Urgent medical assistance

The urgent medical assistance (amu) is the device set up by a state to bring an medical assistance to the people victims of an accident or a brutal and unexpected affection. It in general comprises an alarm system, by which the victim or the witnesses can ask for this urgent medical assistance, and of the mobile services of intervention.

The basic principle of the urgent medical assistance is the Chaîne of the helps : the help with the victims rests on collaboration between various speakers, since the witness to the doctor, possibly hospital, who will deal with the person, while passing by the Secouriste S and Ambulancier S which is dispatched on the spot to ensure the prompt helps.

The links of this chain (various speakers) are coordinated by the medical Régulation, which ensures a graduation of the helps: to mobilize the means necessary but not more, in order to be able to cover another intervention.

History of the urgent medical assistance

The concept of urgent, or “pre-hospital” medical assistance, must much with the medicine of war, and in particular with Dominique-Jean Larrey (1798), Henry Dunant (1864) and Santy (Second world war).

In France, the urgent medical assistance was organized following an epidemic of Poliomyélite in 1955 and to answer the road hecatomb of the years 1960 - 1970.

The expression of “urgent medical assistance” was born in Belgium in the law from the July 8th 1964.

Levels of care and graduation of the answer

The difficulty in managing the urgent medical assistance is the random frequency of the accidents (in the broad sense, sudden and unexpected affection included/understood): if one can determine an average activity ratio, it is also necessary to face peaks of activity due to extraordinary events (Catastrophe, accident of great width), to seasonal events (car accidents due to alcohol Saturday evening, epidemic S of Grippe and Bronchiolite in winter, climbing accidents during the holidays) or randomly (several simultaneous accidents).

One cannot solve this problem while being satisfied to increase manpower and the material. In addition to a money wasting, the periods of underactivity induce a demotivation and a loss of competence on behalf of the actors, and the problems of maintenance and logistics for the material. The answer most usually developed is the graduation of the helps: to propose several levels of care, adapted to the affection. It is necessary for that to have a structure of coordination selecting the means to send: the medical Regulation.

One can distinguish five levels from answer to a call:

  • medical council by telephone (being able to include the council to go to consult a doctor in an not-urgent way);
  • sending of a doctor of guard, or a doctor liberal urgentist (associations type S.O.S Doctors)
  • to ask to bring the person to the urgencies of the hospital nearest, or if the person cannot go there, to proceed to the sending of a Ambulance;
  • sending of a vehicle of Prompt help, a Ambulance with First-aid worker S;
  • sending of ancillary medical Helps: a Ambulance with personnel not-doctor but being able to carry out medical gestures on protocol ( paramedics in North America, Male nurse fireman in France);
  • sending of medical helps: a Ambulance with a Doctor urgentist and one (E) Male nurse (E).
The answers offered vary according to the countries.

This pre-hospital assistance can be considered only if the country lays out already:

  • of a structure of care allowing to manage the nonurgent affections (private doctors, Dispensary S, hospital);
  • of a structure of reception and treatment of the urgencies (emergency service at the hospital) which can deal with the victims brought by the ambulances and vehicles of prompt help.
The formation of the public to the First aid makes it possible to improve the system effectiveness:
  • while informing on the risks, while learning how to make a protection, that decreases the number of accidents and their consequences;
  • while learning how to pass a alarm fast and precise and to conform to the telephone instructions, that makes it possible to improve the medical regulation;
  • by learning how the gestures from first urgency to make while waiting for the helps, that improves the chances of survival of the victims.

Stay and play , scoop and run or play and run ?

