Emergency medical services in France
Encyclopedia
Emergency medical services in France are provided by a mix of organisations under public health control , with the lead taken by a central control function called SAMU, which stands for 'Service d'Aide Médicale Urgente' or urgent medical aid service. This central hub is supported by resources including first response vehicles or ambulances provided by the fire service and physician led ambulance provision from SMUR (Service Mobile d'Urgence et Reanimation - literally translated as mobile emergency and resuscitation service) which are 'mobile intensive care units' (MICU) that have one or more physicians on board.
Because of aggressive triage
(called medical regulation) , only about 65% of requests to SAMU actually receive an ambulance response. Current performance on emergency calls is arrival at scene within 10 minutes, for 80% of responses, and within 15 minutes for 95% of responses.
This means that SAMU controls a variety of resources within a community from general practitioner
s to hospital intensive care services.
SAMU is organised at the 'Département' level, with each Department organising its own service, each of which is identified with a unique code, for instance SAMU 06 in Nice
and SAMU 75 in Paris
.
Additionally, two SAMU have special tasks :
In addition to the mainland French Departements, SAMU also operates in most of the offshore American Departements, such as Guadeloupe
(SAMU 971) Martinique
Guyane or Pacific and Indian French Islands (Tahiti Reunion)
Consequently under the SAMU system in France, there are a number of different providers of emergency medical services, offering different levels of care, and dispatched for different types of condition.
While all of the above types of vehicles attempt to meet some aspects of the European standard for ambulances CEN 1789
, published by the European Committee for Standards, the degree of compliance varies, particularly among those vehicles not officially referred to as ambulances in France. The visual identity provisions of the CEN 1789 standard are not currently being followed by the private companies, their vehicles still are white. The fire service vehicles are more and more (2010) equipped with yellow markers.
Non-emergency and low-priority ambulance services are normally provided by private companies. For other types of medical transportation, the term 'ambulance' is not used; relying instead on the more general term "light vehicle adapted to patient transport".
Emergency response may be through the use of a fire department
based rescue ambulance
, a multi-purpose vehicle or even a fire apparatus
. Here, the cross-trained firefighter
s will provide on scene care and transport for injuries or illness, but are usually backed up by a SMUR unit for more serious issues.
Although they also transport casualties and are, in any practical sense, ambulances, their vehicles are called VSAV; véhicule de secours et d'assistance aux victimes (casualties' rescue and assistance vehicle), or VPS; véhicules de premiers secours (first aid or Rescue vehicles) in case of volunteers from associations. The VSAV and VPS are considered to be means of bringing rescue workers and equipment onsite, with the evacuation of patients being only the logical result of the response, but not the primary duty of these response resources.
The French philosophy on emergency medical care is to provide a higher level of care at the scene of the incident, and so SMUR (Service Mobile d'Urgence et Reanimation) units are staffed by a qualified physician
along with a nurse and/or emergency medical technician
. This contrasts with systems in other parts of the world, notably the Anglo-Saxon countries (United Kingdom, United States, Australia etc.) where care on scene is conducted primarily by paramedic
s or emergency medical technician
s, with physicians only becoming involved on scene at the most complex or large scale incidents.
The result is that a SMUR unit will typically spend a long time on scene compared with a paramedic ambulance in a different system, as the physician may conduct a full set of observations, examinations and interventions before removal to hospital. This feature is often contrasted the British or American system, especially in high profile incidents, such as the death of Diana, Princess of Wales
in Paris, where the nearly 2 hour delay before arrival at hospital has been ascribed by some as a major contributory factor in her death.
SMUR units are hospital based and although the vehicles are typically labelled 'SAMU' that term actually refers to the overall integrated service which controls multiple SMUR units (perhaps even from multiple hospitals) and all emergency care resources within a community from GP to Hospital Intensive Care services.
Despite being hospital based, a SMUR unit may choose to transport a patient to an alternative hospital, where the best definitive care may be provided, and are not necessarily tied to the hospital of origin.
