Dr Zoe Smeed / ST5 Emergency Medicine, Edinburgh
Zoe is an Emergency Medicine and PHEM trainee from Edinburgh, currently working in pre-hospital care in Cambridge. In 2014, she flew north to spend six weeks flying with the Norwegian Emergency Services.
Our Nordic neighbours
There are many similarities between Norway and Scotland in terms of health care provision. Patient populations, disease epidemiology and geographical challenges have much in common, so this experience was an excellent opportunity to compare Pre-hospital and Emergency Medicine systems. During my six week placement I was based in Oslo but also visited Norway’s most northerly and most isolated island of Svalbard.
Pre-hospital and Retrieval Services in Oslo
Due to their geography, the Norwegians have developed a national pre-hospital care service to cope with a population size equivalent to Scotland but spread over nearly five times the geographical area. They aim to ensure that 90% of the population can be reached by a pre-hospital physician within 45 minutes. Within the Oslo area there are two pre-hospital based centres, one at Ullevål Hospital, the other at Lørenscog air base. Ullevål is also the base for Oslo’s Dispatch Centre, the Physician-Based Ambulance Service, Ambulance Leder (Ambulance Commander), city ambulance station and additionally the pre-hospital research centre. Lørenscog is the base for the Norwegian Air Ambulance helicopter (complete with a rapid response vehicle) and fixed wing ambulance service.
The Intensive Care Road Ambulance is used for secondary transportation of paediatric and adult critical care patients. It also has a special airflow system, allowing the vehicle to transport patients involved in chemical/biological incidents (including potential Ebola cases). It even has the capabilities to drive into a Sea King helicopter to allow air transportation if the patient is too unwell to be moved out of the ambulance during transfer!
Oslo’s coastline is scattered with fjords and winding roads, consequently primary and secondary transfers sometimes require the assistance of the Fire Brigade’s boat for transportation. Additionally, some of Norway’s more remote military bases have a physician rapid response car funded by the government health board for civilian incidents.
Norway has a fantastic patient transport service. Several large hospital buses operate throughout the day transporting patients between hospital sites. These are staffed by paramedics or nurses and can take up to five bedbound patients and approximately 30 walking patients per bus – all taking the strain off the emergency ambulance service.
The Dispatch Centre (AMK)
The Dispatch Centre at Ullevål Hospital receives approximately 145,000 emergency ambulance calls, in addition to patient transport calls from Oslo and Akerhus, and co-ordinates the dispatch of Emergency Ambulances, the Norwegian Air Ambulance, Fixed Wing Helicopter and Physician Ambulances. Emergency Call Handlers (typically nurses) triage calls according to the Norwegian Index (a reference guide for call operatives) and paramedics working within the call centre use their local knowledge to identify and dispatch the nearest and most appropriate emergency response vehicle. The “AMK Leder” is in charge of the overall co-ordination of the dispatch centre and services during a major incident.
Physician Ambulance – Oslo
During my fellowship I spent two weeks working alongside the Physician Ambulance based at Ullevål Hospital. The Physician Ambulance is a 24/7 rapid response vehicle manned by an Anaesthetist (as Emergency Medicine is currently not a specialty in its own right in Norway) along with a paramedic trained in critical care. The Physician Ambulance typically responds to approximately five call-outs per day, attending to critically ill medical and trauma patients, and all out of hospital cardiac arrests. In addition, the doctorprovides telephone advice to the ambulance service, and authorises the use of drugs such as morphine for trainee paramedics.
I also spent a day shadowing the “Operativ Leder” (Ambulance Commander), who in addition to co-ordinating all ambulance staff in the Oslo area and at major incidents including road traffic incidents, house fires, stabbings/shootings and ‘one unders’ (people jumping under trains). Their role is diverse, even including providing medical/psychiatric support for ambulance staff and bystanders after traumatic events.
