Pomosch: Emergency Medical Service of the Soviet Union
Skoraya Randolph
B.
Reinhold,
MD
\s=b\ The Emergency Medical Service of the Soviet Union as witnessed in 1975 shows evidence of central communication, organization, and planning. The Skoraya Pomosch has developed into an elite medical corps with general and multispecialty emergency teams that include well-trained physicians and physicians' assistants, with emphasis on bringing medical care to the patient at the site of the emergency. At its optimum, it is an elite corps that is uniformly available and capable of response to minor emergencies as well as major community disasters. Chronic problems of inadequate equipment and inappropriate use of the system continue to plague the Skoraya as they do other aspects of Soviet medicine. Certain qualities, such as the central communication network, are probably adaptable to the United States' situation, but in general, we must continue to improve and devise our own emergency medical system.
(Arch Surg 111:528-531, 1976)
At 11:45 am, a 40-year-old male pedestrian was struck by Il a speeding automobile and thrown 12 meters from the road in the nearby bushes. A passerby ran to the
depositing dispatching later, the special¬
nearest public phone, dialed "03" without money, and notified the central ambulance
station of the accident. Ninety seconds ized trauma ambulance brigade left the station enroute to the scene of the accident—no sirens, only a flashing white light. There was no police escort. Traveling a distance of 3 km in approximately three minutes, the ambulance arrived at the scene at 11:49 am. As the physician and two Accepted
publication Jan 15, 1976. Department of Surgery, Harvard Medical School, Boston. Reprint requests to 185 Dudley St, Roxbury, MA 02119 (Dr Reinhold). From the
for
assistants examined the man lying by the roadside, the driver learned that the pedestrian had been jaywalking when struck by the car on his left side. The patient was conscious but complaining of pain on the left side of the chest with no other apparent major injury. As the driver called ahead on his two-way radio to the nearest hospital, 7.5 km away, the emergency medical team moved the patient by stretcher to the back of the waiting ambulance. Further examination by the physician determined that the patient's pulse was fast and thready; his blood pressure was 80/40 mm Hg. The diagnosis was a fracture of the lower part of the left side of the rib cage with a possible rupture of the spleen. Because of the hypotension, a largebore intravenous needle was inserted into the left antecu¬ bital vein and an infusion of dextran blood substitute was begun. As soon as the needle was secured, the ambulance departed for the nearby hospital, arriving six minutes later, at which time the patient was admitted. Subsequent follow-up confirmed the diagnosis of fractured ribs 9, 10, and 11 on the left side with a question of ruptured
spleen.
thereafter, another call was processed at the dispatch station, indicating that a 48-year-old woman telephone operator was complaining of shortness of breath. Several minutes later, a special cardiology team Soon central
departed and arrived at the factory 0.8 km away. The cardiologist quietly but efficiently took the patient's history and performed a physical examination, using an ancient rigid tubular stethoscope (one end against the patient's chest, the other to the physician's ear). While the female physician was completing her examination, one of the physician's assistants drew a blood sample for white blood cells (WBCs) and prothrombin time while a second
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assistant performed an electrocardiogram. As the results of the ECG and other tests were normal, the cardiologist concluded that the case was primarily cardiac neurosis and administered an injection of a mild tranquilizer. Within 20 minutes from the time of arrival, the patient was resting comfortably and the team departed, leaving a copy of the medical report and ECG with written instructions for the patient to be taken to the family physician in 48 hours for
follow-up.
INTRODUCTION
One of the prime foci in evaluating primary health care of the Soviet Union during an exchange visit of June 1975 with other American physicians was analysis of the Skoraya Pomosch, or Emergency Medical Service. Both of the previously mentioned cases were observed in their entirety during our exchange visit in the city of Kiev. Though there is some evidence to suggest that the excel¬ lence of care we observed is not uniform, there is much to learn from the organization and planning of the Skoraya. It is not my intention to review the available literature, but rather to relate direct observations and opinions. Much of the available literature originates from within the Soviet Union and is, therefore, often not a fair critique of both the strengths and weaknesses. The recent publication, Urban Emergency Medical Service of the City ofLeningrad, by the Department of Health, Education and Welfare1 is a good resource document describing in detail the structure, staff¬ ing, organization, equipment, training, and evaluation of the urban Skoraya. We can best understand the workings of the Skoraya system by tracing the flow of information, personnel, and equipment, as well as the other available resources in the two clinical cases before sited. Following a brief historical note, I shall attempt to trace theorization behind these two patients, pointing out strengths, efficiencies, and short¬
comings
as
they occur. Skoraya volunteer service, the Skoraya
History
of the
was Begun in 1902 as a nationalized in 1917, as were all medical services in the Union of Soviet Socialist Republics (USSR). The Skoraya is free of charge at the point of access and is centrally organized with the constant format from large urban metropolis to small rural village, as is typical of most health care planning in the Soviet Union. Since 1917, there has been progressive specialization of the Skoraya staff to the point where it is now one of the elite medical corps of the USSR. In the early part of the 20th century, the service was concerned with rapid patient transportation, but in recent years it has placed increased emphasis on initiating patient treatment at the site of initial contact.
