A Scottish Perspective of Pre-hospital Care and Emergency Medicine in Norway - Part 3

Dr Zoë Smeed

I am 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 in-between shifts with the Norwegian Air Ambulance helicopters and fixed wing aeroplane, I have attended some more training events.  On Monday, I attended the first day of a three day pre-hospital course run by the Oslo Norwegian Air Ambulance, hidden in the mountains and forests surrounding Oslo.  The course was specifically for doctors working within Scandinavian Pre-hospital services, with doctors from Norway, Sweden, Denmark (and Scotland!) gathering to learn a bit more about pre-hospital care.  The course involved a variety of lectures, skill stations and scenarios.  I attended lectures on birthing and paediatric emergencies, the pathophysiology of trauma and hypotensive resuscitation.  Additionally skills stations for surgical airway (using pig models), managing wounds/traumatic amputations, trauma simulation stations and a major incident table top exercise.  There were additional skills stations in the course including tips for successful pre-hospital RSI's and how to perform thoracotomies (again using pig models), which were sadly on a day I couldn't attend.  Clearly pigs have it hard in Norway!

The highlight of my week was doing some rescue training with the Norwegian Ambulance.  All members of the HEMS crew (pilot, resueman and doctors) have to train at least every 3 months in both land and water rescue.  I was lucky to act as the casualty, being dropped off in various locations in the forest, picked up by the rescueman and dangled on a rope across a lake to another location in the forest - it was awesome fun!  

In Norway, there is no walk in service for hospitals.  Patients either have to be referred by their GP, the Legevakten (similar to GP out of hours) or brought directly to hospital by ambulance or the Pre-hospital physician services.  For the ambulance service, if it is thought a patient would get home (e.g allergic reaction, drug/alcohol ingestion, non specific chest pain) they are taken by ambulance to the Legevakten.  If the patient is critically unwell, or thought to require admission to hospital the ambulance service have to discuss the patient with the relevant specialist in the hospital whilst transferring them. Currently, there is no Emergency Medicine speciality, (although this is something Norway is discussing possibly implementing), patients are referred directly to specialities.  Generally in Norway patients are seen in a general receiving unit by the relevant speciality along with an Anaesthetist to decide where the patient is best placed, and early treatment can be commenced.

Most Legevakts run more like the GP out of hours unit with additional beds to see more unwell patients and those transferred by ambulance with acute problems.  Oslo  Legevakten also has additional services including a Paediatric area, a Consultant Psychiatrist service, a Minor Injuries Unit, an intoxication bed (allowing monitoring of drug/alcohol intoxications for 4 hours) and a 13 bed Clinical Decision Unit.  Additionally there is 24hr on call social work who can be called to arrange emergency care/housing for patients even during the night.  If patients are requiring admission, they then have to be transferred to hospital.  Approximately 20% of patients from the Legevakten are referred to the hospital.  

Oslo's Legevakten receives approximately 90,000 patients per year, with approximately 300-350 per day their GP/small bedded unit.  All patients have to pay a small fee (similar to that which they need to pay to see a GP or outpatient hospital specialist), of approximately 100-130 Kr per visit (around £10-13) (or 250Kr (£25) at night).  All other healthcare costs are covered by the government.   Emergency or critically ill patients who require immediate transfer to hospital do not pay a fee.  If patients are unable to pay, they will still receive a bill but it will be paid by the government. 

At the front door, patients are triaged according to severity (based on basic observations and their presenting complaint), and sent to the appropriate facility.     The Legevakten is located close to the town centre and next to one of the city ambulance stations, allowing a close working relationship with the ambulance crews.

The Legevakten also has its own call centre, taking approximately 30,000 calls/year by nurse operatives.  In the call centre a doctor co-ordinates calls and can either refer patients directly to hospital or specialists, arrange ambulance transfers, or redirect patients to other services (e.g. social work, GP or community nursing services).  The call centre has a close relationship with the emergency 113 Dispatch Centre at Ullevål and can direct patients appropriately. 

Within the GP/small bedded unit, there are approximately 11 doctors per shift and a "shift leader" doctor who is involved in co-ordinating patients.  Doctors have trained in a variety of specialities including General Medicine and GP.  The shift leader is involved in co-ordinating patient flow, answering queries and managing the department along with the nursing coordinators.  The shift leaders are required to have worked for at least 2 years in the Legevakten, but do not have to be consultants or registrars to apply for the position.  Doctors and nurses work the same shift pattern (8 hourly shifts throughout a 24 hr period). 

Rikshopitalet is one of Oslo's tertiary hospitals which mainly receives patients from other hospitals outside Oslo for specialist treatment - mainly Neurosurgery (excluding head injuries which are treated at the main trauma centre in Ullevål), Plastics, ENT, Paediatrics, Neonates, Cardiothoracics and Transplant.  Patients living within Oslo (or those involved in Trauma) are seen at Ullevål Hospital (Scandinavia's largest hospital, treating 1.2 million patients per year).   I am hoping to spend some more time exploring Ulleval Hospital later in my fellowship so I will discuss this at a later date. 

Within Rikshospitalet, there is a small "Emergency Department" however critically unwell patients generally are not treated within this area.  If unwell patients are being received from the Pre-hospital physician services the ED is bypassed, and the Pre-hospital physician transports the patient directly to CT, ITU, the Paediatric Ward or theatre (even if the patient does not require an immediate operation).  (This differs from Ullevål Hospital where acutely unwell patients are received in the resuscitation rooms).  If the patient is transported directly to CT, the specialist (eg the Neurologist) would also attend along with the on call Anaesthetist and a decision would be made from there where to transport the patient.  Despite this there is one small resuscitation bay within the ED if a patient becomes unwell.  As there are no Emergency Medicine doctors, specialists have to be contacted from other areas within the hospital and respond to emergency calls. 

Now comes the controversial bit!  Comparing the Norwegian to UK Emergency Department models, I believe there are many advantages to having doctors trained in Emergency Medicine within the Emergency Department.  In Norway, as the doctors are not based in the Emergency Department there is no medical ownership of the department, and if patients become more unwell there may be no doctor immediately available within the department.  In the resuscitation room, I sometimes found it far more chaotic, and on occasion there appeared to be limited cohesion between the Physicians, Surgeons, Anaesthetists, and Nursing staff.   Additionally, the specialists sometimes appeared more keen to make the diagnosis than managing the initial patient resuscitation through the standard ABC system, (however they do have additional support from the Anaesthetists if the patient is critically unwell).  Doing EM training allows you to be open minded to a number of possible differential diagnoses (both surgical and medical), whereas when patients are directly referred to a speciality, it can take longer for the patient to end up in the correct place.  Additionally, I think Emergency Medicine doctors have more skills in targeting appropriate investigation and triaging whether patients need to be admitted or discharged with appropriate follow up. 

Despite this, Norway has a fantastic Pre-hospital to Hospital interface.  Pre-hospital physicians are able to directly request a specialist on standby and also request to attend theatre/CT on immediate arrival.  Patients can be taken straight from the pre-hospital environment to CT (for example in a potential stroke thrombolysis candidate), theatre, or primary PCI (eg ST elevation MIs or cardiac arrest - a service which is developing in Edinburgh), reducing time to diagnosis and definitive care.   Within the hospital environment, in smaller district general hospitals the Pre-hospital physicians play an important part in supporting the local hospital staff, providing additional help for practical procedures and in decision making skills regarding the most appropriate management for the patient. 

Whilst I leave you to mull over this and draw your own conclusions, I leave you with a cheesy photo of me and my favourite flying machine!  Until next time!