Norwegian Air Ambulance Helicopter and Fixed Wing Service
The national Norwegian Air Ambulance service started as a charity in the 1970s and is now government funded. There are two operators – Norsk Luftambulanse AS and Lufttransport AS. The Air Ambulances operate 12 helicopters in 11 different locations across Norway. There are also a further nine fixed wing planes (all Beechcraft King Air B200) at seven locations. The largest service is at Gardermoen, just outside Oslo, with two fixed wing planes. Approximately 20,000 patients are transported by the Norwegian Air Ambulance services, totalling 18,000 flight hours annually with all services operating 24 hours a day.
A HEMS crew consists of an experienced pilot, a HEMS crewmember (or “Rescueman”) and a HEMS doctor. At Lørsenskog there are two HEMS crews working at any one time. The Rescuemen have the coolest job in the world – they are highly skilled critical care paramedics or nurses who additionally act as winchmen in search and rescue missions, assist the pilot and sometimes even get to fly the helicopters!
The pilots also have some medical training, so can help assist for Rapid Sequence Intubations, draw up medical drugs and fluids, and cannulate patients. Doctors are required to have two years’ pre-hospital experience (mostly through working with the Physician Ambulance Service) and complete aviation and helicopter safety training. They are usually consultant anaesthetists. The HEMS crew live on the base during their shifts as the shift pattern is pretty long and intense; the pilot and Rescuemen work a full week, with doctors typically working 48 or 72 hour shifts, with mandatory nine hour rest periods per 24 hours for all crew members.
The Fixed Wing Ambulance Service is primarily used for critical care (including neonatal) transfers (typically from small district general ITUs to the tertiary centres in Oslo). Each plane can transport two patients on stretchers. Within the more isolated areas of Norway, the fixed wing services are occasionally used for primary missions. Each plane is staffed by two pilots and an experienced ITU nurse (and occasionally an anaesthetist depending on the patient’s clinical condition). The service also uses the critical care road ambulance for shorter road transfers.
Legevakten and Hospital-Based Systems
In Norway, patients are can only attend hospital (including the Emergency Department) if they have been referred by a GP, by Legevakt or by the Pre-hospital Physician or Ambulance Services. The Legevakten is essentially a GP out-of-hours and emergency walk-in service. Patients are also taken to the Legevakten by ambulance if they are thought not to require direct admission to hospital (e.g. non-specific chest pain, allergic reaction, alcohol or drug intoxication). All patients attending the Legevakten have to pay a small fee of approximately 100-130 Kr per visit (around £10-13), or 250Kr (£25) at night, (which is similar to the fee Norwegians pay to see a GP or outpatient hospital specialist).
Oslo’s Legevakten receives approximately 90,000 patients per year, caring for approximately 300-350 per day through their GP service and small bedded unit. Doctors working within the bedded area in Oslo’s Legevakten (known as the Emergency Ward) are typically GP or general medical trainees, with the medical shift leader requiring at least 2 years experience of working in the Legevakt. Unlike other Legevakts, there are additional services including paediatrics, a consultant-led psychiatry service, a Minor Injuries Unit, an intoxication bed (allowing monitoring of drug/alcohol intoxications for 4 hours) and a 13-bed Clinical Decision Unit. The Legevakten also runs its own call-centre receiving approximately 30,000 non-urgent medical calls per year, providing advice and redirecting patients to either appropriate community-based services or direct referral to a hospital specialist. A twenty-four hour social work service is also provided, and is able to arrange emergency support/housing for patients even during the night. Approximately 20% of all patients seen at the Legevakten require referral and transfer to hospital.
Rickshospitalet and Ullevål
Within Oslo there are two main hospitals, Ullevål and Rickshospitalet. Ullevål University Hospital is the largest hospital in Scandinavia and Oslo’s Major Trauma Centre, receiving 1.2 million patients per year. Rickshospitalet is more like a tertiary specialist centre, receiving referrals from all over Norway.
