasonography is sporadically available in Brazilian EDs. Overcrowding is a common problem in Brazilian EDs. In some EDs in Porto Alegre and São Paulo, patients routinely wait 1 to 3 days for admission to an inpatient bed. During this time, complete evaluations are performed and entire hospital courses take place. Patients with myocardial infarctions are ruled out, patients with gastrointestinal bleeding undergo endoscopy, and after surgery, some patients are returned to the ED for postoperative care. Patients with ventilators may remain in the ED for days. Brazil also lacks laws regulating interfacility transfers. Because hospitals often specialize in various areas of medicine, patients presenting to one hospital may be referred to another. Indigent patients who present to private hospitals without a SUS contract are usually turned away without stabilization. Both advanced trauma life support (ATLS) and ACLS are taught in Brazil. ATLS has been offered since 1993 at 12 training centers throughout the country, including one in Porto Alegre. At this time, more than 4,500 physicians have completed ATLS training at more than 300 provider courses. Physicians and medical students have also benefited from the numerous out-of-hospital trauma life support courses offered throughout the country. An ACLS provider course was also recently established in São Paulo. The state government has designated 2 trauma centers in Porto Alegre. Both provide care comparable to Level I trauma centers in the United States, with in-house trauma surgeons and operating rooms, CT, and angiography available 24 hours per day. Located in downtown Porto Alegre, the 130-bed public HPS specializes in trauma care and serves as the central base station for SAMU. In 1998, HPS had 221,000 outpatients and 11,000 inpatient admissions. Because approximately 60% of patient visits involve trauma, surgeons and surgical residents primarily staff the hospital. Accordingly, almost every HPS resident has performed an emergency thoracotomy. The HPS emergency medicine residency recently established the first and only emergency medicine residency training program in Brazil. The residency is a 2year program. The first emergency medicine resident
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began training on January 1, 1996. Recently, the program has been expanded to 4 residents per year. Residents may begin after completion of medical school. As of 1999, there were 8 salaried faculty for the program. Attending faculty of the program have all completed residency training in internal medicine, and most have completed fellowships in either critical care medicine or cardiology. Attending physicians in the program generally have outside private practice, salaried hospital, or other practice commitments. The residency program curriculum was developed by the program director and faculty. This curriculum is based on that of North American emergency medicine training. Clinical training consists of 6 months of resuscitation room (trauma and medical), 4 months of ED and minor emergency clinic, 1 month of combined otorhinolaryngology and ophthalmology, 1 month orthopedics room, 3 months of trauma ICU, 1 month of coronary care unit (CCU), 1 month medical ICU, and 2 months of EMS. In addition, there are outside rotations: 1 month pediatric emergency room, 1 month obstetrics/gynecology emergency room at the Hospital Nossa Senhora Concei¸cão, and 1 month cardiac emergency room at the Insituto de Cardiologia. Residents are responsible for keeping a record of required procedures. There are approximately 5 hours per week dedicated to conference learning. Attendance for residents is mandatory. This includes didactic lecture, journal club, and case review conferences. Residents are responsible for their own textbooks. Commonly used textbooks include American emergency medicine textbooks, and various medical and surgical textbooks from both Brazil and the United States. There is currently no in-training or completion examination taken by the residents. Official recognition of the HPS emergency medicine residency training program awaits official recognition of emergency medicine as a specialty by the Federal Council of Medicine of Brazil. FUTURE OF EMERGENCY MEDICINE
In establishing the HPS emergency medicine residency training program, physicians in southern Brazil have taken an essential step in the development of emergency medicine as a specialty. The creation of a core of specialists in emergency medicine in a country has always enabled improvements in other emergency medicine systems (patient care, academic, and management) and remains the sine qua non for future development. Whether these newly trained emergency physicians should staff SAMU, hospital-based EDs, or both are questions of eco-
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nomic viability and cultural necessity, not of medical utility, at least not until patient outcome data become available. In fashioning a system that mixes characteristics of the Franco-German model of emergency care (a regulated system with emergency physicians on ambulances) with the Anglo-American model (emergency physicians in EDs),11 Brazilian physicians are creating a uniquely Brazilian approach to emergency medicine that promises to improve the lives of millions of Brazilians. Significant obstacles remain to the development of emergency medicine in Brazil. These include the establishment of a comprehensive specialty organization uniting physicians involved in all aspects of emergency care, the development of more emergency medicine residency training programs, the creation of a board certification process, and the official recognition of emergency medicine as a unique medical specialty. Pioneers of emergency medicine in Brazil will also be challenged by the seemingly disparate systems of care for patients with private insurance and patients with SUS. In addition, the provision of emergency care to patients with multiple medical problems remains problematic in a system where the hospitals themselves tend to specialize at the expense of more comprehensive offerings. Nevertheless, with significant advances in out-of-hospital care and trauma care, physicians in southern Brazil have already laid the foundation for the development of emergency medicine into the next century. REFERENCES 1.
