Prehospitalario

Some notes on my work.

About two months ago, I started volunteering with the local emergency medical service. I've been meaning to write something about my experience for some time now. The service is called SAMU here (Servicio de Atencion Medica de Urgencias), is part of a national service, and operates out of the regional hospital located in Valdivia. My role is really more of observation than participation. From time to time I am needed to help with patient movement, vital signs, or basic interventions, but for the most part I'm the extraneous part of their normal three-person crew.

(For non-EMS readers, you may want to read this next paragraph and leave it at that. For those with an EMS background, you may want to skip the next paragraph and read the rest.)

First the story about how I came to work at the hospital: I arrived in Chile without really having thought too much about acquiring an internship (a significant mistake on my part). Before leaving Santiago, however, I mentioned my interest in volunteering with EMS to our program director. Within a couple of weeks he arranged an interview with the doctor in charge of SAMU in our region. Due to faulty lines of communication, however, I only learned of this interview an hour after it was supposed to have taken place. But, no matter, we rescheduled for the next day. It is important to note that at this point I had been confined to a chair for the past four days due to a knee injury suffered the previous week and could barely stand, much less walk. I dressed in shirt and tie for the interview, not sure of what to expect. Don Oscar happened to be heading in the same direction as the hospital that morning so he gave me a lift. Unfortunately, he dropped me off on the wrong side of the hospital, so I spent about half an hour hobbling around the building, which is enormous, asking people where to find the chief of SAMU's office. I finally found SAMU's base, in a separate building behind the hospital. When I knocked, the door was answered by a tall, Germanic-looking man in a lab coat. I had found the boss. It turns out Doctor Schulz doesn't have an office, he operates (not surgically) from a desk in the middle of the communications center at the SAMU base. My interview consisted of him asking me where I was from, what I was studying, and then telling me he didn't have any problem with me working with them. Then he introduced me to the shift on duty, and that was that. I showed up later that afternoon in work clothes and started riding along and getting to know the staff.

I want to note some general observations about the service, narrate a typical run, and comment on some of the significant differences between the service I know in Ohio and what I've seen here. Keep in mind that what follows are impressions that I've developed through a language barrier in less than three months, not established facts.

General observations

There are two ambulances operated out of our base, a basic truck and an advanced truck. The service also has one ambulance based out of Lanco, a smaller city in the north, and La Union, a city in the south. These four trucks are responsible for the Region of Los Rios, an area about 30% bigger than Connecticut. Resources are not as stretched as it sounds at first. SAMU is supplemented by the ambulance services of the local hospitals. There are some eleven hospitals, and each operates two trucks, so the entire region is served by about 26 trucks. We also have a couple of reserve trucks that are only staffed on special occasions like holidays or long weekends, when more people tend to use emergency medical services.

Each truck runs with a crew of three. For the basic ambulance, that means a driver (no medical training), an assistant (equivalent to a first responder), and a paramedic technician (equivalent to an EMT). In the case of the advanced ambulance, the crew is a driver, a paramedic technician, and a nurse (equivalent to a paramedic). (Supposedly there is a third classification of crew with a doctor on board, but I've never seen this happen.) There are crews for two trucks on duty at any given time, so six people per shift. Our base employs about 24 ambulance workers in total.

We also have a communications center that handles all calls for the region. (You have to dial a different number depending on which emergency service you need in Chile; 131 is the number for ambulances.) They have two phone operators and a doctor on duty at any given time. The doctor is there for medical direction, but sometimes he or she with help manage the phones when things get busy. There is also a secretary during business hours and a kid who cleans the base. (We had a dog who hung out for years in the base and in the emergency department of the hospital, but someone stole him about a month ago. He was the only dog I've ever met who liked to chew on gravel.)