(service spécialisé d'accueil et de traitement des urgences) only if it is capable of treating the common trauma and illness conditions that are likely to present. This normally includes a resuscitation unit, general and internal medicine
, cardio-vascular medicine, pediatrics
, anesthesiology-resuscitation, orthopedic surgery
and oncology
, including obstetrics
. The exception would be for specialised units, which only admit specific pathologies or specific types of patients (e.g. pediatrics). These units are termed 'pôle spécialisé d'accueil et de traitement des urgences'.
The hospital must have two operating rooms (and a recovery room) with personnel on duty that allow operation at any time, as well as support services that can perform additional examination or analysis at any time, such as medical imaging
(radiography
, medical ultrasonography
, CAT Scanners, haematology, toxicology
laboratory etc.
The specialized service is managed by an emergency physician
. An emergency physician must always be "on-call," and a specialized physician can be called at any time. In addition the team must have two nurses, care assistants (and possibly child care assistants), a social worker and a receptionist, with all of them having received specific education for dealing with emergency cases.
The service is organized in three zones:
Most services also have a massive crowd room that are designed to allow care of a large number of patients, outside of the normal levels of presenting patients. These plan blanc units are designed to cope with major incidents or epidemics.
SAMU is the regional Medical Emergency Response Center (MERC) in day to day monitoring and "regulation" of all Hospitals and Ambulances Emergency care Resources in its area and is connected with limitroph SAMU. In case of disaster the French SAMU national network of a national Integrated Emergency Medical System (IEMS) is in charge of the first emergency phase medico sanitary planned response called "Plans blancs" and of secondary ground or aerial transports if necessary.
has only recently been recognized as a medical specialty in France, and pre-hospital care is currently struggling to be recognized as a sub-specialty. In the meantime, many SMUR/MICU physicians are actually in training for other specialties, such as anesthesia
, and the system relies on General Practitioners and physicians from other specialties 'filling the gap' when emergency physicians are not available.
The situation is further complicated by the fact that the physicians staffing the SMUR units are among the lowest-paid in Europe. Although salaries have recently improved somewhat, in 2002 it was reported that these physicians, who are, for the most part, full-time employees of public hospitals, had a starting salary of only €1300 (£833; $1278) per month. This economic reality has resulted in understandably high turnover and some difficulty in staffing positions. It has been suggested, however, that the recognition of emergency medicine as an in-hospital specialty in France and elsewhere in Europe is likely to result in the evolution of that system towards more comprehensive in-hospital emergency services.
This will ultimately, in turn, result in less physician response; although the complete replacement of physician response by the type of technician response occurring elsewhere is unlikely to occur any time in the immediate future . Since 1986, fire department-based rescue ambulances have had the option of providing resuscitation service (reanimation) using specially-trained nurses, operating on protocols, in the role that we would normally expect to be performed by the paramedic but with the Samu Medical Physician Regulator Aid . In actual practise, however, such units and Nurse staffed MICU are used for certain purposes of Stable Intensive Care Patients .
uses the emergency telephone number
available across all members 112
, which gives access to police, fire and ambulance services. However, the legacy emergency number of '15' for SAMU and '18' for fire department VSAV are still in use.
. France operates on a system of universally accessible socialized medicine
. Patients have freedom to choose physicians, hospitals etc., and there are prices set for each type of service.
When operating in the public system, patients are asked to co-pay a portion of the cost for each type of care that they receive. To illustrate, a patient requiring hospitalization is liable for 20 percent of costs for the first month, and nothing thereafter.
What this means in terms of funding is that the SAMUs and their SMUR response teams are funded by the government, by means of the hospital funding scheme. They do charge a fee for service, and for a typical patient, 65% of this cost will be covered by the government health insurance scheme and the balance covered by optional additional private insurance. By French law, in an emergency any French hospital or SAMU must treat any patient, regardless of their ability to pay.
As a measure against system abuse, the SAMU physician may refuse to sign the patient's 'treatment certificate', resulting in the patient being liable for the full cost of services provided, although in practice, this is rarely done. Most French citizens also carry private health insurance
in order to cover all co-payment charges.
