Ricardo Matos, MD
Unidade de Cuidados Intensivos Polivalentes (UCIP) Hospital de Santo António dos Capuchos Centro Hospitalar de Lisboa (Zona Central) Lisbon, Portugal
One of the most remarkable aspects of the evolution of medicine in Portugal in the last decade has been the growing development and recognition of emergency medicine.
Portugal has always provided healthcare services to patients who, due to the high risk or seriousness of their clinical situation, have required an emergency approach. However, this work has never been as professional, as organised, as structured and, ultimately, as widely recognised as it is today (Marques and Almeida e Sousa 2004). This article highlights the most important contributing factors in the rise of emergency medicine in Portugal.
The National Institute of Medical Emergency (Instituto Nacional de Emergência Médica, or INEM) was founded in 1981. With the approval of a new law in 2003 (Portuguese Government Publishing Service 2003a) and of a newinternal set of regulations in 2004 (Portuguese Government Publishing Service 2004), INEM was restructured, increasing both its structure and resources. Its areas of action and coverage were also expanded, bringing INEM coverage to nearly all national territories.
In continental Portugal, INEM is responsible for an integrated medical emergency system that guarantees immediate and appropriate healthcare for accident casualties and victims of sudden illness. Among its many tasks, INEM provides initial medical help at the accident site, transportation of victims to the correct hospital and inter-hospital communication services. Through its European emergency call number (112), INEM has several means to respond effectively, at any time, to medical emergency situations (Portuguese Government Publishing Service 1997). In order to provide efficient medical assistance to victims of sudden illness or accident, we have the following emergency services, appropriate for different types of medical emergencies: Emergency Patient Coordination Centres (Centros de Orientação de Doentes Urgentes, or CODUs); the Emergency Patient Coordination Centre for Situations Occurring at Sea (Centro de Orientação de Doentes Urgentes para situações ocorridas no mar, or CODU-Mar); the Poison Information Centre (Centro de Informação Antivenenos, or CIAV); and the High Risk Neonatal Transport Subsystem (Sub-sistema de Transporte de Recém-Nascidos de Alto Risco). CODU is the primary coordinator of emergency medical services and receives all requests for emergency assistance via the call number 112. CODU is staffed around the clock by doctors and central operators with specific training to answer the calls, perform triage and provide pre-emergency counselling. CODU can dispatch various emergency response resources, such as the INEM and CODU Ambulances, the Medical Emergency and Reanimation Vehicles (Viaturas Médicas de Emergência e Reanimação, or VMER), the Catastrophe Intervention Vehicles (Viaturas de Intervenção em Catástrofe, or VIC) and the Medical Emergency Helicopters. Using its telecommunications capabilities, CODU can dispatch and support these emergency response teams, then, based on clinical information from the field, prepare the appropriate hospital for the patient’s reception.
The National Fire and Civil Protection Service (Serviço Nacional de Bombeiros e Protecção Civil, or SNBPC), subject to the Internal Affairs Minister, was created in 2003 (Portuguese Government Publishing Service 2003b). Its objective is to protect and assist people and property, by guiding and coordinating all the civil protection and emergency activities. SNBPC is responsible for preventing collective risks from serious accidents or catastrophes and minimising the impact of these situations when they occur. It also coordinates the activities of the fire services and lends technical and financial support to activities in all civil protection fields, as appropriate. SNBPC promotes, supports, and critiques the development of emergency plans at the national level. Finally, SNBPC fosters emergency and civil protection cooperation with national and international organisations, particularly within the European Union and lusophone diaspora.
Portugal has recently built a number of new hospitals, replacing several old and less functional buildings and, at the same time, ensuring better coverage of the national territory. In addition, Portugal has created new emergency services, recognising emergency medicine’s essential role within hospitals – a fact not always acknowledged in the past, particularly in some central and university hospitals. Even now, many hospitals do not
have a system to respond to internal emergencies, and where a system is in place, it is run on an exclusively volunteer basis.
Particularly during the 1990s, Portugal began opening more intensive care units (Unidades de Cuidados Intensivos, or ICUs) (Direcção-Geral da Saúde 2003), due to the broadening of indications for patient admission; better and faster intra- and extra-hospital assistance resources; and increased requirement of intensive care medicine (with the evolution of more aggressive surgical or medical therapeutics in several areas, like haematology, oncology and transplantation). With the introduction of additional ICUs, progressive and better communication developed between ICUs and other hospital areas, such as intra- and extra-hospital emergency services, surgery rooms, intermediate care units and departments facilitating fasttrack patient admission systems.
Finally, the Health Ministry created the National Hospital Reference Network for Emergency (Redes de Referenciação Hospitalar Nacional para a Urgência/Emergência e para os Cuidados Intensivos) and promulgated suggestions for the development of intensive care in the framework of the National Health Service (Recomendações para o desenvolvimento dos Cuidados Intensivos no quadro do Serviço Nacional de Saúde), thus creating the essential conditions for the justification and planning of the financial and human resources, ensuring better national coverage of emergency medical services (Direcção-Geral da Saúde 2003; Ministério da Saúde 2004a; Ministério da Saúde 2004b).