Although both hospitals have an Emergency Department, there is currently no Emergency Medicine specialty within Norway (although this is something they are considering adopting). Currently Emergency Departments operate more like an acute admission unit with anaesthetics input for standby calls or critically unwell patients. All patients attending the hospital Emergency Department have to be referred directly to a specialist either by GP, the Legevakten or by the Pre-Hospital Ambulance or Physician Services. Although this potentially reduces time to specialist input, this can also have a negative impact on the patient if they are referred to the incorrect speciality due to the difficulty of quick decision making.
Ullevål hospital receives all major trauma from around the Oslo area. Patients arriving by helicopter land on the roof of the car park and are transported directly by a lift to the ED resuscitation rooms. Additionally, patients arriving by ambulance reach the ED through doors immediately outside the resuscitation rooms. The trauma resuscitation room is situated in close proximity to a CT scanner and an interventional radiology suite on the other, allowing critically ill patients to literally be wheeled next door for imaging or interventional radiology. Pre-hospital teams can mobilise either a small trauma team (consisting of a surgical team and anaesthetic SpRs, radiographers and phlebotomists), or large trauma team (with additional consultant input) depending on the patient’s clinical status. All patients receive x-rays with FAST scan during the primary survey prior to a decision being made regarding further imaging, interventional radiology or transfer to theatre.
Rural services – Svalbard
In addition to working within Oslo, I was interested to find out more about the provision of Pre-hospital and Emergency Medicine services in more remote areas of Norway, so I travelled north to Norway’s most remote island, Svalbard. Svalbard is approximately 1,318km from the North Pole, and has a population of approximately 2,600 inhabitants, 2,800 snowmobiles and 3,000 polar bears! The majority of Svalbard remains unpopulated, with the bulk of the population living in and around Longyearbyen (Svalbard’s main “town”) and Barentsburg (a Russian settlement inhabited entirely by Russian miners and their families). As the only roads on the island are in Longyearbyen and Barentsburg, helicopters (or skimobiles) are required to reach critically ill patients.
Svalbard has 2 Super Puma rescue helicopters based at Longyearbyen airport, with 2 crews being on-call at a time. Each helicopter crew consists of 2 pilots, a winchman, assistant winchman and a “rescueman” (HEMS crewman). There are no physicians based on the HEMS crew but the rescueman can request a doctor or nurse from the hospital if required. The rescue crew attend approximately 70-80 primary missions/year, mostly around Svalbard but occasionally provide medical support to ships, and even Greenland. Although medical missions are more common (e.g. cardiac arrest, myocardial infarctions and collapse), crews are often mobilised to trauma patients (including mountain and walking accidents, mining incidents and even polar bear attacks).
All medical emergency telephone calls in Svalbard are received directly by Longyearbyen Hospital. The nurse in charge of the hospital would contact the rescue helicopter, and in addition dispatch a doctor and/or nurse to the airport if required. However, before the helicopter can fly on a rescue mission, they have to contact the Sysselmannen (the Governor of Svalbard) for permission. After the patient is rescued, the helicopter returns to base at the airport, and is met by the one (and only) ambulance on Svalbard (driven by a volunteer fireman), and taken to the hospital in Longyearbyen (figure 7).
The hospital in Longyearbyen is the only medical facility on Svalbard (excluding the Russian hospital at Barentsburg which only provides medical care for the inhabitants of the Russian settlement). The hospital has a GP service, 5 hospital beds (including one “isolation” room), a one bedded Emergency Room, x-ray machine (but no CT), and an operating theatre, in addition to dental, physiotherapy, occupational health, district nurse and midwifery services. The Emergency Room, (set up like a resuscitation room), has a telemetry service to Tromsø University Hospital. X-rays are taken by the nursing staff and formally reported by a radiologist in Tromsø. The operating room is typically used for minor operations and previously has been used for ‘damage-control’ surgery in major trauma. As there are no anaesthetists on the island, anaesthetic nurses deliver the anaesthetic during the operation. The majority of patients are transported off the island (via the fixed wing ambulance from Tromsø) for medical treatment. However the hospital can admit typically well, ambulatory patients, (e.g. those requiring iv antibiotics, patients with fractures awaiting transport for surgical intervention on the mainland) and occasionally those requiring end-of-life palliation. The hospital employs a total of three doctors (2 GPs and 1 surgeon), 3 nurses and 2 anaesthetic nurses, with typically one doctor and 1-2 nurses covering each shift.