The structure of the Samu and the Smur French was born with the end from the Années 1960, with the following observation: the victims of car accidents died most of the time during their transport towards the hospital; in addition, a study of Schœmaker showed in 1988 that the multi-visceral Défaillance, causes late mortality in the event of polytraumatism, was mainly due to the Hypoxie fabrics which settles before an effective medical assumption of responsibility. The victim thus required care on the spot, it was necessary the to stabilize before transporting it, and in particular in the event of Hémorragie, compensating for the heavy bleeding by a perfusion to restore a blood pressure (blood-pressure) “normal”. This method is called by the Britanniques stay and play (literally “to remain and play”, in the direction “to act on the spot”).

The states-uniens developed a different approach. They, them, noticed that, for the serious traumatisms, the victims died in the first hours. In particular, in the event of internal bleeding, only an surgical operation can save the victim. It was necessary thus that the victim can be on the operating table in less than one hour -   it is the concept of golden delicious hour (Heure of gold). They thus developed a structure based on ambulances without doctor, with ancillary medical personnel (EMT-P, emergency medical technician-paramedic ) trained with medical gestures, like the Intubation trachéale, the installation of a peripheral venous Voie (Perfusion), the administration of certain drugs (bronchodilatateurs, adrenalin), but without possibility of initiative if the case leaves the protocols envisaged. These paramedics as soon as possible evacuates the victim towards a trauma center (hospital), the method is called scoop and run (to charge and run).

The two methods have advantages and are legitimate. Benefitting from the experiment of the North America, France made evolve/move its system:

  • to benefit from incompressible time (for example, desincarceration of a victim trapped in its car) to practice the medical gestures, but to reduce the gestures before the evacuation in order to respect the hour of gold, it is the play and run (to act and run); in particular, to stick to have a minimal blood pressure and either a “normal” pressure, to supplement the vascular Filling (perfusion) by drugs Vasopresseur S and a shock-proof Pants;
  • the possibility for the not-doctors (and in particular the ambulance men and the first-aid workers) of using a semi-automatic Défibrillateur (DSA), which now equips the private ambulances with guard to the profit of center 15 and the VSAV of the firemen (many associations of first aid are they also equipped with their expenses with DSA);
  • the intervention of Male nurse S which can apply written emergency protocols, and which can carry out regulations transmitted by radio by the regulating doctor of Samu. These male nurses protocols is for the moment the male nurses firemen -   ISP.
The last point, called “paramedicalisation with the Frenchwoman” or sometimes “infirmierisation of the helps”, makes it possible the victim to have medical gestures in a faster way; indeed, the system urgently French is currently confronted with a problem of manpower, but, it takes 7 years to train a doctor, 3 years to train a male nurse. One thus hopes to be able to lay out of a tighter grid male nurses fireman than of Smur. Compared to the North-American system (EMT-P), the male nurses firemen have a possibility of initiative thanks to the medical regulation by radio.

Bibliography

  • W.C. Schœmaker, P.L. Call and H.E.Kram: Tissue oxygen dept ace has determinant off lethal and sublethal postoperative organ failure. - Critical Care Medicine, 1988, 16,11,117-120

Urgent medical assistance in Belgium

In Belgium, the urgent medical assistance is declined in two forms:

a) Urgent medical assistance, controlled by Center 100:

The terms “medical assistance urgent” and “AMU” also indicate the formation of Secourisme delivered in particular with the firemen, one initial duration of 120h. Then, of the training courses on SMUR and in a service ambulance approved are to be realized by the candidate ambulance man.

b) Urgent medical assistance, for the people in illegal stay:

This urgent medical assistance applies only to the people in illegal stay i.e. those which do not have any authorization of stay, even temporary, which is not in no suspensive appeal procedure and/or the foreigners of which the order to leave it territory expired. For example déboutés request asylums, them clandestine, déboutés within the framework of family gathering, déboutés in procedure of the victim of the human draft,…

The urgent medical assistance appears in the organic law of the CPAS (Public Center of Social action) of the 8.7.1976, Article 57 §2 and is concretized in a.R. of the 12.12.1996 as by various circulars which clarify certain points of the law. There remains however of the obscure points especially with regard to competences of the CPAS. (For more information, to see the site of the Ministry for Social integration)

This type of aid medical urgent is to be distinguished from the service of the urgencies “100” which depends to him on funds for urgent medical care, but applicable only to the care given immediately and not with the later care (example to remove a plaster).