World Factbook. Available at: http://www.odci.gov/cia/publications/factbook/br.html.
2.
United Nations Population Division. Available at: http://www.popin.org/pop1998/2.htm.
3.
Pan American Health Organization. Available at: http://www.paho.org/english/SHA/prflbra.htm.
4. Lewis MA, Medici AC. Private payers of health care in Brazil: characteristics, costs, and coverage. Health Policy Plan. 1995;10:362-375. 5.
Hensley S. Brazilian health care at a crossroads. Mod Healthc. 1999;May 17:34-42.
6. Almeida C, Travassos C, Porto S, et al. Health sector reform in Brazil: a case study of inequity. Int J Health Serv. 2000;30:129-162. 7. CREMERS. Conselho Regional de Medicina do Rio Grande do Sul. Especialdades Reconhecidas pelo Conselho Federal de Medicina. Available at: http://www.via-rs.com.br/ cremers/espec.htm. 8. Marquis’ Who’s Who: The Official ABMS Directory of Board Certified Medical Specialists. 2000. ed 32. New Providence, NJ: Reed Elsevier; 1999;xxi. 9.
Okumura M. An emergency rescue service in Brazil. Accid Anal Prev. 1993;25:225-226.
10. Okumura M, Okumura CH. Atendimento pré-hospitalar de acidentados de tráfego rodoviário: experiˆencia Brasileira. Rev Hosp Clin Fac Med S Paulo. 1994;49:45-49. 11. Dykstra EH. International models for the practice of emergency care [editorial]. Am J Emerg Med. 1997;15:208-209.
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Emergency Medicine in Southern Brazil From the Section of Emergency Medicine, Provena St. Joseph Medical Center, Joliet, IL, and the Department of Emergency Medicine, University of Illinois College of Medicine, Chicago, IL*; the Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, CA‡; General Secretary of the Brazilian Network of Emergency Cooperation, Planning Department, Hospital Municipal de Pronto Socorro,§ and Universidade Federal do Rio Grande do Sul,II Porto Alegre, Brazil.
Ross D. Tannebaum, MD* Jeffrey L. Arnold, MD‡ Armando De Negri Filho, MD§ Viviane S. SpadoniII
Received for publication August 6, 1999. Revisions received March 24, 2000, June 21, 2000, and September 21, 2000. Accepted for publication October 4, 2000. Presented at the 8th International Conference in Emergency Medicine, Boston, MA, May 2000. Address for reprints: Ross Tannebaum, MD, Section of Emergency Medicine, Provena St. Joseph Medical Center, 333 North Madison Street, Joliet, IL 60435; fax 815-741-7660; E-mail [email protected]. Copyright © 2001 by the American College of Emergency Physicians. 0196-0644/2001/$35.00 + 0 47/1/112252 doi:10.1067/mem.2001.112252
FEBRUARY 2001
37:2
ANNALS OF EMERGENCY MEDICINE
Emergency medicine is developing rapidly in southern Brazil, where elements of both the Franco-German and the AngloAmerican models of emergency care are in place, creating a uniquely Brazilian approach to emergency care. Although emergency medical services (EMS) in Brazil have been directly influenced by the French mobile EMS (SAMU) system, with physicians dispatched by ambulances to the scenes of medical emergencies, the first American-style emergency medicine residency training program in Brazil was recently established at the Hospital de Pronto Socorro (HPS) in Porto Alegre. Emergency trauma care appears to be particularly developed in southern Brazil, where advanced trauma life support is widely taught and SAMU delivers sophisticated trauma care en route to trauma centers designated by the state. [Tannebaum RD, Arnold JL, de Negri Filho A, Spadoni VS. Emergency medicine in southern Brazil. Ann Emerg Med. February 2001;37:223-228.] INTRODUCTION
The Federal Republic of Brazil covers 3.3 million square miles, encompassing almost 50% of the entire continent of South America.1 Brazil is also one of the world’s most populous countries, with 165 million people in 1998.2 Although the Brazilian government incorporates 26 states and the Federal District of Brasilia,1 the country itself can be divided into 5 distinct geographic and cultural regions: (1) the south, with the city Porto Alegre; (2) the southeast, with São Paulo and Rio de Janeiro; (3) the northeast, with Salvador and Recife; (4) the central, with Brasília; and (5) the north, which includes the Amazon region. Brazil is a nation of great economic contrast. With recent annual economic growth of 3% lifting the average per capita gross domestic product (GDP) to $6,300, the Brazilian economy now ranks among the top 10 economies in the world ($1.04 trillion GDP in 1997).1 Nevertheless,
