Emergency medical services in France

infobox country
common_name = France

---

capital = Paris [cite web|url=https://www.cia.gov/library/publications/the-world-factbook/geos/fr.html|title=All facts unless otherwise cited, are from: The CIA World Fact Book|accessdate=2008-10-06]
area_km2 = 547030
population_estimate = 62150775
population_estimate_year = July 2008
population_density_km2 = 113.61
healthcare = Public/private mix

Emergency medical service in France is provided by means of a physician-led organization called a SAMU [cite web|url=http://www.samu-de-france.fr/en|title=National SAMU website|accessdate=2008-09-18] for each French Departement (county).

Organization

The SAMU ("Service d'Aide Médicale Urgente" [cite web|url=http://acronyms.thefreedictionary.com/SAMU|title=freedictionary 1|accessdate=2008-09-18] ), ("Emergency Medical Assistance Service") is the French hospital-based emergency medical service. It was founded in 1968 by coordinating the existing SMUR teams (prehospital care units). Although SMUR vehicles are typically labelled 'SAMU' that term actually refers to the system for the centralized coordination of multiple SMUR ("Service Mobile d'Urgence et Reanimation" [cite web|url=http://acronyms.thefreedictionary.com/SMUR|title=freedictionary 2|accessdate=2008-09-18] ) units (perhaps even from multiple hospitals) within a community. SAMU organizations operate at the Departement level, and are identified by numbers, with a different number for each Departement (SAMU 06=Nice, SAMU 75=Paris, etc.) [cite web|url=http://www.samu06.org/en/liens.php?PHPSESSID=e1dcbfb58632d6edb0eb40b4f8cc665c#samu|title=SAMU Numbers|accessdate=2008-09-18] . In addition to mainland French Departements, SAMUs operate in a number of offshore departements, (e.g. Guadeloupe is SAMU 971) and under contracts in a number of other countries. Emergency response may be through the use of a fire department-based ambulance, such as the Paris Fire Department [cite web|url=http://www.pompiersparis.fr|title=Paris Fire Department|accessdate=2008-09-18] , or by an ambulance (labelled SAMU) staffed by a physician-led team (SMUR). European models of care for EMS vary considerably, but generally fall into one of two general categories. [cite journal|author=Cooke MW, Bridge P, Wilson S.|title=Variation in emergency ambulance dispatch in Western Europe|journal=The Scandinavian Journal of Trauma and Emergency Medicine|volume=9|issue=2|pages=57-66|year=2001] The French system may be described as being a part of the Franco-German (as opposed to the Anglo-American) model of EMS delivery. [cite journal |author=Dick WF |title=Anglo-American vs. Franco-German emergency medical services system |journal=Prehosp Disaster Med |volume=18 |issue=1 |pages=29–35; discussion 35–7 |year=2003 |pmid=14694898 |doi= |url=] The French philosophy is to provide more definitive care at the scene during life-threatening emergencies, and a SMUR team, consisting of a physician, a nurse, and an ambulance driver, may elect to conduct the majority of care, even resuscitation attempts, at the scene, prior to transport. SMUR teams are typically hospital-based.

tandards

Vehicles

In France, the word "ambulance" is reserved to transportation on medical prescription, including oral prescription in case of emergency. The term "ambulance" is generally used only to apply to those response vehicles operated by the local SAMU. It does not technically apply to first responders vehicles (most of the time firefighters), although they also transport casualties and are, in any practical sense, ambulances; their vehicles are called VSAV [cite web|url=http://http://www.pompiersparis.fr/accueil.htm|title=French Fire-based VPS|accessdate=2008-09-18] ; "véhicule de secours et d'assistance aux victimes" (casualties' rescue and assistance vehicle), or VPS; "véhicules de premiers secours" (first aid vehicles) in case of volunteers from associations. The VSAV and VPS are considered to be vectors that bring rescue workers and devices onsite, with the evacuation of patients being only the logical result of the response, but not the primary duty of these response resources. In France non-emergency and low-priority ambulance services are normally provided by private companies, with no formal requirements for the training of their staff. For other types of medical transportation, the term 'ambulance' is not used; relying instead on the more general term is "vehicle adapted to patient transport". 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, [cite web|url=http://www.cen.eu/cenorm/homepage.htm|title=European Committee for Standards website|accessdate+2008-09-19,] the degree of compliance varies, particularly among those vehicles not officially referred to as ambulances in France. The visual identity provisions of the standard are not currently being followed anywhere in France.