In some circumstances, particularly on low-priority calls, patients being transported to hospital may be asked to pay for service in advance, and then seek reimbursement from the government insurance scheme or their private insurance. Although not regarded as ambulances in France, fire department ambulances, when used, provide transportation to hospital without charge. All requests for ambulance service are processed by the local SAMU, which will determine what type of assistance and transportation resources are sent; the patient has no choice in the matter when it is an Intensive Urgent Care Need.
Organization
SAMU missions were defined in a law of 1986 as hospital based services providing permanent phone support, choosing and dispatching the proper response for a phone call request. The central component of SAMU is the dispatch centre where a medical regulation team of physicians and assistants has the task of:- analysing calls to decide on patient need
- deciding the best solution for the patient's care
- dispatching the most appropriate mobile care resource (MICU, Ambulance, or Mobile care professional), or
- directing the patient to an alternative fixed resource such as primary care medical surgery or hospital service, or
- offering care advice over the telephone
Because of aggressive triage
Triage
Triage or ) is the process of determining the priority of patients' treatments based on the severity of their condition. This rations patient treatment efficiently when resources are insufficient for all to be treated immediately. The term comes from the French verb trier, meaning to separate,...
(called medical regulation) , only about 65% of requests to SAMU actually receive an ambulance response. Current performance on emergency calls is arrival at scene within 10 minutes, for 80% of responses, and within 15 minutes for 95% of responses.
This means that SAMU controls a variety of resources within a community from general practitioner
General practitioner
A general practitioner is a medical practitioner who treats acute and chronic illnesses and provides preventive care and health education for all ages and both sexes. They have particular skills in treating people with multiple health issues and comorbidities...
s to hospital intensive care services.
SAMU is organised at the 'Département' level, with each Department organising its own service, each of which is identified with a unique code, for instance SAMU 06 in Nice
Nice
Nice is the fifth most populous city in France, after Paris, Marseille, Lyon and Toulouse, with a population of 348,721 within its administrative limits on a land area of . The urban area of Nice extends beyond the administrative city limits with a population of more than 955,000 on an area of...
and SAMU 75 in Paris
Paris
Paris is the capital and largest city in France, situated on the river Seine, in northern France, at the heart of the Île-de-France region...
.
Additionally, two SAMU have special tasks :
- The Paris SAMU is responsible for providing service to fast trains (TGVTGVThe TGV is France's high-speed rail service, currently operated by SNCF Voyages, the long-distance rail branch of SNCF, the French national rail operator....
) and Air FranceAir FranceAir France , stylised as AIRFRANCE, is the French flag carrier headquartered in Tremblay-en-France, , and is one of the world's largest airlines. It is a subsidiary of the Air France-KLM Group and a founding member of the SkyTeam global airline alliance...
aircraft, while in flight. - The Toulouse SAMU is responsible for providing service to ships at sea.
In addition to the mainland French Departements, SAMU also operates in most of the offshore American Departements, such as Guadeloupe
Guadeloupe
Guadeloupe is an archipelago located in the Leeward Islands, in the Lesser Antilles, with a land area of 1,628 square kilometres and a population of 400,000. It is the first overseas region of France, consisting of a single overseas department. As with the other overseas departments, Guadeloupe...
(SAMU 971) Martinique
Martinique
Martinique is an island in the eastern Caribbean Sea, with a land area of . Like Guadeloupe, it is an overseas region of France, consisting of a single overseas department. To the northwest lies Dominica, to the south St Lucia, and to the southeast Barbados...
Guyane or Pacific and Indian French Islands (Tahiti Reunion)
Ambulance provision
In the French system, the word "ambulance" itself is reserved to transportation of one individual on a stretcher on medical prescription, including oral prescription in case of emergency, and the term is generally used to apply to those response vehicles operated by the local SAMU, as well as the emergency vehicles from places such as the fire service or private companies, which are both fully equipped emergency patient transport vehicles, the "reds" (fire service) with 3 or 4 staff members on board, the "whites" (private companies and hospitals) with 2 staff members on board. Basically both teams, "reds" and "whites", have the same first aid-based medical training, the "reds", as they handle road accidents as well, are also trained in taking care of heavily wounded persons, extraction of wounded out of wrecks, etc.Consequently under the SAMU system in France, there are a number of different providers of emergency medical services, offering different levels of care, and dispatched for different types of condition.