The
Skoraya System
Critical to the functioning of the Skoraya is its inter¬ locking communications network of telephones and twoway radio. From any public or private telephone in the entire nation, the dialing of "03" (no coin required) links the caller with the central regional dispatch station. In
Kiev, there is one central station and nine substations, each located in close proximity to the metropolitan general hospital of approximately 300 beds. Subsequent sub¬ stations are built in accordance with housing patterns. In addition, in Kiev, a central trauma hospital of approxi¬ mately 1,000 beds is presently being designed. This pattern is typical of metropolitan organization throughout the Soviet Union. The receiving area for "03" calls is manned by specially trained physicians' assistants (feldsher) around the clock. Eight such feldshers receive calls under the supervision of a staff physician at the Kiev central station. These feld¬ shers record the time of the call, name and address, and special information regarding the exact location of the patient, as well as the chief complaint. In some cases, the patient might be referred to his family physician at the district outpatient department, but in general, the Skoraya is responsible for answering all calls received. Proper utilization of this emergency medical service by the popu¬ lation is one of the critical issues presently facing Soviet medicine. The Skoraya is designed as an immediate response system to be distinguished from the Neotlozhnaya, or urgent medical assistance. The Neotlozhnaya is based at the district outpatient department and is to be used for minor calls, particularly those in which knowledge of the patient's record at the local clinic level would be helpful. Confusion regarding the use of these two services has led to much discussion and some attempts at centralization and unification {The Literary Gazette, May 28, 1975). On receipt of the call, a dispatch slip is placed on an automatic conveyor and fed to a second set of physicians' assistants responsible for dispatching and tracking the ambulance team (brigade) throughout the city. In larger metropolitan areas, specialized teams will be dispatched in accordance with decisions of the feldshers receiving the call. All brigades check with the central dispatch area after making disposition of each patient. In this manner, the team need not return to the substation of origin prior to the next call. While the chief physician of the Kiev Skoraya was emphatic that the average response time from patient call to ambulance contact with patient was less than 15 minutes, this fact was not uniformly agreed to in our limited contact with the general populace. One university student, for example, who had used the Skoraya on many occasions for his grandmother, noted that it was frequently 30 to 45 minutes before the ambulance arrived and, in his experience, many of the general ambulances did not have two-way radios and therefore had to return to the substation between calls. An unannounced visit to a smaller substation in Kiev confirmed this impression to the extent that the central two-way radio dispatch in the substation was broken on the day we visited. Statistics indicated that the average team serviced seven to nine patients per 12-hour period, which would also be consistent with this longer response time. In the larger metropolitan areas, there are a variety of teams that could potentially respond to a given call. The general ambulance brigade consists of a driver, physician,
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and two feldshers, and comprises 85% of the available unit. The general ambulance itself is a plain but efficiently organized panel truck with a two-way radio, stretcher, emergency lights, splints, oxygen, and aspirator. In addi¬ tion to bandages, tourniquets, venipuncture equipment, antiseptics, and sterile supplies, a standard drug inventory would include epinephrine, cortisone, gluconate calcium,
camphor, caffeine, procaine hydrochloride [Novocaine], strophanthin, and analgesics. Throughout the Soviet Union, there is one ambulance per 10,000 people, as per directories of the Ministry of Health. In Kiev, of a total of 195 vehicles, 70 were routine cars for transportation and 125 were ambulances distributed
