A Scottish Perspective of Pre-hospital Care and Emergency Medicine in Norway - Part 2

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.  The Robin Mitchell Travel Fellowship was set up to commemorate Dr Robin Gordon Mitchell, an Emergency Medicine Consultant in Edinburgh and is open by application to all Scottish Emergency Medicine trainees 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. 

This week whilst the Referendum is hotting up in Scotland I have been spending time with the Norwegian Air Ambulance helicopter and fixed wing services, and at the Dispatch Centre (AMK) at Ulleval Hospital in Oslo.  Surprisingly the Referendum is pretty well covered here in Norway and I am frequently met with questions about it from the Norwegians!

The Dispatch Centre covers all 113 Emergency and 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.  Operators are required to answer 90% of all 113 (Medical Emergency) calls within 10 seconds, and 100% within 20 seconds.  They train staff to identify the location, do fullfill a quick ABC check of the patient and dispatch an ambulance within 90 seconds of taking the call.  The Dispatch Centre receives approximately 145,000 113 emergency calls/year. 

Emergency calls are taken by nurses and triaged according to the Norwegian Index.  The Norwegian Index is a reference guide for operatives to identify what questions to ask, and identify if a doctor (lege) should additionally be dispatched.  After taking the calls Paramedics/Ambulance drivers within the dispatch centres then dispatch the nearest and most appropriate Emergency Response vehicle to the location.

Nurse operators are required to have at least 2 years experience either within the Emergency Department or Pre-hospital, and undergo a 3m training programme involving simulated calls, experienced operators listening into their calls (assisting as required) and the completion of multiple assessment criteria.  The "Ambulance Leader" is in charge of the overall co-ordination of the dispatch centre and additionally involved in co-ordinating services for a major incident.  In Norway there are 3 emergency numbers which are used depending on whether someone requires the Fire, Police or Ambulance Services.  The dispatch centre is able to contact the other emergency services dispatch centres by computer to enable dispatch of other services as required.

There are 2 Pre-hospital centres (one at Ulleval Hospital and one at Akerhus Hospital) which both cover the Oslo and Akerhus areas.  The Pre-hospital centre in at Løsenskog, next to Akerhus hospital is the home of the Norwegian Air Ambulance helicopter, the fixed wing ambulance, and ambulance station.  The Pre-hospital centre at Ulleval Hospital houses the Physician Ambulance, Motorbike Paramedics, Ambulance Station and research and clinical guideline centres.  Provision of the Pre-hospital centres allows  close cohesion between the different services, as they all operate from the same centres and training is additionally split between these sites. 

The national Norwegian Air Ambulance service initially started up as a charity in the 1970's and then taken over by government funding.  There are currently 2 operators holding contracts within Norway (Norsk Luftambulanse AS) - the largest of the 2, and Lufttransport AS)1.  

Within Norway there are 9 ambulance fixed wing planes (all Beech KingAir B200) at 7 locations (Kirkenes, Alta, Tromsø, Bodø, Brønnøysund, Ålesund and Gardermoen). The largest service being at Gardermoen (just outside Oslo) has 2 fixed wing planes.  There are 11 locations housing the 12 Norwegian Air Ambulance helicopters (Tromø, Brønnøysund, Trondhein,  Ålesund, Førde, Bergen, Stravanger, Arendal, Ål, Drombås and the largest site housing 2 helicopters at Løsenskog (which covers Oslo).  Norsk Luftambulanse covers 8 of these sites (including Løsenskog) 1. 

Approximately 20,000 patients are transported by the Norwegian Air Ambulance services, with approximately 18,000 flight hours yearly, all services operating 24 hrs/day1.  Additional support is provided by the military, who even have a Physician Response Car provided by the government so a Military Doctor and HEMS crewman (rescue man) can be transported on civilian missions close to the base enabling faster medical backup to a more remote area. 

Whilst working with the Norwegian Air Ambulance Helicopter Service, I have been based at the largest and busiest site at Lørsenskog.  One of the helicopters is used primarily for primary missions, the second is used for secondary transfers within 1hr flight time of Oslo (typically from smaller ITUs from district hospitals to the tertiary hospitals Ulleval and Rickshospitalet in Oslo), however additionally covers primary missions when the first helicopter is in use.  Patients requiring longer critical care transfers (over 1hr flight time from  Oslo) are transported by the fixed wing air ambulance. 

The HEMS crew consists of an experienced pilot, a HEMS crewmember (or rescueman) and a HEMS doctor (typically an anaesthetist).  At Lørsenskog there are 2 HEMS crews working at a time (to cover the 2 helicopters).  The rescueman has probably one of the coolest jobs in the world!  They are highly skilled critical care paramedics or nurses who also have to act as winchmen in search and rescue missions, assist the pilot and even fly the helicopters!  It is not surprising that this is one of the most sought after jobs in Norway, with approximately 100 applicants per job.  To apply to be a rescuemen, applicants have to be an experienced paramedic/nurse with at least 2 years pre-hospital experience, passed several pre-hospital and major incident training courses, have basic climbing qualifications and a pilot licence.  Those that pass these criteria then attend a 1 week interview, where they live in a training centre and undergo written and practical examinations, physical tests, psychometric testing and simulation with the HEMS crews.  Those that are selected then undergo a medical and aviation training course, and shadow experienced rescuemen before being qualified. 

The pilots also have additional medical training so can help assist for Rapid Sequence Intubations, draw up medical drugs and fluids, and cannulate patients.  The resueman and pilots train with the military search and rescue teams and undergo the same training scheme allowing them to both have the same skills.  They additionally have to attend a simulation course and assessment yearly (which takes place in Germany).  Doctors are typically anaesthetics (as there currently is no Emergency Medicine training scheme in Norway!), and have to have 2 years Pre-hospital experience (typically with the Physician Ambulance) before applying through interview.  They additionally undergo additional training in aviation and helicopter safety in addition to further medical training. 

Despite the amazing job the HEMS crew work incredibly long shifts and live at the base whilst working.  The pilot and resuemen live on the base working a full week, with doctors typically work 48/72 hour shifts "on call", with mandatory 9 hr rest periods per 24 hrs for all crew members.  Because of this the facilities at the base are fantastic, with a fully equipped kitchen, living room, sleeping quarters and an outside space for BBQs. 

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 2 patients on stretchers.  Within the more isolated areas of Norway, the fixed wing services are also occasionally used for primary missions.  Each plane is staffed by 2 pilots, typically an experienced ITU nurse (occasionally a paramedic) and Anaesthetist.  Depending on the severity of the patient's condition, the patient is transported either by the experienced ITU nurse/paramedic or with the addition of the Anaesthetist.  The fixed wing ambulance co-ordinate all their critical care missions, with calls taken by the nurses and reviewed by the doctor to identify travel arrangements.  Additionally the service has a critical care road ambulance which can be used to transport patients from neonates to adults to different critical care facilities.  It even has the capabilities to drive into a Sea King helicopter and be transferred by air if necessary! 

Despite the early starts (leaving the house at 05:45!), working with the Norwegian Air Ambulance has certainly been a fantastic and rewarding experience!  Watching the sunset over the Norwegian Fjords in the helicopter en route to another mission is certainly one I won't forget! 

  1. About the National Air Ambulance Services of Norway.  www.luftambulanse.no/printpdf/209