Several entities stand out for their work in emergency medical training in recent years:
INEM’sMedical EmergencyTraining Department, in response to numerous requests from the population and in accordance with its mission, regularly offers courses to non-professionals and professionals alike, such as courses on adult basic life support (BLS) for laymen, paediatric BLS for laymen, BLS for health professionals and basic emergency techniques (http://inem.min-saude.pt).
The Portuguese Society of Surgery (Sociedade Portuguesa de Cirurgia, or SPC) has been offering Advanced Trauma Life Support® (ATLS) courses since 1999, in collaboration with the Committee on Trauma of the American College of Surgeons (www.atlsportugal.org/index.html). ATLS is a postgraduate medical training programme, which aims at improving the quality of initial medical help for the polytraumatised patient, trying to reduce the mortality and incapacity associated with “the 20th century epidemic”- trauma.
The Portuguese Society of Intensive Care (Sociedade Portuguesa de Cuidados Intensivos, or SPCI) offers a regular programme of courses, including Fundamental Critical Care Support (FCCS) and Fundamentals of Disaster Management (FDM), delivered by SPCI in partnership with the American Society of Critical Care Medicine (SCCM). FCCS is a two-day course for non-intensivists that teaches the fundamental principles of the first 24 hours of medical care for the critical patient. This course, offered at several locations throughout the country each year, has been very successful in Portugal, already having trained hundreds of professional doctors and nurses. The same can be said about the FDM course, which has been offered since 2004. It is a one-day course on disaster medicine, which has made possible a closer cooperation between the various entities of emergency medicine, such as SPCI, INEM and SNBPC. One of the most important contributions of SPCI to date was the development of the document “Guidelines for the transport of the critically ill patients”, by an SPCI taskforce in 1997 (www.spci.org/index2.html).
The Portuguese Resuscitation Council (Conselho Português de Ressuscitação, or CPR) focuses on coordination and promotion of initiatives related to reanimation, normalisation of educational programmes to develop education and practice of cardio-respiratory reanimation techniques, in accordance with the European Resuscitation Council (ERC). It was created in 1997 and has been a member of the European Resuscitation School since 1999. CPR has certified seven schools of reanimation training in Portugal, which regularly deliver many courses in basic, intermediate and advanced paediatric and adult life support, as well as automatic external defibrillation courses and basic or advanced life support courses for instructors.
In addition to these key training sources, the Fire Services Corporations, Public Security Corporations, Schools, Societies (Corporações de Bombeiros, Corpos de Segurança Pública, Escolas, Sociedades) and the Portuguese Trauma Society (Sociedade Portuguesa de Trauma) contribute to emergency medical training activities. Portuguese universities are also involved in emergency medical training, such as Oporto University and its Faculty of Medicine, which offers a Master Degree in Emergency Medicine, and the Abel Salazar Biomedical Science Institute, which offers a Master Degree in Disaster Medicine.
Emergency Medicine Accreditation
In 2002, the National Executive Council of the National Medical Board (Conselho Nacional Executivo, or CNE, da Ordem dos Médicos, or OM) recognising the universal development of emergency medicine and its predictable and desirable national expansion, created the Competence in Medical Emergency (Ordem dos Médicos 2002). It established requisite technical-professional qualifications for doctors working in emergency medicine. At the same time, it issued best practice norms, aiming at improvement of healthcare service. Based on these new standards, several specialisations, such as surgery, internal medicine, anaesthesiology and paediatrics, were allowed to access this Competence, through adequate curriculum assessment by a committee appointed by the CNE.
Although the European Society for Emergency Medicine (EuSEM) promotes the creation of a Specialisation in Emergency Medicine (EuSEM 2002a,EuSEM 2002b), specialisation is not an option in Portugal. The Portuguese Medical Board considered it preferable to take advantage of the different experiences in basic training provided by a multidisciplinary staff working together in emergency medicine. Regardless of Portugal’s preference for a Competence over a Specialisation, the country has made significant progress toward a clear curriculum definition and the establishment of excellence services, where high quality technical and scientific training can be done. The OM will be responsible for accreditation and certification in our country.
The Role of Intensive Care Medicine
Intensive care medicine has played an important part in the development of emergency medicine in Portugal. There is obviously a lot in common between the two disciplines,which share the common goal of providing medical care to severely ill or injured patients and are often only distinguishable from one another in where and when this care can be provided. However, the contribution that I deem most important is the training of emergency medicine practitioners, which occurs mostly in ICUs. This ICU training often develops the trainee’s taste for emergency medicine, effectively recruiting trainees to the vocation. Several intensivists played an important role in the creation of the Competence in Emergency Medicine, and their interest in the field continues. Many intensivists are firmly committed to contributing to the training of those who provide healthcare to critical or emergency patients.
In Portugal, the intensivist has embraced the role of “older brother” to the emergency medicine practitioner. The intensivist arrived first, grew earlier, contributed decisively to the emergency practitioner’s training and will, I am sure, continue to do so. But now they will work together, and their work will be more equitable, with mutual benefits for these complementary areas of medicine and for their patients.