between the central station and its nine substations, nine vehicles being the minimum at any substation. Even within metropolitan areas, additional services included air and river transportation where appropriate. Specialty brigades for this city of 1.7 million people included three antimyocardial infarction vehicles, three antitraumatic shock vehicles, one brigade for bleeding problems such as hemophilia or hypofibrinogenemia, and five pediatrie specialty units, three psychiatric and one each for neurol¬ ogy, toxicology, and maternity. The trauma specialty ambulance included additional equipment of dextran, normal human serum albumin, and mannitol as well as equipment for the administration of nitrous oxide-oxygen general anesthesia, halothane [Fluothane], and neuroleptic analgesia. In years past, whole blood was carried on the vehicles, but because its usage was so low and vibration destroyed the red blood cells (RBCs), the Soviets now use plasma expanders exclusively. The antimyocardial infarc¬ tion vehicle is equipped with an ECG, a small portable laboratory with microscope, and defibrillating equipment for the pediatrie specialty vehicles. It should be noted that even within the Skoraya, one of the premiere services of the Soviet health care system, equipment availability and maintenance are chronic prob¬ lems. It was noted above that the unexpected visit to the Kiev substation revealed that the two-way radio was not working. This anecdotal experience was confirmed several times over when, for example, in the town of Sochi, we were shown a specialty cardiac ambulance with the defibrillator missing because it was "out being repaired." Throughout the analysis of the Soviet system, one must be cautious in appraising what is written or prescribed by central planning as opposed to the actual availability and usage patterns on a daily basis. Certainly, the brigades that responded to the two patients previously cited showed ample evidence of rigid quality performance and adequate and well-maintained equipment with an excellent commu¬ nication network. The degree to which this represents "show and tell" can only be evaluated by continued exchange between Soviet and American health profession¬ als. The manpower of the Skoraya team consists of a physi¬ cian with specialty training for ten months beyond medical school. While training varies between specialty brigades, in general, the course consists of first-aid, cardiopulmonary resuscitation, basic principles of anesthesia, diag-
nosis, and management of trauma and heart disease. The esprit is high and in general, the physicians and feldshers remain with the Skoraya for 10 to 20 years. In addition, many physicians "moonlight," as do their American coun¬ terparts, for the emergency medical system affords the young Soviet MD supplemental income by working addi¬
tional and unusual hours. The feldsher (physicians' assistant) undergoes a training program of o% years, three months of which are spent with the Skoraya for those hoping to join the brigade. Because of the honor, the turnover is extremely low. Every five years, the feldsher must take a certifying examination given by the Office of the Ministry of Health in addition to the continuing education courses that many Skoraya feld¬ shers take as often as every six months. It is the function of the dispatch department to relay calls to the nearest substation to the geographic location of the patient. Because of the centralized and nationalized system, the problem does not exist of patients wanting to cross town to a different hospital facility, as it is presumed by patient and professional alike that the nearest available vehicle will respond and take the patient to the closest appropriate hospital. In addition, the dispatcher can monitor the location of all 125 ambulances at any given time and dispatch them directly as they return from one call, bypassing the substation if an urgent need has arisen. The centralized communication network permits rapid mobilization of the emergency medical system for a civil disaster, such as a major fire or train wreck. As was noted in the second case, it is the responsibility of the Skoraya physician to leave the appropriate instructions for follow-up, including record of the emergency care rendered for the patient's normal physician. The Skoraya physician is required to log the time arrived, care delivered, time of departure, and tentative diagnosis. At the national level, statistics are kept at the Sklikosovsky Institute of Emergency Health Care to indicate the competency of diagnostic skills for each Skoraya team. Recent data by the Soviets claim an "8% error" of diagnosis in a sample of 10,125 cases. Clearly, at its optimal level, this evaluation is an important link in quality control. Statistics made available in Kiev indicate that 58% of the patients serviced by the Skoraya were hospitalized and 11% of all cases were secondary to trauma. The director of the Kiev Skoraya indicated that less than 1% of all calls were false alarms, ie, malicious mischief. The exact nature of inappropriate usage is difficult to determine, for philo¬ sophically, the leaders of the Skoraya indicate that any and all calls must be appropriate simply by virture of the call having been made. Other more candid professionals indi¬ cate that up to two thirds of the calls are probably not necessary for the highly specialized nature of the services, the two main problems being drunkenness and chronic complainers with insignificant problems. One Soviet edito¬ rial even suggested a fine of seven dollars each time a patient uses the system incorrectly (The Literary Gazette,
May 28, 1975)!