It is not a question here necessarily, and as opposed to what the " term; urgente" medical assistance; let suppose, of a medicine urgently exempted in the hospitals at the time of a specific and immediate intervention or only when the life of the patient is in danger. Within the framework of the urgent medical assistance for the people in stays illegal, one also includes any required assistance in order to avoid any medical situation at the risk for the person and his entourage.

Urgent medical assistance in Canada

With the Canada, there are two levels of answer:

  • first guarantors: they have a fast action, but cannot transport; they carry out the gestures of prompt help and condition the victim while waiting for the arrival of the Ambulance
  • the technicians ambulance men (level 1) and paramédics (level 2): they can carry out medical acts like the administration of drugs on protocol, and carry out the evacuation towards the hospital.

External bonds

  • Introduction of the care advanced into the services emergency préhospitaliers to Quebec, Arranges evaluation of technologies and modes of intervention in health (AETMIS), Quebec, April 2005

Urgent medical assistance in the United States

With the the United States, the urgent medical assistance is managed by the (EMS). They have two pre-hospital levels of care:

  • Certified first responder S (CFR): first-aid workers;
  • : ancillary medical personnel, being able to carry out medical gestures on protocol, with three levels:
    • BASIC (EMT-B);
    • Intermediate (EMT-I);
    • paramedic (EMT-P).
The doctors almost never leave the services of the urgencies, the organisaiton consists in as soon as possible transporting the victim to the urgencies.

According to an investigation of the newspaper USA Today, the cities having the best organization of the helps are those which adopted an organization on two levels:

  • of many little trained fast operating teams (EMT-B);
  • some teams being able to make advanced care (EMT-P).
The cities being directed towards theancillary medical one (EMT-P) have not only one system which is more expensive (in wages), but which is moreover less less effective: on the one hand the EMT-P leave on all the interventions and thus see few true medical emergency, and on the other hand, the follow-up of competences and the levelling become ingérable because of manpower. With the final one, although having people initially better trained, their competences drop and they are less effective at the time of the true medical emergency.

External bonds

  • Paramedics not always the saviors off cardiac-arrest patient, R. Davis, USA Today, 2005

Urgent medical assistance in France

In France, the urgent medical assistance rests mainly on two ministries:

  • ministry for Health:
    • Samu : Service of urgent medical assistance, administration in charge of the coordination of the urgent medical assistance (regulation) and the reception of the calls of the private individuals;
    • Smur: emergency Mobile service and of reanimation, mobile team of the Service of the urgencies of a hospital;
    • Associations of liberal urgentists (Type S.O.S Doctors)
    • general doctors;
    • Ambulance man S private (also ministry for Transport but with a diploma of the ministry for health);
  • ministry for the Interior:
    • firemen: Vehicle of help and assistance to the victims (VSAV); until in 1984, the prompt helps were mainly an attribution of Police force-help;
    • First-aid worker S voluntary associative.

History of Samu and Smur

The origin of Samu and Smur in France is the fight against two “national plagues”: an epidemic of Poliomyelitis (disease being able to go until a respiratory paralysis) in 1952 and road accidents of growing number (the hecatomb will culminate in 1972 with seventeen thousand dead this year).

The first mobile service of reanimation was created with Paris in 1956 by professor Maurice Cara (Necker hospital), for inter-hospital transport of patients under respiratory assistance with a doctor. Doctor Bourret created the first mobile unit for the help with the victims of the road with Living room-of-Provence in 1957. The first decree on the organization of the helps to the victims of road accidents dates from the August 3rd 1959. Professors Cara, Lareng (Toulouse) and Tightens (Montpellier) noticed the shift between the lavished care once arrived at the urgencies and those lavished before and during transport; they reflect in place the medicalisation of the helps (presence of a doctor in the ambulances).

