SAMU - System of Emergency Medical Assistance in France
Dr Marc GIROUD
Service d'Aide Médicale Urgente
PONTOISE - France
1. HISTORICAL BACKGROUND
The first step towards the modern organization of Emergency Medical Assistance (EMA) was taken by Dominique LARREY, surgeon-in-chief of Napoleon Bonaparte's "Grande Armée", who, in 1792, would go out to the wounded, even under enemy fire, and treat casualties rapidly on the spot. His principle was to forestall complications (mainly gangrene) by treating wounds without delay, by means of excision, immobilization and, if necessary, amputation. Larrey himself carried out up to 200 amputations per day on the open battlefields.
More recent wars have confirmed the importance of very early treatment.
In civil practice, doctors have not been quick to follow in the footsteps of their military counterparts, particularly in contending with the scourge of road accidents. Hospital doctors, even though they are directly concerned, have very often closed their eyes to the incidence of mortality between the time of the accident and admission to hospital. Like doctors, the health authorities have delegated their responsibilities in this field to the rescue services.
The history of the "SAMU" system, in France, began in the 1960s. A handful of doctors were struck by the astonishing disproportion between the often impressive means available for treating the sick and injured on their arrival at the hospital, and, on the other hand, the still very superficial and archaic procedures of pre hospital care during the long minutes following an accident. They also were aware of the fact that hospital facilities for the seriously ill or injured are not always available at any time, anywhere. Thus, to increase the patient's chances of survival, it seemed necessary to provide medical care on the spot and better initial orientation of the patient, directly to the most suitable hospital, according to his condition.
This understanding was greeted with skepticism by health authorities and even hospital colleagues. Do doctors have a role to play in providing immediate pre-hospital medical care in the field ?
Owing to its constant concern for improving road safety, the French Ministry of Transport contributed to the development of the first pilot Hospital Mobile Intensive Care Units (H-MICU) thirty years ago.
Few years later, Hospital Mobile Intensive Care Units visited patients at home more and more often (for intoxication’s, infarctions, etc....) although such practice had not been initially planned. This revealed the need for some form of medical "regulation" of the response. Hence the need for a whole range of possible means of intervention according to the gravity of each case.
Today, the era of adventurers and pioneers is over and the SAMU system has acquired popular recognition.
The SAMU system is based on 6 principles
1. "Emergency Medical Assistance (EMA) is a health care activity".
Everything which, in a critical situation, contributes to the provision of care to the victims is a health care action, whoever provides it (witnesses, police, rescue worker, and, of course, medical staff).
Hence, EMA has to be within the control of health authorities. EMA is to be regarded as the first step (and therefore a key one) in medical care.
2. "Interventions in the field must be speedy, efficient and use suitable resources".
The resources deployed on EMA are not infinite. Each time a resource is deployed to aid a victim, the resources available for the simultaneous treatment of other victims are depleted accordingly. Hence, one of the objectives of the organizational arrangements must be to provide a suitable response, proportionate to the gravity of the case.
3. "The approach to each individual case is simultaneously medical, operational and human".
The approach is medical, insofar as the ultimate purpose of the action is to provide care.
The approach is operational, insofar as action is inconceivable without a movement. Distance, time, weather exert a very strong influence, as do availability of resources, telecommunications etc....
And the approach is, of course, human. Patient's confidence or anxiety conditions possible lines of action and has repercussions on their conditions. Respect for the patient's freedom of choice must be observed in emergency care as in general practice (even if the range of possibilities is frequently very limited). Respect for confidentiality between medical staff and patient is just as important. Even if there are several obstacles in the way of this, the dignity of the patient must be one of the main concerns of the medical team.
4. "The responsibilities and detailed arrangements for co-ordination between the persons involved must be regulated by a set of working rules".
The first point is to affirm the general responsibility of the health authorities in this fields (i.e. organization, training, supervision of interventions, funding).
The second point of this set of working rules relates to technical responsibilities of doctors (on system conception, training and control of intervening persons, co-ordination, direct intervention in most severe cases).