An additional benefit of the centrally planned emer¬ gency medical system in metropolitan areas is the more
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efficient
use of the hospital-based emergency services and outpatient departments. Each substation is located near a general hospital with its own emergency receiving room. Kiev, like most large metropolitan areas, has addi¬ tional outpatient units established primarily for the treat¬ ment of minor injuries such as lacerations, fractures, contusions, etc. During nights and weekends, certain hospi¬ tals will be designated as receiving centers for the entire city. Thus, only three of ten hospitals might need an entire
trauma
staff for 24 hours, in contradistinction to the situation in the United States, where each emergency room tends to operate independently. This pattern in the Soviet Union is clearly dependent on the fact that the patient has no choice of the hospital facility because the system is "uniform." The trauma outpatient department I visited in Sochi, a coastal resort town on the Black Sea, was the busiest health care facility witnessed during the entire visit. The mix of patients with anything from Colles fracture to pediatrie diarrhea closely parallels that seen in United States community emergency rooms. Each physician will see 50 patients per 12-hour shift in these Soviet emergency wards. Cost effectiveness is a difficult principle to apply to medical care in the Soviet Union but must be answered when translating the experience of the Skoraya to the United States. In Sochi, as in Kiev, it was stated that the average brigade responded to between seven and nine calls per 12-hour shift. Such low utilization of less than one patient-visit per hour can only survive with a large, relatively inexpensive, professional work force. Even within the Soviet system, it is dramatic to contrast eight calls per 12 hours with the 50 patients seen by the physician who is hospital or clinic based. Manpower utilization comes to an even more difficult problem when considering the specialty brigades when a cardiologist or skilled anesthe¬ siologist is seeing so few patients. While the principle of bringing the physician to the patient is admirable, there is no good controlled study to indicate that the overall morbidity and mortality of illnesses such as myocardial infarction or fractured hip is actually lowered by the presence of a physician vs a skilled emergency medical technician. One must be careful not to compare the best of the Skoraya with the worst of the American emergency nonsystem, where on occasion, untrained "moonlighting" personnel respond to critical medical emergencies. In Kiev, it was stated that of 1,084 patients brought by the Skoraya to the hospital with proven myocardial infarctions, 15 had been successfully resuscitated enroute, while another 31 died between the time they were picked up and delivered at the hospital. Comparable statistics for well-trained US emergency medical teams are needed to fully evaluate the necessity of physician staffing on the ambulance. Sochi, a resort town of 120,000 people, is a central administrative area serving 143 km of coastline along the Black Sea, ringed by the Balkan Mountains. Because of the linear spread, there are six stations serving this area, each its own dispatching center. This pattern is more typical of the rural nonmetropolitan areas. Additional facilities avail¬ able included helicopter service because of the distance
Because of the low population density, many of the stations in rural areas have multispecialty brigades, not specific cardiac or trauma units. These multispecialty teams differ from the general ambulances of metropolitan areas in that the physicians and feldshers have been continuing education in cardiology, anesthesia, and trauma
problem.
management. A related system, the Neotlozhnaya, deserves brief are vehicles primarily used for patient/ physician transportation to and from the district outpa¬ tient departments. In many instances, the physician on duty is driven to the patient's home, where care is rendered and disposition is made. Because a single outpatient department will serve 40,000 individuals with only one or two physicians on call at night, the response time is slow and therefore precipitates activation of the Skoraya when the Neotlozhnaya is more appropriate. It is this fact that the proponents of unification cite when encouraging these two entities to merge to a single emergency care system. Proponents of separation note the availability of the clinic record, and therefore, continuity of care is improved by the clinic-based Neotlozhnaya. At the moment, confici still comment. These
persists (The Literary Gazette, May 28, 1975). Comment
What are the lessons to be learned? It seems quite clear that the central organization and planning of the Skoraya incorporate logic and reason for the distribution of the essential service. Under ideal circumstances, there is a single unified communication network with highly qual¬ ified (in some cases, specialized) teams of professionals, including physicians capable of reaching the patient in less than 15 minutes with appropriate diagnostic aid for adequate and prompt disposition. Uniformity permits planning of hospital emergency room staffing and geographic distribution of patient load. Continuing educa¬ tion, performance evaluation, and quality control over professional and support services are all major strengths of the Skoraya, in contradistinction to the often fragmented system in both urban and rural America. Obviously, such a system necessitates nationalization of medical care, for neither payment mechanism nor patient preference are factors under Soviet medicine. Even so, central communication and updated knowledge of the distribution of emergency medical resources and patients is a clearly appropriate lesson. The Soviet experience has yet to prove conclusively that physician staffing of emer¬ gency vehicles is really appropriate to the maximum delivery of high-quality care. So long as people are human, use the best system inappropriately, and our medical manpower remains a precious resource, health profes¬ sionals in the United States must continue to revise and create their own unique emergency medical systems. Reference 1. Messel MA: Urban Emergency Medical Service of the City of Leningrad, publication (NIH) 75-671. US Dept of Health, Education and Welfare, 1975.