Typical run

Our salidas normally go down as follows: an operator answers the call, generally on the sixth or seventh ring to make sure it's a serious call. The operator then spends several minutes trying to firmly persuade the caller that they don't need an ambulance. (The operators' main job is to allocate very scarce resources, and they get a great deal of nonsense calls.) After getting information about the patient's location and problem, the operator alerts the ambulance crew via the radio. "Mobile unit such and such. Code such and such." It's usually a code 101 "medical problem of unknown etiology". The crew then goes to the ambulance and marks that they're ready. Then the operator relays the location and the patient details. We don't have GPS or maps in the trucks. The driver generally knows where all the streets are, and if they can't find the address, they radio the base for directions. We generally don't use emergency lights during the day and rarely use the siren (only for cardiac arrests and such). When we arrive on scene, the in charge person, either a paramedic or a nurse, goes into the house to assess the patient. They usually make a transport decision in the first 30 seconds and call for the cot. We only change the sheet on the cot once per day, so generally we ask for a thick blanket from the patient's house to lay the patient on. The houses are small with narrow hallways and steep stairs. We don't have a stairchair and the cot doesn't fold, so patient movement is usually one person grabbing the patient by the armpits and another by the legs and just carrying them. Once we have the patient in the truck, the secondary medical crewmember, either an assistant or a paramedic, checks the pulse, oxygen saturation, and blood pressure (almost never manually). The in charge person reads the patient's medical documents, takes a short history, gives basic interventions like oxygen, bleeding control, or starting an IV, and then calls medical control on the radio and gives a report. Sometimes medical control will indicate an additional drug, but usually the doctor just says to transport as is. Then the in charge person tells the driver to go. One family member is allowed to accompany the patient in the back of the ambulance during the transport. The in charge person often uses the rest of the transport time to finish up the paperwork. When we get to the hospital, the driver unloads the patient on the cot and wheels him or her into the emergency department. Then he finds a vacant bed, we move the patient onto the bed, and wheel him or her to the side of the hallway to wait until a nurse or doctor is available (this usually takes several hours for non-critical patients). The in charge person gets the on-duty nurse to sign for the patient, and then we drive the 200 meters back to the base.

Notable differences

I'll start with the nitpicky and move on to the bigger things:

• Unlike in Ohio, examination gloves are optional here, and most opt not to wear them unless they see blood or vomit.
• Handwashing before and after runs is also infrequent.
• Patients are almost never strapped to the cot, and on some of the cots, the Velcro is so old that the straps are more decorative than functional in any case. (Frankly I don't understand why we strap patients down in Ohio. I've never seen a patient come close to falling off a cot- it's rather implausible under normal circumstances- but I have seen several patients hurt by carelessly misapplied straps.)
• Whereas in Ohio we walk into the house (and the hospital) with everything we think we'll need to treat the patient, here we usually walk in without any equipment whatsoever. (I've only seen vital signs taken inside the house twice; I took them both times, and it was for patients who weren't transported.)
• Vital signs are only taken once during a run, whereas we almost always take multiple sets in Ohio.
• The twelve lead ECG monitor is a separate machine from the three lead monitor here, and it's a monster. Setting up a twelve lead is a five-minute process that involves spring-clip bracelets and anklets, a bottle of conducting gel, and a large array of suction cups.
• It's perfectly normal here for a paramedic to take or make personal calls on his or her cell phone during a run.
• Every patient is asked to present their national identity card, and their RUN (identification number) is recorded, along with information like address and DOB, directly from the card.
• We reuse a lot of things in Chile that we throw out in Ohio. For example: cervical collars, oxygen masks, Yauger tips, those little ear condoms for the tympanic thermometer, etc.

Some broader differences between EMS in Chile and in the US have to do with attitude. In the fire service in Ohio, we talk about maintaining a sense of urgency. That is to say, you don't necessarily want to rush, but you do want to strictly prioritize your expenditure of time. Our system is constructed to reflect this priority. In SAMU, that sense of urgency is not so strongly felt. They are very aggressive about getting the patient into the ambulance, but at that point things become far more relaxed, even if the patient is in critical condition. They usually finish all interventions before leaving the scene, even though the driver is sitting in the cab throughout the whole process. One time I saw a patient exhibiting clear signs of a stroke spend eight minutes in the back of the truck getting an IV stick before getting oxygen therapy much less transport. Part of this lack of urgency might be traced to the knowledge on the part of the paramedics that, unless the patient is rapidly dying, he or she is going to have a long wait at the hospital before receiving definitive care.

Another attitude difference manifests itself in the patient-caregiver relation. Paramedics here seem to prefer talking about the patient to talking with the patient. They generally read the patient's medical documents and talk to family members and other emergency workers as if the patient weren't even there. It's not uncommon for the nurse to not speak a word to the patient in the back of the rig aside from asking for his or her ID card.

A third big difference is the degree of centralization. SAMU is a national service. Everywhere in Chile they wear the same uniform, drive the same ambulances, and use the same equipment with the same training. The in charge person reports to medical control on all runs. All calls for the entire region are handled out of one call center in Valdivia. This is almost diametrically opposed to how things are structured in Ohio where EMS is organized at a local level and varies from volunteer fire service, to contracted private services and every combination in between.

That's all I can think of for now. I'll add more if more occurs to me. I've been meaning to take pictures of the base and the trucks, but both my cameras were broken for quite a while, and now one is stolen and the other loaned out.

EDIT: formatting and some more differences.