The third point is to stipulate the co-ordination arrangements between first-aiders, medical transport teams, general practitioners, doctors specialized in emergency care, health care centers, hospitals...
5."Results depend in large measure upon the skill of those involved".
6."Preventive action must complement emergency action".
The EMA services make excellent health observation posts, able to provide important epidemiological data. Furthermore, integration of these services onto multi-disciplinary programs on epidemiology or health education generates efficient outcomes.
3. MAIN CHARACTERISTICS
The SAMU of France may be schematically described in four main points
1.INTEGRATION OF THE MEANS.
Firemen (playing in France a role in EMA as both first rescuer and public ambulance men), private ambulance men, private general practitioners, Hospital Mobile Intensive Care Units (H-MICU), hospitals... are all included in local EMA schemes.
2.HOSPITAL DOCTORS INVOLVMENT IN THE FIELD.
To implement medical techniques.
To treat patients on the scene and during transport, both with "defensive therapy", as we could say, such as controlled ventilation, and, most recently, with "curative therapy", like thrombolysis at the very beginning of a myocardial infarction.
To make diagnosis, in order to deliver immediate appropriate care and to determine where to transport the patient and how to prepare his or her reception at a hospital. Half of the SAMU efficiency depends on its ability to give to the patient a suitable orientation. To avoid going to the wrong hospital save precious time.
3.MEDICAL TELE-CO-ORDINATION. ("REGULATION")
People have to dial "15" (or, now, 112) to call the SAMU call center.
There a physician (attended by secretaries) determine the most suitable response, implement it, by giving a piece of information or advice, or by sending an appropriate mean (ambulance, G.P., H.MICU...).
The outcome of this SAMU call center by choosing the appropriate solution is :
. improving the care of patients in live-threatening conditions
. avoiding useless medical procedures
. avoiding unnecessary hospitalizations
. ensuring and simplifying the access to G.P. on duty
. monitoring emergency procedures
. preparing the reception of the patient at a suitable hospital.
Thus, the SAMU call center gives confidence to the patients and contributes to effectiveness, progress, economy.
The hospital is, in France, the "pivot" of out-of-hospital Emergency Medical Assistance.
The law gives to the hospital the responsibility of
. managing SAMU call centers, and thus coordinating all the intervening persons or services in pre-hospital phase
. implementing Hospital Mobile Intensive Care Units (H-MICU)
. receiving the patients (in accident and Emergency Departments or directly in specialized services after medical regulation by the Samu call center).
4. MEDICAL CALL CENTERS
For a too long time the reception of emergency medical calls has been regarded as of minor importance.
The search of better response to the patient and better efficiency in the use of resources induces, in France today, to regard this action as the "pivot" of emergency medicine.
In France people has to choose between 3 call numbers
18for fire brigade
15for SAMU call center
Hospitals are in charge of "15 centers".
"18" and "15" centers are closely linked and interconnected.
112, the European emergency call number is, now, implemented. The calls are received by either SAMU or Fire brigade and, then, dispatched to the suitable service.
These centers cover populations from 200 000 to 2 000 000, according to administrative regions (called, in French, “départments”). These centers are called "SAMU call centers" or "15 centers", or "Medical Regulation Centers".
After a short and precise telephone conversation with the caller (having dialed "15" or “112”), the "regulator doctor", who takes into account the resources available at the time and the patient's right to choose freely, decides on the most suitable solution to the problem posed and proposes it. The "regulator doctor" then assumes responsibility for starting up the appropriate procedure, monitoring its progress and coordinating all the personnel involved.
"Medical regulation" is conducted from within a public hospital. There are 100 "SAMU call centers" in France (for roughly 600 hospitals receiving emergency). Private GPs are welcomed when they want to participate in the functioning of these centers along with hospital doctors.
Hospital "regulator doctors" are emergentists, recruited from among those who have already acquired a solid experience of work in emergency units, particularly in Hospital Mobile Intensive Care Units. These doctor's human qualities are also very much taken into account.