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Skoraya Randolph
B.
Reinhold,
MD
\s=b\ The Emergency Medical Service of the Soviet Union as witnessed in 1975 shows evidence of central communication, organization, and planning. The Skoraya Pomosch has developed into an elite medical corps with general and multispecialty emergency teams that include well-trained physicians and physicians' assistants, with emphasis on bringing medical care to the patient at the site of the emergency. At its optimum, it is an elite corps that is uniformly available and capable of response to minor emergencies as well as major community disasters. Chronic problems of inadequate equipment and inappropriate use of the system continue to plague the Skoraya as they do other aspects of Soviet medicine. Certain qualities, such as the central communication network, are probably adaptable to the United States' situation, but in general, we must continue to improve and devise our own emergency medical system.
(Arch Surg 111:528-531, 1976)
At 11:45 am, a 40-year-old male pedestrian was struck by Il a speeding automobile and thrown 12 meters from the road in the nearby bushes. A passerby ran to the
depositing dispatching later, the special¬
nearest public phone, dialed "03" without money, and notified the central ambulance
station of the accident. Ninety seconds ized trauma ambulance brigade left the station enroute to the scene of the accident—no sirens, only a flashing white light. There was no police escort. Traveling a distance of 3 km in approximately three minutes, the ambulance arrived at the scene at 11:49 am. As the physician and two Accepted
publication Jan 15, 1976. Department of Surgery, Harvard Medical School, Boston. Reprint requests to 185 Dudley St, Roxbury, MA 02119 (Dr Reinhold). From the
for
assistants examined the man lying by the roadside, the driver learned that the pedestrian had been jaywalking when struck by the car on his left side. The patient was conscious but complaining of pain on the left side of the chest with no other apparent major injury. As the driver called ahead on his two-way radio to the nearest hospital, 7.5 km away, the emergency medical team moved the patient by stretcher to the back of the waiting ambulance. Further examination by the physician determined that the patient's pulse was fast and thready; his blood pressure was 80/40 mm Hg. The diagnosis was a fracture of the lower part of the left side of the rib cage with a possible rupture of the spleen. Because of the hypotension, a largebore intravenous needle was inserted into the left antecu¬ bital vein and an infusion of dextran blood substitute was begun. As soon as the needle was secured, the ambulance departed for the nearby hospital, arriving six minutes later, at which time the patient was admitted. Subsequent follow-up confirmed the diagnosis of fractured ribs 9, 10, and 11 on the left side with a question of ruptured
spleen.
thereafter, another call was processed at the dispatch station, indicating that a 48-year-old woman telephone operator was complaining of shortness of breath. Several minutes later, a special cardiology team Soon central
departed and arrived at the factory 0.8 km away. The cardiologist quietly but efficiently took the patient's history and performed a physical examination, using an ancient rigid tubular stethoscope (one end against the patient's chest, the other to the physician's ear). While the female physician was completing her examination, one of the physician's assistants drew a blood sample for white blood cells (WBCs) and prothrombin time while a second
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assistant performed an electrocardiogram. As the results of the ECG and other tests were normal, the cardiologist concluded that the case was primarily cardiac neurosis and administered an injection of a mild tranquilizer. Within 20 minutes from the time of arrival, the patient was resting comfortably and the team departed, leaving a copy of the medical report and ECG with written instructions for the patient to be taken to the family physician in 48 hours for
follow-up.
INTRODUCTION
One of the prime foci in evaluating primary health care of the Soviet Union during an exchange visit of June 1975 with other American physicians was analysis of the Skoraya Pomosch, or Emergency Medical Service. Both of the previously mentioned cases were observed in their entirety during our exchange visit in the city of Kiev. Though there is some evidence to suggest that the excel¬ lence of care we observed is not uniform, there is much to learn from the organization and planning of the Skoraya. It is not my intention to review the available literature, but rather to relate direct observations and opinions. Much of the available literature originates from within the Soviet Union and is, therefore, often not a fair critique of both the strengths and weaknesses. The recent publication, Urban Emergency Medical Service of the City ofLeningrad, by the Department of Health, Education and Welfare1 is a good resource document describing in detail the structure, staff¬ ing, organization, equipment, training, and evaluation of the urban Skoraya. We can best understand the workings of the Skoraya system by tracing the flow of information, personnel, and equipment, as well as the other available resources in the two clinical cases before sited. Following a brief historical note, I shall attempt to trace theorization behind these two patients, pointing out strengths, efficiencies, and short¬
comings
as
they occur. Skoraya volunteer service, the Skoraya
History
of the
was Begun in 1902 as a nationalized in 1917, as were all medical services in the Union of Soviet Socialist Republics (USSR). The Skoraya is free of charge at the point of access and is centrally organized with the constant format from large urban metropolis to small rural village, as is typical of most health care planning in the Soviet Union. Since 1917, there has been progressive specialization of the Skoraya staff to the point where it is now one of the elite medical corps of the USSR. In the early part of the 20th century, the service was concerned with rapid patient transportation, but in recent years it has placed increased emphasis on initiating patient treatment at the site of initial contact.
