Emergency medical services in France

Emergency medical service in France is provided by means of a physician-led organization called a SAMU for each French Departement (county).

Organization

French IEMS is a Public Health Integrated EMS (IEMS) and a Professional Care Givers organization based on a Medico Sanitary Regulation process. This Regulator process is the principal function of the SAMU.

The SAMU (Service d'Aide Médicale Urgente), ("Emergency Medical Assistance Service") is the French hospital-based Integrated emergency medical service. It was founded in 1968 by coordinating (regulating is the best term) the existing SMUR teams (Mobile Intensive Care Units PICU). Although SMUR vehicles are typically labelled 'SAMU' that term actually refers to the service for the centralized regulation center of multiple SMUR (Service Mobile d'Urgence et Reanimation) units (perhaps even from multiple hospitals) and all emergency care resources within a community from GP to Hospital Intensive Care services. SAMU organization operate at the Departement level, and are identified by numbers, with a different number for each Departement (SAMU 06=Nice, SAMU 75=Paris, etc.). In addition to mainland French Departements, SAMUs operate in a number of offshore departements, (e.g. Guadeloupe is SAMU 971) and under contracts in a number of other countries. Emergency response may be through the use of a fire department-based rescue ambulance, such as the Paris Fire Department , or by an ambulance (labelled SAMU) staffed by a physician-nurse-staffed team called in english MICU (SMUR). The French philosophy is to provide the best Medical Intensive Care at the scene during life-threatening emergencies, and a SMUR team, may elect to conduct initial stabilizing critical care, even resuscitation attempts, at the scene, prior to transport and to orient critical patient towards best Hospital available service not forcedfully the nearest . SMUR MICU teams are hospital-based.

• EMS in France
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  SAMU Strasbourg MICU
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  Rescue Ambulance Extrication of a Patient
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  SAMU Helicoptered MICU

Standards of French Integrated EMS

Medical Regulation of Samu orients grave patients towards the next Emergency Room or towards best Hospitals vailable Critical Care Resources.

French hospital (public or private) must have a specialized service (service spécialisé d'accueil et de traitement des urgences) only if it can already take care of the most probable trauma and disease in classical hospitalization: resuscitation unit, general and internal medicine, cardio-vascular medicine, pediatrics, anesthesiology-resuscitation, orthopedic surgery and oncology, including obstetrics. The hospital must have

• two operating rooms (and a wake-up room) with personnel on duty that allow operation at any time;
• services that can perform examination and analyses at any time: medical imaging (radiography, medical ultrasonography, computed tomography, angiography...), haematology, biochemistry, de toxicology laboratories, 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 anytime. This depends on the specific pathology of the patient, (i.e. in the hospital, not in the emergency service).

The team must have, in addition to the emergency physician:

• two nurses ;
• care assistants, possibly child care assistants;
• a social worker;
• a receptionist;

all must have a specific education for emergencies.

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 allow to take care of a great number of patients (plan blanc).

There are also specialized poles (pôle spécialisé d'accueil et de traitement des urgences) that can anly take care of specific pathologies or specific types of patients (e.g. pediatrics).

Hospitals Intensive Care Services and Operating Rooms.

All participate to french IEMS and Samu Regulation regional monitoring of Resources

If the patient needs critical care the MICU with be oriented by the Samu Regulator Physician, even shortcircuiting the next Emergency Room, to the most adapted pont of critical care of his region or even in neighbouring ones.

French EMS Vehicles

In French EMS EMS the word "ambulance" is reserved to transportation on medical prescription, including oral prescription in case of emergency. The term "ambulance" is generally used only to apply to those response vehicles operated by the local SAMU. It does not technically apply to first responders vehicles (most of the time firefighters), 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 vectors that bring rescue workers and devices onsite, with the evacuation of patients being only the logical result of the response, but not the primary duty of these response resources. In France 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 is "vehicle adapted to patient transport". 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. The visual identity provisions of the standard are not currently being followed anywhere in France.