While all of the above types of vehicles attempt to meet some aspects of the European standard for ambulances CEN 1789
CEN 1789
CEN 1789:2007 is the European Union standard for ambulances and medical transportation vehicles. This European standard specifies requirements for the design, testing, performance and equipping of road ambulances used for the transport and care of patients...
, published by the European Committee for Standards, the degree of compliance varies, particularly among those vehicles not officially referred to as ambulances in France. The visual identity provisions of the CEN 1789 standard are not currently being followed by the private companies, their vehicles still are white. The fire service vehicles are more and more (2010) equipped with yellow markers.
Private ambulance services
Fire department services
Fire department
A fire department or fire brigade is a public or private organization that provides fire protection for a certain jurisdiction, which typically is a municipality, county, or fire protection district...
based rescue ambulance
Ambulance
An ambulance is a vehicle for transportation of sick or injured people to, from or between places of treatment for an illness or injury, and in some instances will also provide out of hospital medical care to the patient...
, a multi-purpose vehicle or even a fire apparatus
Fire apparatus
A fire apparatus, fire engine, fire truck, or fire appliance is a vehicle designed to assist in fighting fires by transporting firefighters to the scene and providing them with access to the fire, along with water or other equipment...
. Here, the cross-trained firefighter
Firefighter
Firefighters are rescuers extensively trained primarily to put out hazardous fires that threaten civilian populations and property, to rescue people from car incidents, collapsed and burning buildings and other such situations...
s will provide on scene care and transport for injuries or illness, but are usually backed up by a SMUR unit for more serious issues.
Although they also transport casualties and are, in any practical sense, ambulances, their vehicles are called VSAV; véhicule de secours et d'assistance aux victimes (casualties' rescue and assistance vehicle), or VPS; véhicules de premiers secours (first aid or Rescue vehicles) in case of volunteers from associations. The VSAV and VPS are considered to be means of bringing rescue workers and equipment onsite, with the evacuation of patients being only the logical result of the response, but not the primary duty of these response resources.
SMUR
Physician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...
along with a nurse and/or emergency medical technician
Emergency medical technician
Emergency Medical Technician or Ambulance Technician are terms used in some countries to denote a healthcare provider of emergency medical services...
. This contrasts with systems in other parts of the world, notably the Anglo-Saxon countries (United Kingdom, United States, Australia etc.) where care on scene is conducted primarily by paramedic
Paramedic
A paramedic is a healthcare professional that works in emergency medical situations. Paramedics provide advanced levels of care for medical emergencies and trauma. The majority of paramedics are based in the field in ambulances, emergency response vehicles, or in specialist mobile units such as...
s or emergency medical technician
Emergency medical technician
Emergency Medical Technician or Ambulance Technician are terms used in some countries to denote a healthcare provider of emergency medical services...
s, with physicians only becoming involved on scene at the most complex or large scale incidents.
The result is that a SMUR unit will typically spend a long time on scene compared with a paramedic ambulance in a different system, as the physician may conduct a full set of observations, examinations and interventions before removal to hospital. This feature is often contrasted the British or American system, especially in high profile incidents, such as the death of Diana, Princess of Wales
Diana, Princess of Wales
Diana, Princess of Wales was the first wife of Charles, Prince of Wales, whom she married on 29 July 1981, and an international charity and fundraising figure, as well as a preeminent celebrity of the late 20th century...
in Paris, where the nearly 2 hour delay before arrival at hospital has been ascribed by some as a major contributory factor in her death.
SMUR units are hospital based and although the vehicles are typically labelled 'SAMU' that term actually refers to the overall integrated service which controls multiple SMUR units (perhaps even from multiple hospitals) and all emergency care resources within a community from GP to Hospital Intensive Care services.
Despite being hospital based, a SMUR unit may choose to transport a patient to an alternative hospital, where the best definitive care may be provided, and are not necessarily tied to the hospital of origin.
Hospital standards for SAMU
French hospitals (whether publicly or privately run) must operate an emergency departmentEmergency department
An emergency department , also known as accident & emergency , emergency room , emergency ward , or casualty department is a medical treatment facility specialising in acute care of patients who present without prior appointment, either by their own means or by ambulance...