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vast areas of Brazil still reflect third world conditions, including much of the north and northeast and the peripheries of major cities, where people live in slums or favelas that rank among the poorest places on earth. This report focuses on the emergency care system in Porto Alegre, as representative of the wealthier southern region of Brazil. Porto Alegre, with 1.5 million inhabitants, is the capital city of the southernmost state of Rio Grande do Sul. Most inhabitants of this region descend from Italians and Germans who immigrated there during the 19th century. Porto Alegre prospers from the largest middle class in Brazil. Although favelas exist (30% of the population lives below the poverty line), they are less common in Porto Alegre than in São Paulo or Rio de Janeiro. MEDICAL ENVIRONMENT
The major cause of death in Brazil today is cardiovascular disease, followed by cancer, respiratory disease, and trauma.3 In general, patients in urban areas of southern Brazil have diseases of lifestyle similar to those in developed countries. Trauma, from motor vehicle crashes and interpersonal violence, is a major problem in southern Brazil and the leading cause of death from age 15 to 60 years.3 Much penetrating trauma stems from the drug trade in the poorly policed and impoverished favelas. Substance abuse is an increasing concern in the favelas, where crack cocaine abuse is growing and alcohol abuse, petroleum solvent sniffing, and other drug abuse are prevalent. Several tropical diseases are endemic in different regions of Brazil. Even physicians in urban Brazil must be familiar with tropical medicine, because they occasionally see patients from rural areas presenting with cardiac or colonic complications of Chagas disease, portal hypertension from schistosomiasis, malaria contracted in the Amazon, dengue fever, and occasional snake or scorpion envenomations.3 H E A LT H C A R E E C O N O M I C S
Both the public and the private sectors finance health care in Brazil. The federal government funds universal medical care through the Sistema Único de Saúde (SUS) program, which was passed into constitutional law in 1988.3,4 SUS funds public hospitals in Brazil and contracts for medical care at individual private hospitals. Because Brazilians are not required to qualify or register for SUS, any person in Brazil can receive free medical care at any hospital with an
2 2 4
SUS contract. Although the federal constitution guarantees universal health care to all Brazilians through SUS, the actual delivery of this care is limited by insufficient government funding. Brazilian health care is also funded by private medical insurance, which both complements, and in some cases, competes with SUS.4-6 Certain national corporations and government entities also provide employees with medical insurance, which is only valid at specified hospitals. H E A LT H C A R E S Y S T E M
The health care system in Brazil is also divided into public and private sectors, operating in parallel. Accordingly, Brazil has both public and private medical schools, hospitals, and out-of-hospital care services.4,6 Even private hospitals with SUS contracts often divide their emergency departments into separate areas for patients with private medical insurance and patients with SUS, creating an often jarring disparity between modern, well-equipped sides for the insured and often overcrowded, third world– appearing sides for patients with SUS. Brazilian hospitals tend to specialize in specific areas of medicine, such as trauma or cardiology. For example, trauma hospitals provide care for patients with virtually any type of trauma, including orthopedic or hand injuries, but will refuse to admit patients with medical disease. Hospitals specializing in internal medical care, such as the Hospital de Clínica in Porto Alegre, will transfer a patient with even a simple shoulder fracture. Hospitals specializing in cardiology, such as the Instituto de Cardiologia in Porto Alegre, may even have cardiac EDs, but only for patients with cardiac emergencies. Major centers offer the same state-of-the-art medical technology available in more developed