• French Basic Ambulances'
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  Private Basic Ambulance in Pontarlier
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  Private Basic Ambulance Company

EMS Staffing

Paramedics, as we understand the role, do not exist in France.(Paramedical Personals means Professionals who ar Physician Assistants like the Nurse), rescue and First aid vehicles are staffed by EMT. The majority of high priority emergency calls are serviced by physician-led MICU SMURs, through the SAMU Regulation dispatching. The Ambulatory emergencies are oriented to the General Parctitionners Emergency Systems and Basic Ambulances Services.

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 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 . Since 1986, fire department-based rescue ambulances have had the option of providing resuscitation service (reanimation) using specially-trained nurses, operating on protocols, in the role that we would normally expect to be performed by the paramedic but with the Samu Medical Physician Regulator Aid . In actual practise, however, such units and nurses are extremely rare outside of the City of Paris.

Samu Medical Regulation of Samu in France

Medical Regulation or Medico Sanitary Regulation of Emergencies is the job a french Samu samu Medico Sanitary Regulation of Emergencies Régulation Médicale des Urgences

Public Acces to Samu

Even if France now uses the also the General emergency number 112 the european Not specialized emergency number the Samu 15 emergency number, 15, will still work and is considered as one of the qualities of the Samu. Dialling either of Emergency numbers of Police or Fire men can be connected to the SAMU medical Regulation Team : it means that all requests for Integrated Medical Emergency Service are received and processed by the local Samu.

Calls are screened and patients interviewed by the Physician Regulator medical Team, with a variety of possible outcomes. The Regulator physician may elect to provide simple medical advice over the telephone, avoiding the need for a mobile resource dispatch response. The physician may also order the assignment of a transport resource, either private, fire-based, or SMUR (MICU) , at their own discretion. SMUR response may consist a Hospital Mobile Intensive Care Unit (MICU) with a Medical Doctor, a Nurse and an Ambulance Technician. Because of aggressive triage called Medical Regulation , only about 65% of requests for EMS service 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.

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. The good news is that in France, as a general rule, the more sick or injured you are, the less you will be asked to co-pay! 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, the SAMU physician may refuse to sign the patient's 'treatment 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, particularly on low-priority calls, patients being transported to hospital may be asked to pay for service in advance, and then seek reimbursement from the government insurance scheme or their private insurance. Although not regarded as ambulances in France, fire department ambulances, when used, provide transportation to hospital without charge. All requests for ambulance service are processed by the local SAMU, which will determine what type of assistance and transportation resources are sent; the patient has no choice in the matter.

Medical Regulation of the SAMU

Regulation has here is second meaning and says more sophisticated concept than the Dispatch elemental EMS concept. French has an Integrated EMS (IEMS) with all Regional Medical Care and Sanitary Resources (Mobile and Fixed). The Medical Regulator is a Physician who "regulates" , it means, analyses, classifies, the Medical Needs of the patients and orients them to the best in terms of Care not only on delays and distances.

In this Central Call Center , the Regulator Physician and his Medical Regulation Assistants have a new special medical Praxis based on telemedecine and an also a new Medical Care organization.

SAMU in France

SAMU missions

SAMU missions are defined in a law of 1986. SAMU are defined as hospital services providing permanent phone support, choosing and dispatching the proper response for the call in the shortest possible time. These responses may include:

• Medical advice (28% of the calls)
• Sending ambulances, from the fire department for accidents or illnesses in public places, or for life-threatening emergencies at home (24% of the calls),
• Sending ambulances from private companies (under French law these are not officially recognized as 'ambulances') for relative emergency transportation from home (8% of the calls)
• Sending a generalist physician to see the patient at home (22% of the calls)
• Sending a resuscitation ambulance (H-MICU: hospital mobile intensive resuscitation unit, called UMH-Unité Mobile Hospitalière), rapid response vehicle or medical helicopter for the most serious cases
• Management of crisis with large numbers of casualties (plan rouge, plan blanc), they maintain the mobile sanitary kits (postes sanitaires mobiles, PSM).

