Emergency medical services in France

A typical Hospital French SAMU with Helicoptered MICU on the roof and ground MICU on the basement (Dreux)

Emergency medical services in France are provided by a mix of organisations under public health control , with the lead taken by a central control function called SAMU, which stands for 'Service d'Aide Médicale Urgente' or urgent medical aid service. This central hub is supported by resources including first response vehicles or ambulances provided by the fire service and physician led ambulance provision from SMUR (Service Mobile d'Urgence et Reanimation - literally translated as mobile emergency and resuscitation service) which are 'mobile intensive care units' (MICU) that have one or more physicians on board.

Organisation

SAMU missions were defined in a law of 1986 as hospital based services providing permanent phone support, choosing and dispatching the proper response for a phone call request. The central component of SAMU is the dispatch centre where a medical regulation team of physicians and assistants has the task of:

• analysing calls to decide on patient need
• deciding the best solution for the patient's care
• dispatching the most appropriate mobile care resource (MICU, Ambulance, or Mobile care professional), or
• directing the patient to an alternative fixed resource such as primary care medical surgery or hospital service, or
• offering Medical emergency care advice over the telephone Telemedecine

Because of SAMU Medical Regulation aggressive triage Medico Sanitary Regulation , only about 65% of requests to SAMU actually receive an ambulance response . Current performance on emergency calls is arrival at scene within 10 minutes, for 80% of responses, and within 15 minutes for 95% of responses.

This means that SAMU regulates a variety of all regional Emergency Medical Resources within a community from general practitioners to hospital intensive care services, ambulances etc

SAMU is organised at the 'Departement' level, with each Departement organising its own service, each of which is identified with a unique code, for instance SAMU 06 in Nice and SAMU 75 in Paris.

Additionally, two SAMU have special tasks :

• The Paris SAMU is responsible for providing service to fast trains (TGV) and Air France aircraft, while in flight.
• The Toulouse SAMU is responsible for providing service to ships at sea.

SAMU also operates in most of the offshore french Departements, such as Caribean French Islands Guadeloupe Martinique , Indian Ocean Reunion , Pacific Ocean Tahiti and the South American Amazonian French Guyana

File:SAMUGUY.jpg

SAMU of French Guyane Amazonian Helicoptered MICU

Ambulance provision

In the French system, the word "ambulance" itself is reserved to transportation on medical prescription, including oral prescription in case of emergency and the term itself is therefore generally used only to apply to those response vehicles operated by the local SAMU, rather than the emergency vehicles from places such as the fire service or private companies, even though they are fully equipped emergency patient transport vehicles, and would almost certainly be described as ambulances in other parts of the world.

Consequently under the SAMU system in France, there are a number of different providers of emergency medical services, offering different levels of care, and dispatched for different types of patient condition.

While all of the above types of vehicles attempt to meet some aspects of the European standard for ambulances CEN 1789, published by the European Committee for Standards, the degree of compliance varies, particularly among those vehicles not officially referred to as ambulances in France.

Private ambulance services

Private Basic Ambulance in Pontarlier

Non-emergency and low-priority ambulance services are normally provided by private companies, with no formal requirements for the training of their staff. For other types of medical transportation, the term 'ambulance' is not used; relying instead on the more general term "vehicle adapted to patient transport". In many cases Private ambulance services hire they Vehicles and Ambulance Techinicians for the Hospital SMUR MICUS , the Medical professionals staying Hospital payed personals.

Fire department services

Fire service rescue ambulance extrication of a patient

Emergency response may be through the use of a fire department based rescue ambulance, a multi-purpose vehicle or even a fire apparatus. Here, the cross-trained EMT firefighters will provide on scene care and transport for injuries or illness, but are backed up by a MICU SMUR Ambulance or Light MICU on site intervention after SAMU Medical Regulator decision.

Although they also transport casualties and are, in any practical sense, ambulances, their vehicles are called VSAV; véhicule de secours et d'assistance aux victimes (casualties' rescue and assistance vehicle), or VPS; véhicules de premiers secours (first aid or Rescue vehicles) in case of volunteers from associations. The VSAV and VPS are considered to be means of bringing rescue EMT and BLS equipment onsite, with the evacuation of patients being only the logical result of the response, but not the primary duty of these response resources.

SMUR

SAMU Strasbourg MICU

SAMU helicoptered MICU

The French philosophy on emergency medical care is to provide a higher level of stabilizing care at the scene of the incident, and so SMUR (Service Mobile d'Urgence et Reanimation) units are staffed by a qualified physician along with a nurse and/or ambulance technician. This contrasts with systems in other parts of the world, notably the Anglo-Saxon countries (United Kingdom, United States, Australia etc.) where care on scene is conducted primarily by paramedics or emergency medical technicians, with physicians exceptionnaly involved on scene at the most complex or large scale incidents.

The result is that a SMUR unit intervening in Intensive Care Cases will typically spend a longer time on scene compared with an Anglosaxon paramedical ambulance in a different system, as the physician may conduct a full set of observations, examinations and interventions before removal to hospital. This feature is often contrasted the British or American system, especially in high profile incidents, such as the death of Diana, Princess of Wales in Paris, where the nearly 2 hour delay before arrival at hospital has been ascribed by some malicious as a major contributory factor in her death.