As for H-MICU, most doctors are part-time personnel who devote the rest of their time to other hospital activities (emergencies, intensive therapy, anesthesiology, cardiology, pediatrics etc...).
Medical regulation auxiliaries are generally recruited from among secretarial and administrative staff (some of them are nurses). They, too, must have certain human qualities.
The premises of the "SAMU call centers" are situated within the main hospital of each local administrative area, usually next to the premises of the Hospital Mobile Intensive Care Unit and to the hospital emergency and intensive care units. The "regulation room" is equipped with
. work stations
. telecommunications equipment
. documentation …
100SAMU call centers in France
10 000 000 cases taken in charge per year (1 call per 6 inhabitant)
The response given is :
information, advice30 %
sending GP on duty30 %
sending ambulance30 %
sending H-MICU10 %
5. HOSPITAL MOBILE INTENSIVE CARE UNITS
The Hospital Mobile Intensive Care Units (H-MICU) are the most potent means of action at the disposal of SAMU call centers.
Medically, administratively, and financially, H-MICU are hospital units. They operate in close collaboration with the hospital departments responsible for the reception of emergency patients. Outside the hospital, they work in close collaboration with the Fire Brigade, at least with respect to road accidents, and in close collaboration with GPs. Their internal organization varies from one hospital to another. But the vehicles are always based within hospital premises and the medical emergency team is composed of hospital personnel.
Hospital Mobile Intensive Care Units (H-MICU) provide medical life support services for the seriously ill and injured on the roads (resuscitation of patients suffering from multiple traumas, making up for losses of blood, pain-killing etc...), at home (intensive care of respiratory disorders, severe intoxications, cardiac diseases, premature births, psychiatric disorders etc...) at places of work, leisure parks, sports fields (accidents, loss of consciousness etc …) in public places and on public thoroughfares as well as on sites of catastrophes both in France and abroad.
In addition to patients with life-threatening conditions imperatively requiring immediate care by H-MICU, other patients whose condition is, at first sight, less serious may also benefit from the pre-hospital medical care provided by H-MICU. As well as its immediate effects, such care averts complications the onset of which is astonishingly rapid and often surreptitious. Furthermore, the medical assessments radioed by the doctor in charge of the H-MICU team to the SAMU regulator doctor enable the latter, when necessary, to look for the hospital facility best suited to the patient's illness or injury and which has resources available. Such a procedure expedites preparations for admitting the patient ot a hospital.
Thus, from the provision of life-support medical care in the field up to and including procedures for hospital admission and medical emergency care, there is a continuum of coordinated health care that gives everybody an equal and better chance to survive life-threatening conditions.
The H-MICU vehicles have “SAMU” written on the sides.
The H-MICU means include light rapid-intervention vehicles, Resuscitation Ambulances and helicopters.
The vehicles are equipped with essential resuscitation and intensive care equipment.
Hospital "SAMU doctors" are emergentists, recruited from among those who have already acquired a solid experience of work in emergency units.
The nurses are recruited from among those who have had experience of hospital emergency or intensive care units or anesthesiology.
Ambulance men are all recruited among qualified personnel.
SAMU call centers2 €/year/inhabitant
The cost of medical regulation in obviously low. All the more because the medical regulation contributes to avoid misuse of resources.
7.ASSESSMENT AND PERSPECTIVES
The following direct effects are generally acknowledged, even if not exactly measured :
. better and swifter medical emergency care
. improved physical and moral comfort of the patient
. more favorable use of existing resources
Indirect effects are probably as important as direct effects
. fostering the development of "alternatives to hospitalization" by making it possible to keep certain patients at home
. improving management of heavy medical equipment and reducing the number of hospitals involved in emergency
. reinforcing the ability to cope with disasters
. improving epidemiological research programs
. promoting of new techniques
After 30 years' existence, SAMU in France has come of age.
Many goals still remain to be achieved.
In this context, French SAMU doctors wish to cooperate with their colleagues in other countries who are also seeking to improve the quality of medical emergency care.