The Robin Mitchell Fellowship
I has this fantastic opportunity thanks to receiving the Robin Mitchell Travel Fellowship.
The Robin Mitchell Fellowship was set up to commemorate Dr Robin Gordon Mitchell, an Emergency Medicine Consultant who studied and trained in Edinburgh. He developed the first high fidelity simulator based course in Scotland and became the Training Programme Director and Regional Specialty Advisor for the South East Scotland Emergency Medicine training scheme. After working as an Emergency Medicine Consultant in Edinburgh, he made the move to Auckland City Hospital in New Zealand working alongside the Auckland Rescue Helicopter in providing training and clinical support to the paramedics, and constructing the educational framework for a retrieval programme. He was also appointed as Director of Emergency Medicine Training. Sadly, he died in 2010 from pancreatic cancer, and the Robin Mitchell Travel Fellowship was set up by his family to commemorate him. The Robin Mitchell Travel Fellowship is open to all Scottish Emergency Medicine trainees, allowing them to pursue a 4-6 week placement away from their base hospital, within the setting of Emergency Medicine or another associated clinical specialty to enhance their clinical experience and expertise.
Comparing the Norwegian and UK Emergency Department systems has reinforced to me the important role Emergency Medicine doctors play in the management of acutely unwell patients. Doing EM training allows you to be open-minded to a number of possible differential diagnoses (both surgical and medical), whereas when patients are directly referred to a specialty team, it can sometimes take longer for the patient to end up in the correct place. Additionally, I think Emergency Medicine doctors have valuable skills in targeting appropriate investigation and triaging whether patients need to be admitted or discharged with appropriate follow-up. In the resuscitation room (particularly the medical resuscitations), I sometimes found it far more chaotic, and on occasion there appeared to be limited cohesion between the Physicians, Surgeons, Anaesthetists, and Nursing staff. Additionally, the specialists sometimes appeared more keen to make the diagnosis than managing the initial patient resuscitation.
Despite this, there are certain advantages for increasing the availability of direct referral to a specialist from the pre-hospital environment. There are a few situations which seemed to work particularly well. These included patients with ROSC (return of spontaneous circulation) following out of hospital cardiac arrest being transported directly to primary PCI and potential stroke thrombolysis patients being transferred directly to CT and being met by a Neurologist at the scanner. Additionally, early surgical input during trauma calls could additionally be beneficial for the patient in reducing time to theatre or definitive care.
This fellowship has been an absolutely fantastic opportunity for me to develop my interest and experience in Pre-hospital Emergency Medicine. Gaining insight into different Pre-hospital and Emergency Medicine systems has also enabled me to think more about our systems within Scotland and potential areas which we can develop to improve the service we provide our patients.
Special thanks and contributions
I would especially like to thank Robin Mitchell’s family, the Robin Mitchell Travel Fellowship committee and the Medic 1 Trust Fund for funding my travel fellowship, in addition to my supervisors Dr Dave Caesar and Dr Richard Lyon in Edinburgh, and Dr Theresa Olasveengen in Oslo. Additionally thanks to the staff at Oslo’s Dispatch centre, Physician Ambulance and Air Ambulance helicopter and fixed wing services and Oslo’s Legevakten, Riskshospitalet and Ullevål hospital who were all extremely helpful and made me feel so welcome.
1 About the National Air Ambulance Services of Norway. www.luftambulanse.no/printpdf/209
2 Ulleval University Hospital website http://www.oslo-universitetssykehus.no/om-oss/english.