countries. Physicians are more widely specialized in Brazil, with 63 officially recognized medical specialties compared with 24 specialty boards in the United States.7,8 Emergency medicine per se is not yet an officially recognized medical specialty in Brazil. The recent trend of reducing the number of medical specialties in Brazil poses a major obstacle to the future recognition of emergency medicine as an independent medical specialty. Although the health care system in different regions of Brazil is based on similar law and organizational framework, facilities in the less-populated northern and Amazon regions are usually less well-equipped and physicians tend to be less well-trained. As in the United States, there is a maldistribution of physicians with an overabundance
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of physicians in the metropolitan areas, and a shortage of physicians, especially specialists, in the poorer rural areas.3,4,6 MEDICAL SCHOOL AND RESIDENCY TRAINING
Students enter medical school in Brazil immediately after graduation from high school and after passing a competitive qualifying state examination. Medical school lasts 6 years. Emergency medicine is included in the curricula at the 4 medical schools in Porto Alegre. Brazil offers residency training in most medical specialties. Training in either internal medicine or general surgery generally takes 2 years. Training in medical subspecialty areas consists of an additional 1 to 3 years after 1 to 2 years of internal medicine residency, whereas training in surgical subspecialties begins after 1 to 2 years in general surgery. On completing postgraduate training, many Brazilian subspecialists take a qualifying examination, although it is not necessary to pass this examination to practice a subspecialty. Recently, residency training in emergency medicine was established at the Hospital de Pronto Socorro (HPS) in Porto Alegre. EMERGENCY MEDICAL SERVICES
The emergency medical services (EMS) system in Porto Alegre is similar to EMS in other metropolitan areas of Brazil. It is relatively well developed and involves a number of often overlapping services. In the country’s north, ambulances are less well equipped and the organizational structure is looser. In the Amazon region east of Manaus, EMS may be nonexistent. The various services that comprise EMS in Porto Alegre can be grouped into 3 categories: (1) the public service represented by the Servic¸ o de Atendímento Médico de Urg eˆ ncia (SAMU) and the fire department, (2) privatized highway services, and (3) fully privatized (nonhighway) ambulance services. There has been a recent trend to regulate and coordinate all of these diverse EMS services by Brazilian federal and state governments. In the 1990s, the Federal Council of Medicine and the Ministry of Health established out-of-hospital care standards for EMS systems. The Franco-German model of emergency medicine has influenced all of these systems, with physicians frequently riding in ambulances. Paramedics do not exist in Brazil because Brazilian law precludes nonphysicians from performing intubation, defibrillation, and other advanced life support (ALS) procedures. Brazilian law
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also recognizes the public SAMU service as having the authority to set additional standards and to coordinate all public and private services. There are no standards governing qualifications of EMS physicians, except that they must hold a valid state license to practice medicine. SAMU is the major provider of out-of-hospital trauma care in Porto Alegre. It also currently provides about half of the nontrauma EMS care in the city. SAMU is free to all citizens and is supported by SUS, mostly through municipal funds. SAMU was established in 1995 after an agreement between Brazil and France to exchange technical information. A major characteristic of the SAMU system is the evaluation or screening of emergency calls (medical regulation) by a physician at the communication or dispatch center. Medical regulation may result in medical advice to the caller, basic life support (BLS) ambulance dispatch, or ALS ambulance dispatch. Importantly, not every call to SAMU results in an ambulance dispatch. The management tool of medical regulation was sanctioned by the Federal Council