The
Skoraya System
Critical to the functioning of the Skoraya is its inter¬ locking communications network of telephones and twoway radio. From any public or private telephone in the entire nation, the dialing of "03" (no coin required) links the caller with the central regional dispatch station. In
Kiev, there is one central station and nine substations, each located in close proximity to the metropolitan general hospital of approximately 300 beds. Subsequent sub¬ stations are built in accordance with housing patterns. In addition, in Kiev, a central trauma hospital of approxi¬ mately 1,000 beds is presently being designed. This pattern is typical of metropolitan organization throughout the Soviet Union. The receiving area for "03" calls is manned by specially trained physicians' assistants (feldsher) around the clock. Eight such feldshers receive calls under the supervision of a staff physician at the Kiev central station. These feld¬ shers record the time of the call, name and address, and special information regarding the exact location of the patient, as well as the chief complaint. In some cases, the patient might be referred to his family physician at the district outpatient department, but in general, the Skoraya is responsible for answering all calls received. Proper utilization of this emergency medical service by the popu¬ lation is one of the critical issues presently facing Soviet medicine. The Skoraya is designed as an immediate response system to be distinguished from the Neotlozhnaya, or urgent medical assistance. The Neotlozhnaya is based at the district outpatient department and is to be used for minor calls, particularly those in which knowledge of the patient's record at the local clinic level would be helpful. Confusion regarding the use of these two services has led to much discussion and some attempts at centralization and unification {The Literary Gazette, May 28, 1975). On receipt of the call, a dispatch slip is placed on an automatic conveyor and fed to a second set of physicians' assistants responsible for dispatching and tracking the ambulance team (brigade) throughout the city. In larger metropolitan areas, specialized teams will be dispatched in accordance with decisions of the feldshers receiving the call. All brigades check with the central dispatch area after making disposition of each patient. In this manner, the team need not return to the substation of origin prior to the next call. While the chief physician of the Kiev Skoraya was emphatic that the average response time from patient call to ambulance contact with patient was less than 15 minutes, this fact was not uniformly agreed to in our limited contact with the general populace. One university student, for example, who had used the Skoraya on many occasions for his grandmother, noted that it was frequently 30 to 45 minutes before the ambulance arrived and, in his experience, many of the general ambulances did not have two-way radios and therefore had to return to the substation between calls. An unannounced visit to a smaller substation in Kiev confirmed this impression to the extent that the central two-way radio dispatch in the substation was broken on the day we visited. Statistics indicated that the average team serviced seven to nine patients per 12-hour period, which would also be consistent with this longer response time. In the larger metropolitan areas, there are a variety of teams that could potentially respond to a given call. The general ambulance brigade consists of a driver, physician,
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and two feldshers, and comprises 85% of the available unit. The general ambulance itself is a plain but efficiently organized panel truck with a two-way radio, stretcher, emergency lights, splints, oxygen, and aspirator. In addi¬ tion to bandages, tourniquets, venipuncture equipment, antiseptics, and sterile supplies, a standard drug inventory would include epinephrine, cortisone, gluconate calcium,
camphor, caffeine, procaine hydrochloride [Novocaine], strophanthin, and analgesics. Throughout the Soviet Union, there is one ambulance per 10,000 people, as per directories of the Ministry of Health. In Kiev, of a total of 195 vehicles, 70 were routine cars for transportation and 125 were ambulances distributed