taffing

Paramedics, as we understand the role, do not exist in France. The majority of high priority emergency calls are serviced by physician-led SMURs, through the SAMU system. It should be noted that, while the concept of a physician responding to emergency calls seems logical, it is far from perfect. In hospital emergency medicine has only recently been recognized as a medical specialty in France, [cite journal |author=Fairhurst R |title=Pre hospital care in Europe |journal=Emerg Med J |volume=22 |issue=11 |pages=760 |year=2005 |month=November |pmid=16244329 |doi=10.1136/emj.2005.030601 |url=] [cite journal |author=Fleischmann T, Fulde G |title=Emergency medicine in modern Europe |journal=Emerg Med Australas |volume=19 |issue=4 |pages=300–2 |year=2007 |month=August |pmid=17655630 |doi=10.1111/j.1742-6723.2007.00991.x |url=] and pre-hospital care is currently struggling to be recognized as a sub-specialty. In the meantime, many SMUR 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 [cite journal |author=NIKKANEN H. E.; POUGES C.; JACOBS L. M.|title=Emergency medicine in France |journal= Annals of emergency medicine|volume=31 |issue=1 |pages=116-120 |year=1998 |pmid=9437354|url=http://cat.inist.fr/?aModele=afficheN&cpsidt=2115418] . 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 [cite journal |author=Dorozynski A |title=French emergency services reach crisis point |journal=BMJ |volume=325 |issue=7363 |pages=514 |year=2002 |month=September |pmid=12217987 |pmc=1124052 |doi= |url=http://bmj.com/cgi/pmidlookup?view=long&pmid=12217987] . 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 ambulances have had the option of providing resuscitation service (reanimation) using specially-trained nurses, [cite web|url=http://http://www.interieur.gouv.fr/sections/a_l_interieur/defense_et_securite_civiles/sapeurs-pompiers/sdis/sssm/downloadFile/attachedFile_2/Protocoles.pdf?nocache=1143132331.45| title=Infermier Sapeur-Pompiers (French govt website)|accessdate=2008-09-19] operating on protocols, in the role that we would normally expect to be performed by the paramedic. In actual practise, however, such units [cite web|url=http://www.pompiersparis.fr/accueil.htm|title='Reanimation' Ambulance-Paris|accessdate=2008-09-19] and nurses are extremely rare outside of the City of Paris.

Dispatch

France now uses the emergency number 112 as a national emergency number for ambulances. The new number is an attempted European standard, although the old emergency number, 15, will still work in a great many locations. Such emergency numbers conflicts persist across Europe, often creating confusion for the public, and particularly for those who are visiting an area. [cite journal|author=Cooke MW, Bridge P, Wilson S.|title=Variation in emergency ambulance dispatch in Western Europe|journal=The Scandinavian Journal of Trauma and Emergency Medicine|volume=9|issue=2|pages=57-66|year=2001] Dialling either of these numbers automatically connects the caller to the SAMU office which is physically closest to their location. All requests for emergency ambulance service are received and processed by the local SAMU. Calls are screened and patients interviewed by a physician, with a variety of possible outcomes. The physician may elect to provide simple medical advice over the telephone, avoiding the need for a response. The physician may also order the assignment of a transport resource, either private, fire-based, or SMUR, at their own discretion. SMUR response may consist of a conventional emergency ambulance or, when appropriate, a Hospital Mobile Intensive Care Unit (H-MICU) [cite web|url=http://www.samu-de-france.fr/en/System_of_Emergency_in_France_MG_0607|title=Ambulance Dispatch System (SAMU website)|accessdate=2008-09-18] . Because of aggressive triage, only about 65% of requests for ambulance service actually receive an ambulance response [cite journal |author=NIKKANEN H. E.; POUGES C.; JACOBS L. M.|title=Emergency medicine in France |journal= Annals of emergency medicine|volume=31 |issue=1 |pages=116-120 |year=1998 |pmid=9437354|url=http://cat.inist.fr/?aModele=afficheN&cpsidt=2115418] . Current performance on emergency calls is arrival at scene within 10 minutes, for 80% of responses, and within 15 minutes for 95% of responsescite journal |author=Dick WF |title=Anglo-American vs. Franco-German emergency medical services system |journal=Prehosp Disaster Med |volume=18 |issue=1 |pages=29–35; discussion 35–7 |year=2003 |pmid=14694898 |doi= |url=] . Private carriers may also self-dispatch to non-emergency transports.

Funding and costs

In France, the 100 or so SAMUs (one for each Departement) are all operated by public hospitals. Public hospitals (unlike private hospitals, and France has both) receive government funding. France operates on a system of universally accessible socialized medicine. [cite web|url=http://www.nchc.org/facts/France.pdf|title=National Coalition on Health Care website|accessdate=2008-09-19] 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. The good news is that in France, as a general rule, the more sick or injured you are, the less you will be asked to co-pay! [cite journal|title=The French Lesson in Health Care|journal=Business Week|date=July 9, 2007|url=http://www.businessweek.com/magazine/content/07_28/b4042070.htm] 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. [cite web|url=http://www.businessweek.com/magazine/content/07_28/b4042070.htm|title=Parisvoice website|accessdate=2008-09-19] By French law, in an emergency any French hospital or SAMU must treat any patient, regardless of their ability to pay. It should also be noted that, 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. [cite web|url=http://www.french-property.com/guides/france/public-services/health/receiving-treatment/emergency-treatment/|title=French Property website|accessdate=2008-09-19] 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 tranportation resources are sent; the patient has no choice in the matter.

ee also

* Emergency medicine in France

References