of Medicine in 1998 and was more recently made official by the Ministry of Health. One physician works with the team of communication operators to screen cases. Two other physicians are available to be sent to the scene of medical emergencies. SAMU ambulances are dispatched from 5 bases throughout Porto Alegre. The public accesses SAMU by calling 192. The current SAMU director is attempting to popularize this number for all medical emergency calls. At the dispatch center, 5 to 6 communication operators act as medical regulation assistants, answering about 2,000 calls per day, with most callers simply requesting information. SAMU dispatches approximately 1,800 ambulance runs per month. Similar to US advanced cardiac life support (ACLS) ambulances, SAMU ambulances are well equipped with oxygen, airway equipment, intravenous equipment, cardiac monitors/defibrillators, standard ACLS medications, and even respirators. Because 45% of SAMU dispatches are presently for trauma, most patients are brought to 1 of Porto Alegre’s 2 trauma centers. The fire department and military police each have their own ambulance system and public access numbers. Both systems are currently being absorbed into SAMU, and most calls are now routed to the dispatch center in Porto Alegre. In regions where the highway system is privatized, an EMS system exists with BLS ambulances placed 30 km apart on private roads. This system also provides ALS ambulances staffed by relatively well-compensated physicians ($25 to $30 per hour). The guiding philosophy of this service is to transport patients as rapidly as possible to
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previously selected hospitals, including the 2 trauma centers in Porto Alegre.9,10 This service is paid from money generated by tolls. As with the SUS-supported SAMU service, patients are not charged directly for these services. Several private ambulance services operate in Porto Alegre. Patients pay a monthly insurance premium for private ambulance service (approximately $10 to $15). Uninsured patients may also access private ambulances, but must pay at a higher rate of $100 to $150 per transport. The physicians who provide care in these ambulances are usually moonlighting residents or other physicians with no training in emergency care. Many emergency physicians believe that an inappropriate number of seriously ill medical patients are brought to EDs by taxi or private vehicle. Some reasons suggested for this are that the public is generally unaware that SAMU can be accessed for conditions other than trauma, and that private ambulances are expensive for uninsured patients. Because emergency medicine does not yet exist as a specialty in Brazil, an emergency physician may be any physician with a license to practice medicine. In the large urban academic medical centers, teams of internists, general surgeons, and occasionally orthopedists see adult emergency patients. These teams may also include residents and medical students. Residents and young physicians building their private practices frequently moonlight in smaller EDs. Pediatricians see children in the EDs of pediatric hospitals. Emergency physicians are not well compensated in Brazil. In Porto Alegre, physicians working in EDs earn approximately $10 to $20 per hour. EDs at both public and private hospitals serve the people of Porto Alegre. The largest public ED in Porto Alegre is at the Hospital Nossa Senhora Conce¸cão complex, providing care to a reported 360,000 patients per year. Comprised of 4 hospitals and 1,100 beds, this complex is the largest in Porto Alegre and includes the 300-bed Hospital Cristo Redentor, which specializes in trauma. Consequently, the ED is flooded with indigent patients, many who arrive by bus from throughout the state seeking care for chronic medical problems. During the day, 6 internists, 2 surgeons, 1 gynecologist, 4 dentists, and 6 medical residents staff this ED. During the night, even fewer physicians and residents are on duty. The ED at the public Hospital de Clínica de Porto Alegre sees about 70,000 patients per year and is staffed by internists, surgeons, pediatricians, and residents in internal medicine, surgery, and pediatrics. This hospital is the main teaching facility for the Universidade Federal do Rio Grande do Sul medical school.
