A Scottish Perspective of Pre-hospital Care and Emergency Medicine in Norway

Dr Zoë Smeed

I am currently a ST5 Emergency Medicine trainee in Edinburgh, Scotland.  After receiving the Robin Mitchell Travel Fellowship, I have been given a fantastic opportunity to explore the Pre-hospital and Emergency care services in Oslo, Norway.  Over the course of my placement I aim to write a personal account about what I have experienced over here in Norway, and about how the Pre-hospital and Emergency Medicine services operate. 

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, simulating medical emergencies 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 worked in Auckland City Hospital, in New Zealand working alongside the Auckland Rescue Helicopter providing training and clinical support to the paramedics and constructing the educational framework for a retrieval programme. Additionally he was 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.

There are many similarities between Norway and Scotland in terms of health care provision, patient populations, disease epidemiology and geographical challenges, providing an excellent location to compare Pre-hospital and Emergency Medicine systems.  Whilst in Norway I will spend time with the physician, helicopter and fixed wing ambulance services, and visit the dispatch centre.  Additionally I will spend time looking at the management of patients in the Emergency Departments and ITU, particularly, in the management of trauma and cardiac arrests.  I will also attend training and simulation sessions for the pre-hospital services. 

Due to geographical challenges, Norway has developed a national Pre-hospital care service, aiming to fulfil the government's target that 90% of the Norwegian population can be attended to by pre-hospital physician within 45 minutes.  Pre-hospital services include road ambulances, motorbike paramedics, the physician ambulance, HEMS and fixed wing ambulance services.  There is additionally an intensive care ambulance which is used specifically for ITU transfers from neonates to adults.  Many pre-hospital services are onsite at Ulleval Hospital, including the Physician Ambulance, the Dispatch Centre and largest ambulance station.  This enables a close working relationship between the services, and also with Ulleval Hospital (Scandinavia's largest hospital and Oslo's trauma centre).  The physician and HEMS services all use the same computer programme, and radio frequencies allowing discussion with the paramedics en route to a call out. 

For the past week I have been working alongside the Physician Ambulance based at the Ulleval hospital site in Oslo.  Within Norway there are 2 physician ambulances based at Ulleval Oslo and Akershus.   The Physician Ambulance is a service which enables the provision of a doctor (typically an Anaesthetic Senior Registrar or Consultant, as Emergency Medicine is not currently a speciality in Norway) along with a very experienced paramedic to deliver medical support  to critically unwell patients.  The service works very closely with the road ambulances and motorbike paramedics.  The Physician Ambulance attends all out of hospital cardiac arrests, multiple traumas and provides additional medical support for critically ill patients.  Call outs are typically initially via dispatch, however paramedics and trainee paramedics (similar to ambulance technicians) in the UK can also request back up from the physician ambulance.  Additionally the doctors provide telephone medical advice, and can also authorise the use of drugs (eg morphine) to trainee paramedics who are unable to prescribe.  Recently the service has changed from working office hours Monday - Friday to now having a 24hr service.  Doctors typically work either a 24 hr shift or split shift (08:00-16:00/16:00 - 08:00) and paramedics work a 12 hr shift (07:30-19:30/19:30-07:30).  

Experienced paramedics who want to work with the physician ambulance have to pass an exam and interview, then train with the physician ambulance paramedics and doctors before working on the service.  They get further critical care training including how to assist in RSIs, set up arterial and central lines and chest drains.   Doctors have to pass an interview and undergo both simulation and training under supervision of another Physician Ambulance doctor before working on the service. 

Over the past week and a half I have attended some teaching sessions, including case-based simulation sessions with the Physician Ambulance, paramedic training sessions and dispatch services.  Working alongside the Oslo University Resuscitation Research Group, I have attended 2 sessions with the research group and dispatch centre aimed at improving early identification of patients in cardiac arrest and initiation of bystander CPR.  This involved simulated scenarios with dispatch operators acting as either bystanders/telephone operatives, in an aim to improve the operators protocols on when to initiate CPR and improve on early identification of cardiac arrest.

Another teaching session with trainee paramedics, involved an anaesthetised pig to identify the importance of good quality chest compressions, appropriate ventilation and management of patients in cardiac arrest, and how to manage cardiac tamponade after penetrating trauma.  Interestingly all doctors and paramedics use anaesthetised animals such as pigs during the course of their training, which of course is very different to the UK!  The session involved inducing VF in an anaesthetised pig and  getting the paramedics to work at CPR and ventilation, then after thoracotomy, the use of internal paddles.  Simulated myocardial infarction (by clipping the LAD artery), enabled visualisation of the changes to the heart during myocardial infarction.  Additionally, paramedics were taught how to manage stab wounds to the heart resulting in cardiac tamponade.  The session enabled paramedics to get hands on training and visual insight into the pathophysiology behind the cardiovascular system, myocardial infarction, cardiac arrest and cardiac tamponade.  It is certainly a teaching session I will never forget!

On that note I would like to thank the Medic 1 Trust Fund and Robin Mitchell Fellowship for providing me with this fantastic experience, along with my supervisors Dr Richard Lyon and Dr Dave Caesar in Edinburgh, Dr Theresa Olasveengen in Oslo and all the staff at the Physician Ambulance Service.  Next week I am spending time with the HEMS and fixed wing ambulance service so I will keep you all updated! 

Thanks for reading!