(service spécialisé d'accueil et de traitement des urgences) only if it is capable of treating the common trauma and illness conditions that are likely to present. This normally includes a resuscitation unit, general and internal medicine
Internal medicine
Internal medicine is the medical specialty dealing with the prevention, diagnosis, and treatment of adult diseases. Physicians specializing in internal medicine are called internists. They are especially skilled in the management of patients who have undifferentiated or multi-system disease processes...
, cardio-vascular medicine, pediatrics
Pediatrics
Pediatrics or paediatrics is the branch of medicine that deals with the medical care of infants, children, and adolescents. A medical practitioner who specializes in this area is known as a pediatrician or paediatrician...
, anesthesiology-resuscitation, orthopedic surgery
Orthopedic surgery
Orthopedic surgery or orthopedics is the branch of surgery concerned with conditions involving the musculoskeletal system...
and oncology
Oncology
Oncology is a branch of medicine that deals with cancer...
, including obstetrics
Obstetrics
Obstetrics is the medical specialty dealing with the care of all women's reproductive tracts and their children during pregnancy , childbirth and the postnatal period...
. The exception would be for specialised units, which only admit specific pathologies or specific types of patients (e.g. pediatrics). These units are termed 'pôle spécialisé d'accueil et de traitement des urgences'.
The hospital must have two operating rooms (and a recovery room) with personnel on duty that allow operation at any time, as well as support services that can perform additional examination or analysis at any time, such as medical imaging
Medical imaging
Medical imaging is the technique and process used to create images of the human body for clinical purposes or medical science...
(radiography
Radiography
Radiography is the use of X-rays to view a non-uniformly composed material such as the human body. By using the physical properties of the ray an image can be developed which displays areas of different density and composition....
, medical ultrasonography
Medical ultrasonography
Diagnostic sonography is an ultrasound-based diagnostic imaging technique used for visualizing subcutaneous body structures including tendons, muscles, joints, vessels and internal organs for possible pathology or lesions...
, CAT Scanners, haematology, toxicology
Toxicology
Toxicology is a branch of biology, chemistry, and medicine concerned with the study of the adverse effects of chemicals on living organisms...
laboratory etc.
The specialized service is managed by an emergency physician
Emergency physician
An emergency physician is a physician who works at an emergency department to care for acutely ill patients. The emergency physician is a specialist in advanced cardiac life support , trauma care such as fractures and soft tissue injuries, and management of other life-threatening situations.In...
. An emergency physician must always be "on-call," and a specialized physician can be called at any time. In addition the team must have two nurses, care assistants (and possibly child care assistants), a social worker and a receptionist, with all of them having received specific education for dealing with emergency cases.
The service is organized in three zones:
- a reception zone,
- a zone for the examination and the cares (including intensive cares),
- a zone for the watch over short durations (patients waiting to go out or for a transfer in another service).
Most services also have a massive crowd room that are designed to allow care of a large number of patients, outside of the normal levels of presenting patients. These plan blanc units are designed to cope with major incidents or epidemics.
SAMU is the regional Medical Emergency Response Center (MERC) in day to day monitoring and "regulation" of all Hospitals and Ambulances Emergency care Resources in its area and is connected with limitroph SAMU. In case of disaster the French SAMU national network of a national Integrated Emergency Medical System (IEMS) is in charge of the first emergency phase medico sanitary planned response called "Plans blancs" and of secondary ground or aerial transports if necessary.
Emergency medicine speciality
In hospital emergency medicineEmergency medicine
Emergency medicine is a medical specialty in which physicians care for patients with acute illnesses or injuries which require immediate medical attention. While not usually providing long-term or continuing care, emergency medicine physicians diagnose a variety of illnesses and undertake acute...
has only recently been recognized as a medical specialty in France, and pre-hospital care is currently struggling to be recognized as a sub-specialty. In the meantime, many SMUR/MICU physicians are actually in training for other specialties, such as anesthesia
Anesthesia
Anesthesia, or anaesthesia , traditionally meant the condition of having sensation blocked or temporarily taken away...