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The ED for the private Hospital da Santa Casa complex actually consists of 2 separately staffed departments located on opposite sides of the main hospital. The private side is staffed by 2 internists during the daytime and the indigent side is staffed by 1 internist. These departments see a combined 77,000 patients per year. The hospital complex is composed of 5 separate hospitals, including hospitals specializing in cardiology, neurology, and pulmonary medicine and serves as the main teaching facility for another medical school. The ED at the private Pontificia Universidade Catolica (PUC) Hospital São Lucas consists of 6 separately staffed emergency care units, 3 for adults and 3 for children. For adults, there are separate public and private general EDs and a combined critical care ED for critically ill patients regardless of insurance. These 3 units provide emergency care to an estimated 120,000 adult patients per year. During the day, 2 internists staff the privately insured adult unit and 1 internist, 1 resident, and 1 student staff the indigent unit. Two internists, 1 resident, and 1 student also staff the adult critical care unit. The 3 pediatric emergency units are also separated into areas for the privately insured, indigent, and critically ill and follow the same pattern of staffing. Although the PUC hospital is considered private, it has contracted with SUS to provide 70% of its inpatient beds to SUS patients. Approximately 70% of its emergency patients are also funded by SUS. This modern hospital also serves as the main teaching hospital for the PUC medical school. These ED volumes may be inflated because the total number of ED visits tends to include the total number of hospital admissions or outpatient clinic visits. In addition, SUS patients often seek care in the public hospital EDs for all of their medical needs, including primary care for chronic medical problems. The volumes reported by private hospitals may be skewed because hospital admissions are often routed from private physician offices through the ED. Porto Alegre also has many private clinics advertising themselves as emergency hospitals, but which are actually the equivalents of US walk-in centers. These freestanding clinics are not usually affiliated with hospitals, making diagnostic evaluations and arrangements for inpatient care problematic. EDs in southern Brazil stock the same drugs and equipment available in more developed countries, although there is often a 3- to 5-year delay before new drugs become available. Other standard ACLS medications are typically in supply. Defibrillators, intubation equipment, and ventilators are standard equipment in southern Brazilian
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EDs. Although emergency physicians perform thrombolysis with streptokinase, conscious sedation and rapid sequence intubation are rarely performed (usually only by anesthesiologists). Angiography and computed tomography (CT; often on older-generation imaging equipment) are available in most hospitals. Ultrasonography is sporadically available in Brazilian EDs. Overcrowding is a common problem in Brazilian EDs. In some EDs in Porto Alegre and São Paulo, patients routinely wait 1 to 3 days for admission to an inpatient bed. During this time, complete evaluations are performed and entire hospital courses take place. Patients with myocardial infarctions are ruled out, patients with gastrointestinal bleeding undergo endoscopy, and after surgery, some patients are returned to the ED for postoperative care. Patients with ventilators may remain in the ED for days. Brazil also lacks laws regulating interfacility transfers. Because hospitals often specialize in various areas of medicine, patients presenting to one hospital may be referred to another. Indigent patients who present to private hospitals without a SUS contract are usually turned away without stabilization. Both advanced trauma life support (ATLS) and ACLS are taught in Brazil. ATLS has been offered since 1993 at 12 training centers throughout the country, including one in Porto Alegre. At this time, more than 4,500 physicians have completed ATLS training at more than 300 provider courses. Physicians and medical students have also benefited from the numerous out-of-hospital trauma life support courses offered throughout the country. An ACLS provider course was also recently established in São Paulo. The state government has designated 2 trauma centers in Porto Alegre. Both provide care comparable to Level I trauma centers in the United States, with in-house trauma surgeons and operating rooms, CT, and angiography available 24 hours per day. Located in downtown Porto Alegre, the 130-bed public HPS specializes in trauma care and serves as the central base station for SAMU. In 1998, HPS had 221,000 outpatients and 11,000 inpatient admissions. Because approximately 60% of patient visits involve trauma, surgeons and surgical residents primarily staff the hospital. Accordingly, almost every HPS resident has performed an emergency thoracotomy. The HPS emergency medicine residency recently established the first and only emergency medicine residency training program in Brazil. The residency is a 2year program. The first emergency medicine resident
