Sunday, November 15, 2009


Just a couple of things that got me thinking...

1. There are no paramedics in Portugal.

When someone calls 112 (the "911" of Portugal, as well as, most of Europe) the call goes to a call center, and the operator at the call center assesses the situation and sends help.
One of 2 things will occur based on the situation:

1. An ambulance is sent to the location. The ambulance is ONLY to transport the patient to the hospital. The people in the ambulance are NOT medically trained staff, they are simply transporters.
2. If the operator determines that the situation requires immediate medical attention, then in addition to the ambulance, a separate car containing a nurse and a medical doctor is sent to the scene.

As an outsider who is used to a system where the ambulances are staffed with specially trained medical personnel (Paramedics) that are sent to every medical emergency, I found this system to be a bit problematic:

Operator at the call center The call center operator is not medically trained, yet he/she has the responsibility of determining whether or not a medical emergency requires a doctor at the scene. Mara told me that the job of an operator requires a short amount of training that is probably not adequate given their level of responsibility. For example, there was a case where an operator told a patient suffering stroke that he did not need an ambulance. The operator did not recognize sudden onset of slurred speech as a possible stroke, but instead told the caller that the patient was probably just drunk.

To be fair, I'm not exactly sure what level of training 911 call center operators in the US receive. However, the critical difference is that if an ambulance is sent to a medical emergency, it is always staffed with paramedics. This way, the call center operator is not who determines whether or not a particular case warrants medical personnel or a trip to the hospital.

I'm an open-minded person, and therefore I realize that there are pros and cons to most things. I've only heard the "con" side to this system. I'm very curious to find out the "pro" side because this has been around for a while (there is also a similar system in Spain), so obviously it gets the job done.

2. There is no Emergency specialty in Portugal!
I had lunch with Mara last week, and we got to talking about her schedule. She works one day a week in the ED. At UNC, the medicine residents rotate through the ED, so I just assumed that it was a similar system. But in fact, it's not...
The ED is basically run by internal medicine. Patients are triaged (using a color coding system) and sent to different areas of the department. The most emergent patients (traumas, etc) go directly to the surgeons. The non surgical emergent cases (MI, stroke, seizures, etc) are seen right away by one of the internal medicine physicians. And of course the patients that are not emergencies at all, must wait. I spent a little bit of time in the ED, and it is quite nice. It is completely renovated, so everything is new. The yellow zone (non emergent) is set up like small consultations. There are divided work stations for each physician. Each station has a computer, exam table, and anything else they physician may need. It really looks more like an outpatient clinic than an emergency room. I also visited the "A Flu" area, which is in a separate building. Patients with fever and any respiratory complaints are masked and sent to this building for further questioning.
Ok, so back to Portugal not having an emergency specialty...The next day, I asked Dr. Basto about this, and he didn't really think an emergency specialty is necessary. He believes that internal medicine docs can manage acute MI's, seizures, and other non surgical cases, while the surgeons can manage anything potentially surgical. He has a point...He did add, however, that he feels that Portugal will adopt an ED specialty in the future.

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