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TRACK H

Developing EMS in Bulgaria and Promoting Emergency

Medicine as an Independent Specialty

Dr. Assen Geshev - Center for Emergency Medicine and Accidents - Stara Zagora, Bulgaria

Prof. M. Milanov MD – National Institute for EM – Sofia

Maxim Gaidev MD – Ministry of Health

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Bulgaria is situated in the south - east part of Europe, and in the eastern part of the Balkan Peninsular.

Country information

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Country informationGeneral Information Territory - 110 993,6 km2  Population - 7 973 671 Capital - Sofia Official language - Bulgarian Political system - Parliamentary Republic

Population - Demographic data: (01.03.2001): Population - 7 973 671 Men - 3 888 440 Population in towns - 5 500 695 Population growth - (%)  – 5,1

Socio-economics - The economy in 2001 Actual growth of GDP (%) 5,8 GDP (thousand Lvs) 25 453 649 GDP per capita (USD) 1459 Budget surplus (% GDP) - 1,1

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Country informationBurden of disease Life expectancy – 71.5 years Major causes of morbidity and mortalityIschemic heart disease and Cerebrovascular disease

Health care system GPs – all over the country Regional hospitals with basic wards only and small number of beds 28 county hospitals 5 university hospitals Several centers of national significance Financing –by state budget and by NHIF, a small number of private

hospitals and medical centersMedical education 5 Medical Faculties 6 years of study 4-5 years residency programme according to specialty Medical Specialty Board certification mechanism - still not

introduced

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EM specialty statusIn 1996 Emergency Medicine is declared an independent specialty by Ministry of Health . A national residency programme based in the National

Institute of Emergency Medicine was developed and carried out in five Academic Medical Centers

The first admission exams were carried out in 1997. The duration of the programme is four years. During this

time the resident has to pass 8 theoretical terms with an exam at the end of each.

Final specialty exam by the National Examination Committee at the end of the residency programme

Special attention is paid to anesthesiology and intensive care, cardiology, toxicology, pediatrics and surgery.

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Residency Programme in EMAnesthesia and Intensive Care 9 weeks

Pediatrics 9 weeksSurgery 8 weeksCardiology 7 weeksNeurology and Neurosurgery 5 weeksToxicology 4 weeksOrthopedics and Traumatology 4 weeksObstetrics and Gynecology 4 weeksPulmonology 4 weeksPsychiatry 1 weekOphthalmology 2 weeksOrganization of EM 1 weekUrology 2 weeksBurns 2 weeksGastroenterology 1 week Total practice 64 weeks

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Bulgarian Association of EM Physicians

In 1999 Bulgarian Association of EM Physicians was founded

The main goals of the association are:To unite all the emergency physiciansTo work on the public image of EMTo promote standard protocols in EM To support physicians in their qualification and scientific researchTo support public education and training in EMTo help international collaboration in EM

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EM System information Both Pre-hospital and In-hospital emergency care is provided by 28 CEMA. Emergency care is a state policy and is totally funded by Ministry of Health.At present time the national system for Emergency Medical Care consists of: 28 centers for emergency medicine

1507 doctors and 2532 nurses 186 branches for emergency medicine 92 mobile intensive care units 251 mobile medical units 50 transport units 50 emergency departments 136 emergency sectors

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EM System information Structure of CEMAadministrative unitdispatch center = regional

coordination centeremergency department mobile intensive care units mobile medical unitstransport units

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Dispatch Center (regional coordination

center)It is based in the administrative center of the county. It has a computerized system for registering and recording the phone calls on the unified emergency number 150 and creating a data base of all missions on which mobile units are sent. Radiocommunication system was at first introduced. Through the years with the development of mobile technologies, and having in mind the geographic characteristics of the country the system was doubled by GPS with voice modules providing bi-directional communication. Thus the communications between ambulances, emergency departments and dispatch centers became safer. The dispatchers in these centers are nurses supervised by a physician 24 hours a day. Neither special training or requirements are needed for the dispatchers, nor any protocols are followed.

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Mobile units are three types

mobile intensive care unit – crew - consist of a physician, a nurse and a driver. qualification - both the physician and the nurse

have passed courses for ACLS, APLS and ATLS. The driver has accomplished a course of BLS and helps the medical staff.

equipment - the ambulances are large vans, equipped with standard resuscitation drugs, cervical collars, backboards, monitors, defibrillators, perfusion pumps, respirators and communication devices. The mean response time for such a unit is 3 to 9 minutes. These units are usually sent to traffic and industrial accidents or to patients at high risk.

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Mobile units are three types

mobile medical unit crew- consists of a physician and a driver. qualification - the physician has passed

courses for ACLS, APLS and ATLS and the driver has accomplished a course of BLS and helps the medical staff.

equipment - the ambulances have the same design and are equipped as mobile intensive care units. These units are dispatched to patients who are not in life threatening situation and resuscitation won’t be needed. The mean response time for such a unit is 6 to 12 minutes.

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Mobile units are of three types

transport unit crew–a driver who has accomplished a

course of BLS obligations - provides emergency

transport of bioproducts and blood, and

specialists between hospitals.

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Emergency DepartmentIt is a part of the Emergency Center and not of the hospital. The emergency departments can use the diagnostic facilities of the hospital – laboratory, X-ray, CT scanner.In major cities these departments usually have: room for resuscitation and intensive care –

equipped with monitors, respirators, defibrillators, ECG-machines and variety of emergency drugs.

trauma room – where surgical activities are run, such as sutures, immobilizations, extraction of foreign bodies.

some departments have specialized pediatric sectors

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Challenges

To overcome the use of ED as a round a clock GP

To introduce National Standards in EMTo intoduce the credit system in Certification

doctors in EM

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Comparative Analysis of Bulgaria’s EMS

Features Underdeveloped Developing Mature Bulgaria

Specialty systems

National organization

Residency Training

Board Certification

Official specialty status

No

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Academic EM

Specialty Journal

Research

Database

Subspecialty training

No

No

No

No

Yes

Yes

No

No

Yes

Yes

Yes

Yes

Yes

Yes, clinical

No

No

Patient Care System

EM physicians

ED director

Prehospital care

Transfer system

Trauma system

Other physicians

Other physicians

Private car

No

No

EM residency trained

EM residency trained

EM physician, EMT

No

No

EM residency trained

EM residency trained

EM physician, EMT

Yes

Yes

EM residency trained

EM physician, EMT

Yes

Yes

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SummaryThe number dialed for a medical emergency is 150. It is well known and easy to dial from everywhere. The usage of one tier system providing a physician at the scene is a guarantee for an on-time highly qualified help and gives a great chance of survival. Absence of protocols does not unify the activities carried by the emergency physicians not only at the accident scene but at the ED as well. The absence of a special training, standard protocols and requirements needed for the dispatchers is lowering the effectiveness of their work. It leads to a high percentage of non emergency cases and more expenses. Less then 1% of the population is trained in CPR and for any type of emergency help. The community is not familiar with what to expect from the ED..

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SummarySummaryEducating more people how to behave in emergency situations and well managed public relations will be the next step aheadEducating more people how to behave in emergency situations and well managed public relations will be the next step ahead.All the emergency services – Fire Department, Police and EMS have different emergency numbers and the delay caused by having to dial different numbers in emergency situation has been shown to delay the response times of ambulances, police and fire department. On the other hand being under different supervision all three emergency services do not work in team. Making emergencies a teem effort and teaching firemen and policemen how to act as first responders will help us in fight for our patients.A better payment and ways to fight the everyday stress in our work will help too.

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