That led in 1965 to the creation of the emergency services and the intensive care units in the hospitals on the one hand, and of the emergency mobile services and reanimation (Smur) on the other hand. The first service of urgent medical assistance (Samu), charged to coordinate the medical efforts between the teams préhospitalières (Smur) and the services urgently hospital, was created in 1968 in Toulouse by professor Louis Lareng, but it will be necessary to await 1976 to see their officialization, with the notion of centralized reception of the calls and the concept of medical regulation; the SAMU then did not receive a direct call of the public.

The medicalisation of the road helps was only précaunisée in the circular of the June 22nd 1978. It is in 1979 (Simone Veil was then Minister for Health) which were created the centers of reception and regulation of calls (CRRA), called “Center 15”, with the concept of reception of the calls of the public and co-operation between extra-hospital hospital structures and structures (circular of the February 6th 1979.

Interventions préhospitalières France

In France, all the levels of answer are assured. The various emergency vehicles being able to be sent are:

  • a private Ambulance with a crew of two people: a graduate ambulance man and an Auxiliary Ambulance man (generally formed with first aid or holder of the diploma of Auxiliary Ambulance man);
  • a Vehicle of help and assistance to the victims (VSAV) of the firemen with a crew of three First-aid worker S;
  • a vehicle male nurse of the firemen in reinforcement of the VSAV;
  • a hospital mobile Unité (UMH) of a smur
    • is a Ambulance;
    • is a Light vehicle medicalized which converges with a private ambulance or a VSAV;
    • is a helicopter.

; See the articles

Legislative texts

  • Public health code , in particular the L6111-1 article, L6111-2, L6112-1, L6112-2, L6112-5, L6112-6, L6141-4, book 3 of the sixth part of the new legislative part “urgent Medical assistance, permanence of the care, transport medical and other departments of health. ”, and in the lawful part “decrees the simple” articles D 712-66 with D 712-74

  • Law n° 86-11 of the January 6th 1986 on the urgent medical assistance and medical transport
  • Decree n° 87-1005 of the December 16th 1987 relating to the missions and the organization of the units taking part in the called Service of urgent medical assistance S.A.M.U. (NOR: ASEP8701666D)
  • the obligation for the operators of telecommunication to convey the calls to center 15 raises of the decision n° 2002-1179 of the December 19th 2002 of the Regulatory agency of telecommunications, drawing up the list of the emergency numbers having to be conveyed free by the telecommunications operators authorized in accordance with the articles L. 33-1 and L. 34-1 of the Code of the stations and telecommunications NOR : ARTL0200744S ( Official journal n° 155 of the July 6th 2003 page 11520).

Urgent medical assistance in Switzerland

In Swiss, the intervention pre-hospital are made by ancillary medical ambulance men having a three years formation, intervening by two. They are controlled by the Sanitary service coordinated (SC).

See too

Related articles

External bonds

  • Samu de France

  • Waiter of emergency medicine (Online Urgencies - University Paris V)
  • Association the transmitters (Xavier Emmanuelli)
  • Data sheet: urgent medical assistance in France
  • SAMU 94
  • infirmiersp
  • Ministry for health
  • Recommendations concerning the methods of the medicalized assumption of responsibility préhopitalière of the patients in serious condition, article of the site of Sfar
  • Organization of the helps in France, an article of the site of the Medical college of the University of Rennes 1
  • social and institutional logics of the extra-hospital urgent medical assistance in Paris - Analysis of the activity of the Brigade of the firemen of Paris and Samu of Paris, NR. Bajos, Thesis of public health, University of Southern Paris UFR the Kremlin-Bicêtre, September 24th 1990
  • Paramedics not always the saviors off cardiac-arrest patient, R. Davis, USA Today, March 1st 2005

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