between the central station and its nine substations, nine vehicles being the minimum at any substation. Even within metropolitan areas, additional services included air and river transportation where appropriate. Specialty brigades for this city of 1.7 million people included three antimyocardial infarction vehicles, three antitraumatic shock vehicles, one brigade for bleeding problems such as hemophilia or hypofibrinogenemia, and five pediatrie specialty units, three psychiatric and one each for neurol¬ ogy, toxicology, and maternity. The trauma specialty ambulance included additional equipment of dextran, normal human serum albumin, and mannitol as well as equipment for the administration of nitrous oxide-oxygen general anesthesia, halothane [Fluothane], and neuroleptic analgesia. In years past, whole blood was carried on the vehicles, but because its usage was so low and vibration destroyed the red blood cells (RBCs), the Soviets now use plasma expanders exclusively. The antimyocardial infarc¬ tion vehicle is equipped with an ECG, a small portable laboratory with microscope, and defibrillating equipment for the pediatrie specialty vehicles. It should be noted that even within the Skoraya, one of the premiere services of the Soviet health care system, equipment availability and maintenance are chronic prob¬ lems. It was noted above that the unexpected visit to the Kiev substation revealed that the two-way radio was not working. This anecdotal experience was confirmed several times over when, for example, in the town of Sochi, we were shown a specialty cardiac ambulance with the defibrillator missing because it was "out being repaired." Throughout the analysis of the Soviet system, one must be cautious in appraising what is written or prescribed by central planning as opposed to the actual availability and usage patterns on a daily basis. Certainly, the brigades that responded to the two patients previously cited showed ample evidence of rigid quality performance and adequate and well-maintained equipment with an excellent commu¬ nication network. The degree to which this represents "show and tell" can only be evaluated by continued exchange between Soviet and American health profession¬ als. The manpower of the Skoraya team consists of a physi¬ cian with specialty training for ten months beyond medical school. While training varies between specialty brigades, in general, the course consists of first-aid, cardiopulmonary resuscitation, basic principles of anesthesia, diag-
nosis, and management of trauma and heart disease. The esprit is high and in general, the physicians and feldshers remain with the Skoraya for 10 to 20 years. In addition, many physicians "moonlight," as do their American coun¬ terparts, for the emergency medical system affords the young Soviet MD supplemental income by working addi¬
tional and unusual hours. The feldsher (physicians' assistant) undergoes a training program of o% years, three months of which are spent with the Skoraya for those hoping to join the brigade. Because of the honor, the turnover is extremely low. Every five years, the feldsher must take a certifying examination given by the Office of the Ministry of Health in addition to the continuing education courses that many Skoraya feld¬ shers take as often as every six months. It is the function of the dispatch department to relay calls to the nearest substation to the geographic location of the patient. Because of the centralized and nationalized system, the problem does not exist of patients wanting to cross town to a different hospital facility, as it is presumed by patient and professional alike that the nearest available vehicle will respond and take the patient to the closest appropriate hospital. In addition, the dispatcher can monitor the location of all 125 ambulances at any given time and dispatch them directly as they return from one call, bypassing the substation if an urgent need has arisen. The centralized communication network permits rapid mobilization of the emergency medical system for a civil disaster, such as a major fire or train wreck. As was noted in the second case, it is the responsibility of the Skoraya physician to leave the appropriate instructions for follow-up, including record of the emergency care rendered for the patient's normal physician. The Skoraya physician is required to log the time arrived, care delivered, time of departure, and tentative diagnosis. At the national level, statistics are kept at the Sklikosovsky Institute of Emergency Health Care to indicate the competency of diagnostic skills for each Skoraya team. Recent data by the Soviets claim an "8% error" of diagnosis in a sample of 10,125 cases. Clearly, at its optimal level, this evaluation is an important link in quality control. Statistics made available in Kiev indicate that 58% of the patients serviced by the Skoraya were hospitalized and 11% of all cases were secondary to trauma. The director of the Kiev Skoraya indicated that less than 1% of all calls were false alarms, ie, malicious mischief. The exact nature of inappropriate usage is difficult to determine, for philo¬ sophically, the leaders of the Skoraya indicate that any and all calls must be appropriate simply by virture of the call having been made. Other more candid professionals indi¬ cate that up to two thirds of the calls are probably not necessary for the highly specialized nature of the services, the two main problems being drunkenness and chronic complainers with insignificant problems. One Soviet edito¬ rial even suggested a fine of seven dollars each time a patient uses the system incorrectly (The Literary Gazette,
May 28, 1975)!