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began training on January 1, 1996. Recently, the program has been expanded to 4 residents per year. Residents may begin after completion of medical school. As of 1999, there were 8 salaried faculty for the program. Attending faculty of the program have all completed residency training in internal medicine, and most have completed fellowships in either critical care medicine or cardiology. Attending physicians in the program generally have outside private practice, salaried hospital, or other practice commitments. The residency program curriculum was developed by the program director and faculty. This curriculum is based on that of North American emergency medicine training. Clinical training consists of 6 months of resuscitation room (trauma and medical), 4 months of ED and minor emergency clinic, 1 month of combined otorhinolaryngology and ophthalmology, 1 month orthopedics room, 3 months of trauma ICU, 1 month of coronary care unit (CCU), 1 month medical ICU, and 2 months of EMS. In addition, there are outside rotations: 1 month pediatric emergency room, 1 month obstetrics/gynecology emergency room at the Hospital Nossa Senhora Concei¸cão, and 1 month cardiac emergency room at the Insituto de Cardiologia. Residents are responsible for keeping a record of required procedures. There are approximately 5 hours per week dedicated to conference learning. Attendance for residents is mandatory. This includes didactic lecture, journal club, and case review conferences. Residents are responsible for their own textbooks. Commonly used textbooks include American emergency medicine textbooks, and various medical and surgical textbooks from both Brazil and the United States. There is currently no in-training or completion examination taken by the residents. Official recognition of the HPS emergency medicine residency training program awaits official recognition of emergency medicine as a specialty by the Federal Council of Medicine of Brazil. FUTURE OF EMERGENCY MEDICINE
In establishing the HPS emergency medicine residency training program, physicians in southern Brazil have taken an essential step in the development of emergency medicine as a specialty. The creation of a core of specialists in emergency medicine in a country has always enabled improvements in other emergency medicine systems (patient care, academic, and management) and remains the sine qua non for future development. Whether these newly trained emergency physicians should staff SAMU, hospital-based EDs, or both are questions of eco-
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nomic viability and cultural necessity, not of medical utility, at least not until patient outcome data become available. In fashioning a system that mixes characteristics of the Franco-German model of emergency care (a regulated system with emergency physicians on ambulances) with the Anglo-American model (emergency physicians in EDs),11 Brazilian physicians are creating a uniquely Brazilian approach to emergency medicine that promises to improve the lives of millions of Brazilians. Significant obstacles remain to the development of emergency medicine in Brazil. These include the establishment of a comprehensive specialty organization uniting physicians involved in all aspects of emergency care, the development of more emergency medicine residency training programs, the creation of a board certification process, and the official recognition of emergency medicine as a unique medical specialty. Pioneers of emergency medicine in Brazil will also be challenged by the seemingly disparate systems of care for patients with private insurance and patients with SUS. In addition, the provision of emergency care to patients with multiple medical problems remains problematic in a system where the hospitals themselves tend to specialize at the expense of more comprehensive offerings. Nevertheless, with significant advances in out-of-hospital care and trauma care, physicians in southern Brazil have already laid the foundation for the development of emergency medicine into the next century. REFERENCES 1.
World Factbook. Available at: http://www.odci.gov/cia/publications/factbook/br.html.
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United Nations Population Division. Available at: http://www.popin.org/pop1998/2.htm.
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Pan American Health Organization. Available at: http://www.paho.org/english/SHA/prflbra.htm.
4. Lewis MA, Medici AC. Private payers of health care in Brazil: characteristics, costs, and coverage. Health Policy Plan. 1995;10:362-375. 5.
Hensley S. Brazilian health care at a crossroads. Mod Healthc. 1999;May 17:34-42.
6. Almeida C, Travassos C, Porto S, et al. Health sector reform in Brazil: a case study of inequity. Int J Health Serv. 2000;30:129-162. 7. CREMERS. Conselho Regional de Medicina do Rio Grande do Sul. Especialdades Reconhecidas pelo Conselho Federal de Medicina. Available at: http://www.via-rs.com.br/ cremers/espec.htm. 8. Marquis’ Who’s Who: The Official ABMS Directory of Board Certified Medical Specialists. 2000. ed 32. New Providence, NJ: Reed Elsevier; 1999;xxi. 9.
Okumura M. An emergency rescue service in Brazil. Accid Anal Prev. 1993;25:225-226.
10. Okumura M, Okumura CH. Atendimento pré-hospitalar de acidentados de tráfego rodoviário: experiˆencia Brasileira. Rev Hosp Clin Fac Med S Paulo. 1994;49:45-49. 11. Dykstra EH. International models for the practice of emergency care [editorial]. Am J Emerg Med. 1997;15:208-209.
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