, and the system relies on General Practitioners and physicians from other specialties 'filling the gap' when emergency physicians are not available.
The situation is further complicated by the fact that the physicians staffing the SMUR units are among the lowest-paid in Europe. Although salaries have recently improved somewhat, in 2002 it was reported that these physicians, who are, for the most part, full-time employees of public hospitals, had a starting salary of only €1300 (£833; $1278) per month. This economic reality has resulted in understandably high turnover and some difficulty in staffing positions. It has been suggested, however, that the recognition of emergency medicine as an in-hospital specialty in France and elsewhere in Europe is likely to result in the evolution of that system towards more comprehensive in-hospital emergency services.
This will ultimately, in turn, result in less physician response; although the complete replacement of physician response by the type of technician response occurring elsewhere is unlikely to occur any time in the immediate future . Since 1986, fire department-based rescue ambulances have had the option of providing resuscitation service (reanimation) using specially-trained nurses, operating on protocols, in the role that we would normally expect to be performed by the paramedic but with the Samu Medical Physician Regulator Aid . In actual practise, however, such units and Nurse staffed MICU are used for certain purposes of Stable Intensive Care Patients .
Public access
France, along with the rest of the continental European UnionEuropean Union
The European Union is an economic and political union of 27 independent member states which are located primarily in Europe. The EU traces its origins from the European Coal and Steel Community and the European Economic Community , formed by six countries in 1958...
uses the emergency telephone number
Emergency telephone number
Many countries' public telephone networks have a single emergency telephone number, sometimes known as the universal emergency telephone number or occasionally the emergency services number, that allows a caller to contact local emergency services for assistance. The emergency telephone number may...
available across all members 112
1-1-2
112 is the principal emergency telephone number that can be dialed free of charge from any telephone or any mobile phone in order to reach emergency services in the European Union , its candidates for accession, members of the EEA agreement, as well as several other countries in the world...
, which gives access to police, fire and ambulance services. However, the legacy emergency number of '15' for SAMU and '18' for fire department VSAV are still in use.
Funding and costs
In France, the 100 or so SAMUs (one for each Department) are all operated by public hospitals. Public hospitals (unlike private hospitals, and France has both) receive government fundingFunding
Funding is the act of providing resources, usually in form of money , or other values such as effort or time , for a project, a person, a business or any other private or public institutions...
. France operates on a system of universally accessible socialized medicine
Socialized medicine
Socialized medicine is a term used to describe a system for providing medical and hospital care for all at a nominal cost by means of government regulation of health services and subsidies derived from taxation. It is used primarily and usually pejoratively in United States political debates...
. Patients have freedom to choose physicians, hospitals etc., and there are prices set for each type of service.
When operating in the public system, patients are asked to co-pay a portion of the cost for each type of care that they receive. To illustrate, a patient requiring hospitalization is liable for 20 percent of costs for the first month, and nothing thereafter.
What this means in terms of funding is that the SAMUs and their SMUR response teams are funded by the government, by means of the hospital funding scheme. They do charge a fee for service, and for a typical patient, 65% of this cost will be covered by the government health insurance scheme and the balance covered by optional additional private insurance. By French law, in an emergency any French hospital or SAMU must treat any patient, regardless of their ability to pay.
As a measure against system abuse, the SAMU physician may refuse to sign the patient's 'treatment certificate', resulting in the patient being liable for the full cost of services provided, although in practice, this is rarely done. Most French citizens also carry private health insurance
Health insurance
Health insurance is insurance against the risk of incurring medical expenses among individuals. By estimating the overall risk of health care expenses among a targeted group, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is...
in order to cover all co-payment charges.
In some circumstances, particularly on low-priority calls, patients being transported to hospital may be asked to pay for service in advance, and then seek reimbursement from the government insurance scheme or their private insurance. Although not regarded as ambulances in France, fire department ambulances, when used, provide transportation to hospital without charge. All requests for ambulance service are processed by the local SAMU, which will determine what type of assistance and transportation resources are sent; the patient has no choice in the matter when it is an Intensive Urgent Care Need.