An additional benefit of the centrally planned emer¬ gency medical system in metropolitan areas is the more
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efficient
use of the hospital-based emergency services and outpatient departments. Each substation is located near a general hospital with its own emergency receiving room. Kiev, like most large metropolitan areas, has addi¬ tional outpatient units established primarily for the treat¬ ment of minor injuries such as lacerations, fractures, contusions, etc. During nights and weekends, certain hospi¬ tals will be designated as receiving centers for the entire city. Thus, only three of ten hospitals might need an entire
trauma
staff for 24 hours, in contradistinction to the situation in the United States, where each emergency room tends to operate independently. This pattern in the Soviet Union is clearly dependent on the fact that the patient has no choice of the hospital facility because the system is "uniform." The trauma outpatient department I visited in Sochi, a coastal resort town on the Black Sea, was the busiest health care facility witnessed during the entire visit. The mix of patients with anything from Colles fracture to pediatrie diarrhea closely parallels that seen in United States community emergency rooms. Each physician will see 50 patients per 12-hour shift in these Soviet emergency wards. Cost effectiveness is a difficult principle to apply to medical care in the Soviet Union but must be answered when translating the experience of the Skoraya to the United States. In Sochi, as in Kiev, it was stated that the average brigade responded to between seven and nine calls per 12-hour shift. Such low utilization of less than one patient-visit per hour can only survive with a large, relatively inexpensive, professional work force. Even within the Soviet system, it is dramatic to contrast eight calls per 12 hours with the 50 patients seen by the physician who is hospital or clinic based. Manpower utilization comes to an even more difficult problem when considering the specialty brigades when a cardiologist or skilled anesthe¬ siologist is seeing so few patients. While the principle of bringing the physician to the patient is admirable, there is no good controlled study to indicate that the overall morbidity and mortality of illnesses such as myocardial infarction or fractured hip is actually lowered by the presence of a physician vs a skilled emergency medical technician. One must be careful not to compare the best of the Skoraya with the worst of the American emergency nonsystem, where on occasion, untrained "moonlighting" personnel respond to critical medical emergencies. In Kiev, it was stated that of 1,084 patients brought by the Skoraya to the hospital with proven myocardial infarctions, 15 had been successfully resuscitated enroute, while another 31 died between the time they were picked up and delivered at the hospital. Comparable statistics for well-trained US emergency medical teams are needed to fully evaluate the necessity of physician staffing on the ambulance. Sochi, a resort town of 120,000 people, is a central administrative area serving 143 km of coastline along the Black Sea, ringed by the Balkan Mountains. Because of the linear spread, there are six stations serving this area, each its own dispatching center. This pattern is more typical of the rural nonmetropolitan areas. Additional facilities avail¬ able included helicopter service because of the distance
Because of the low population density, many of the stations in rural areas have multispecialty brigades, not specific cardiac or trauma units. These multispecialty teams differ from the general ambulances of metropolitan areas in that the physicians and feldshers have been continuing education in cardiology, anesthesia, and trauma
problem.
management. A related system, the Neotlozhnaya, deserves brief are vehicles primarily used for patient/ physician transportation to and from the district outpa¬ tient departments. In many instances, the physician on duty is driven to the patient's home, where care is rendered and disposition is made. Because a single outpatient department will serve 40,000 individuals with only one or two physicians on call at night, the response time is slow and therefore precipitates activation of the Skoraya when the Neotlozhnaya is more appropriate. It is this fact that the proponents of unification cite when encouraging these two entities to merge to a single emergency care system. Proponents of separation note the availability of the clinic record, and therefore, continuity of care is improved by the clinic-based Neotlozhnaya. At the moment, confici still comment. These
persists (The Literary Gazette, May 28, 1975). Comment
What are the lessons to be learned? It seems quite clear that the central organization and planning of the Skoraya incorporate logic and reason for the distribution of the essential service. Under ideal circumstances, there is a single unified communication network with highly qual¬ ified (in some cases, specialized) teams of professionals, including physicians capable of reaching the patient in less than 15 minutes with appropriate diagnostic aid for adequate and prompt disposition. Uniformity permits planning of hospital emergency room staffing and geographic distribution of patient load. Continuing educa¬ tion, performance evaluation, and quality control over professional and support services are all major strengths of the Skoraya, in contradistinction to the often fragmented system in both urban and rural America. Obviously, such a system necessitates nationalization of medical care, for neither payment mechanism nor patient preference are factors under Soviet medicine. Even so, central communication and updated knowledge of the distribution of emergency medical resources and patients is a clearly appropriate lesson. The Soviet experience has yet to prove conclusively that physician staffing of emer¬ gency vehicles is really appropriate to the maximum delivery of high-quality care. So long as people are human, use the best system inappropriately, and our medical manpower remains a precious resource, health profes¬ sionals in the United States must continue to revise and create their own unique emergency medical systems. Reference 1. Messel MA: Urban Emergency Medical Service of the City of Leningrad, publication (NIH) 75-671. US Dept of Health, Education and Welfare, 1975.
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