The French philosophy for medical emergencies allows the reanimation units to be dispatched only in life-threatening cases.

SAMU are also tasked with providing the training of 'emergency physicians', although emergency medicine, as a medical specialty, does not exist in France, and the majority of those identified as 'emergency physicians' are probably, but not necessarily, anaesthetists.

SAMU organisation

Each French Département operates one SAMU (roughly one for every 500,000 people), or a total of 100 SAMUs, and 350 SMUR units, in the whole of France.

Additionally, two SAMU have special tasks :

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

The main component of the SAMU is the dispatch, called Centre 15 (15 is the emergency number for medical emergency) or CRRA (centre de réception et de régulation des appels: call reception and dispatch center). The CRRA received about 10 million calls in 2004, with a regular increase of 10% per year:

• 57% from individuals (witnesses or victims of an accident or disease);
• 27% from the firefighters (NB: in France, firefighters are in charge of emergency ambulances, as certified first responders)
• 5% from the hospitals (usually life threatening emergencies in a department)
• 5% from a general practitioner (usually visiting a patient at home)
• 5% rest (police, ambulance - in France, private ambulance society mainly act as transport for programmed acts, a kind of paramedical taxi).

Prehospital Emergency Care Strategy

The French doctrine relies on the hopes of survival for a critically ill or injured patient decreasing exponentially with time, which explains why so many patients die during transportation. To maximise the chances of recovery, it is believed important to cut down on transportation time, and bring a fully equipped and qualified team to the patient, rather than sending an ambulance to pick up the patient and double the travel back to hospital. To this effect, Mobile Intensive Care Units (MICU depending of Hospital SMURs) are equipped with both a fully qualified emergency physician: nurse and ambulance technician and Portable Intensive Care medical equipment. If needed the patient shortcircuits the Emergency Room and is admited direcrtly in the Intensive Care Unity that has been alerted previously by Samu Medical Regulation. French gain time by organisation of an Integrated EMS based on Samu Regulation.

This doctrine also simplifies greatly the Emergency department of hospitals (eliminating the need for a "smaller hospital within the hospital"), and ensuring that the stabilised patient will receive care from a specialist rather than an emergency generalist.

In extreme cases, heart surgery has been performed on the street (resulting in surviving patients). Overall, the French SAMU is arguably one of the very best in the world, innovating in lots of areas (the French SAMU are the only emergency teams to have tested portable cardiopumps on scene) and inspiring equivalent services in other countries.

The French emergency system is very different from emergency systems from the USA and the United Kingdom; one notable difference is that intervention units may decide to stay on the scene for a long time (much more than the typical 10 minutes that ambulances spend on a scene before picking up a patient in most other countries).

This is often maliciously described as stay and play, opposed to the scoop and run strategy performed in the United States and in the United Kingdom. This is not totally true as in most cases, the patient is at the hospital within the golden hour, the best description would be think before run.

This feature is often misunderstood among the American or British public. For instance, when Diana, Princess of Wales died in Paris, some British tabloids took outrage that the patient had stayed on the scene for two hours, leaving the impression that the delay might have caused the death. Actually, the SAMU doctrine allowed the patient to receive extensive care during these two hours, including cardiac resuscitation in the ambulance [1].

See Emergency medical service: Prehospital Care Strategies for more details .

Miscellaneous information

SAMU Social, which is a service for aiding homeless people is not a SAMU that iis a Registered Term , Label and Logo.

SAMU Medical Regulation of Emergencies

See also

• Health in France

External links

• SERVICES D'AIDE MEDICALE URGENTE - SAMU, SMUR
• SAMU de France
• SAMU de Paris
• System of Emergency Medical Assistance in France