SMUR units are hospital based and although the vehicles are typically labelled 'SAMU' that term actually refers to the overall integrated service which controls multiple SMUR units (perhaps even from multiple hospitals) and all emergency care resources within a community from GP to Hospital Intensive Care services.

Despite being hospital based, a SMUR unit may choose to transport a patient to an alternative hospital, where the best definitive care may be provided, and are not necessarily tied to the hospital of origin.

French Integrated Emergency Medical System Hospital standards for SAMU

French hospital (whether publicly or privately run) must only operate an emergency department (service spécialisé d'accueil et de traitement des urgences) only if it is capable of treating the common trauma and illness conditions that are likely to present. This normally includes a resuscitation unit, general and internal medicine, cardio-vascular medicine, pediatrics, anesthesiology-resuscitation, orthopedic surgery and oncology, including obstetrics. The exception would be for specialised units, which only admit specific pathologies or specific types of patients (e.g. pediatrics). These units are termed 'pôle spécialisé d'accueil et de traitement des urgences'.

The hospital must have two operating rooms (and a reecovery room) with personnel on duty that allow operation at any time, as well as support services that can perform additional examination or analysis at any time, such as medical imaging (radiography, medical ultrasonography, CAT Scanners, haematology, toxicology laboratory etc.

The specialized service is managed by an emergency physician. An emergency physician must always be "on-call," and a specialized physician can be called at any time. In addition the team must have two nurses, care assistants (and possibly child care assistants), a social worker and a receptionist, with all of them having received specific education for dealing with emergency cases.

The service is organized in three zones:

• a reception zone,
• a zone for the examination and the cares (including intensive cares),
• a zone for the watch over short durations (patients waiting to go out or for a transfer in another service).

Most services also have a massive crowd room that are designed to allow care of a large number of patients, outside of the normal levels of presenting patients. These plan blanc units are designed to cope with major incidents or epidemics.

All these Emergency rooms are connected with the IEMS SAMU Medical Regulation center as all other Emergency Hospital Resources. Certain Hospitals have a SMUR Service Mobile d'Urgence et Reanimation with one or more MICU who are the out of hospital Mobile Intesive Care SAMU responders.

Emergency medicine speciality

In hospital emergency medicine has only recently been recognized as a medical specialty in France, and pre-hospital care is currently struggling to be recognized as a sub-specialty. In the meantime, many SMUR/MICU physicians are actually in training for other specialties, such as anesthesia, and the system relies on General Practitioners and physicians from other specialties 'filling the gap' when emergency physicians are not available .

The situation is further complicated by the fact that the physicians staffing the SMUR units are among the lowest-paid in Europe. Although salaries have recently improved somewhat, in 2002 it was reported that these physicians, who are, for the most part, full-time employees of public hospitals, had a starting salary of only €1300 (£833; $1278) per month. This economic reality has resulted in understandably high turnover and some difficulty in staffing positions. It has been suggested, however, that the recognition of emergency medicine as an in-hospital specialty in France and elsewhere in Europe is likely to result in the evolution of that system towards more comprehensive in-hospital emergency services.

This will ultimately, in turn, result in less physician MICU response; although the complete replacement of physician response by the type of technician response occurring elsewhere is unlikely to occur any time in the immediate future because Paramedical true Professionals are progressively integrated . Hospital MICU SMUR and Fire department-based rescue ambulances have had the option of providing Registered nurses manned ATLS ambulances but regulated by SAMU regulator physician .

Public Access

France, along with the rest of the European Union uses the emergency telephone number available across all members 112, which gives access to police, fire and ambulance services. However, the legacy emergency number of '15' specific of Medical Care and SAMU Medical Regulation Centers will stay still in use.

Funding and costs

In France, the 100 or so SAMUs (one for each Departement) are all operated by public hospitals. Public hospitals (unlike private hospitals, and France has both) receive government funding. France operates on a system of universally accessible socialized medicine. Patients have freedom to choose physicians, hospitals etc., and there are prices set for each type of service.

When operating in the public system, patients are asked to co-pay a portion of the cost for each type of care that they receive. To illustrate, a patient requiring hospitalization is liable for 20 percent of costs for the first month, and nothing thereafter.

What this means in terms of funding is that the SAMUs and their SMUR response teams are funded by the government, by means of the hospital funding scheme. They do charge a fee for service, and for a typical patient, 65% of this cost will be covered by the government health insurance scheme and the balance covered by optional additional private insurance. By French law, in an emergency any French hospital or SAMU must treat any patient, regardless of their ability to pay.

As a measure against system abuse of Basic Ambulances , the SAMU physicians may refuse to sign the patient's 'ambulance certificate', resulting in the patient being liable for the full cost of services provided, although in practice, this is rarely done. Most French citizens also carry private health insurance in order to cover all co-payment charges.

In some circumstances, like on low-priority ambulance journeys, patients being transported to hospital may be asked to pay for service in advance, and then seek reimbursement from the Social Security insurance scheme or their private insurance. Although not regarded as ambulances in France, fire department ambulances, when used, provide transportation to hospital without patient charge. All requests for ambulance service are regulated by the local SAMU, which will determine what type of assistance and transportation resources are sent and will be free of charge; the patient has no total choice in the matter when it is an Intensive Urgent Care Need.

See also

• Health in France

External links

• SAMU de France
• SAMU de Paris