Sep 3, 1995 - We outline recent developments in the delivery of emergency medicine and prehospital care in the Republic of Turkey. Residency training in ...
INTERNATIONAL REPORTS/CONCEPTS
Emergency Medical Care in Turkey: Current Status and Future Directions II
From the Department of Emergency Medicine, Ronald Reagan Institute of Emergency Medicine, George Washington University, Washington DC; and the Department of Emegency Medicine, Dokuz Eylul University, Izmih Turkey.
Kevin A Bresnahan, MD John Fowler, MO, FACEP
We outline recent developments in the delivery of emergency medicine and prehospital care in the Republic of Turkey. Residency training in emergency medicine is in its infancy in Turkey, and the presence of specialists will heJp define the future of emergency medical care in this country. [Bresnahan KA, Fowler J: Emergency medical care in Turkey: Current status and future directions. Ann EmergMed September 1995;26:357-360.]
Recdved for publication April I8, 199~. Acceptedfor publication May 9, I994. Dr Bresnahan was supported by a fellowship grantfrom the Ronald Reagan Institute of Emergency Medicine. Copyright © by the American College of Emergency Physicians.
INTRODUCTION The modern Republic of Turkey emerged in the 1920s after victory over a consortium of World War I allies. Since then, Turkey's population and economy have grown rapidly, and its medical system is facing pressures similar to those faced by other developing nations. The rapid introduction of new technology and medical knowledge creates a continuous push to modernize that can easily overtax available resources. The challenge Turkey now faces is to integrate these changes intelligently into an evolving medical care delivery system. Although many specialties are highly developed in Turkey (lasers, magnetic resonance imaging machines, lithotripters, and transplantation are found in the three largest cities), prehospital and emergency medical care are in their infancy. For example, the first program to train emergency medical technicians (for ambulance and emergency department work) was begun in late 1993, and Turkey's first emergency medicine residency was started in the summer of 1994.
HEALTH POLITICS When modern Turkey emerged in the 1920s, it adopted a strong central government. The strength of this government is clearly evident in the day-to-day provision of Turkey's health care. Virtually all hospitals are run directly by the government, by universities (which are
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government funded), or by one of a small number of specific government insurance programs. Very few private hospitals exist. Because all tax money goes to the central government and no local or regional taxation is allowed, all decisions regarding disbursement of health care funds are made in the capital, Ankara. As a result, communities cannot expand hospitals, hire new personnel, or modernize ambulance services without central approval and money. As one might anticipate, the bureaucracy is often inefficient and unreliable, and it can be insensitive to specific local needs. A positive byproduct of the strong central government is an extensive network of public health clinics. In Izmir (Turkey's third-largest city, with a population of 2.5 million), for example, 473 physicians staff 80 such clinics, which operate during business hours. The government clinics supply prenatal care, immunizations, and very basic medical care. They are typically equipped with microscopes, centrifuges, otoscope/ophthalmoscopes, and suturing equipment. The existence of these clinics, coupled with the availability of most medications without prescription, makes emergency department visits for minor problems less frequent than in the United States. MEDICAL EDUCATION
An overview of Turkey's medical education system is necessary to understand emergency medicine as it is currently practiced. At present there are 22 active medical schools, which graduate approximately 5,000 medical students each year. Medical education is a 6-year undertaking beginning at about age 18, after the equivalent of a high school education. The first 3 years of medical school are spent in the classroom and include some liberal-arts instruction in addition to basic sciences. The fourth year is spent observing on wards and attending lectures on basic clinical topics. The fifth year is composed of 3-week rotations through medical and surgical subspeciahies. The final year is a rotating internship consisting of 2-month block rotations through internal medicine, general surgery, obstetrics-gynecology, pediatrics, psychiatry, and community health. A portion of the surgery rotation is usually spent in the ED. After finishing medical school, each new physician must complete 1 year of service as a general practitioner in a rural health clinic or small government hospital as a prerequisite to practicing in the community. No national form of broad examination or licensure system exists.
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For those who desire more than a general community practice, about 2,000 entry-level residency positions are available each year. Securing of a residency position is based solely on a standardized examination score, without an allowance for interviewing, medical school grades, or letters of recommendation. This examination is given twice a year and may be taken more than once. In the fall of 1993, 22,000 physicians took the examination to compete for the 2,000 first-year residency positions. Currently, 55,000 physicians (25% residency trained) and 40,000 nurses are practicing in Turkey, serving a population of 60 million. The large group of medical school graduates without residency training staff nearly all of the country's EDs. As government employees, many of these emergency physicians endure the fiat salary of $300 to $400 a month to receive social security benefits. They receive no additional compensation per patient seen or procedure performed. Emergency physicians with sufficient capital often earn additional income in their off hours by opening private OffiCeS. CURRENT ED CARE The organization of the EDs in lzmir, which we use to exemplify emergency care in Turkey, varies according to
the physical size of the hospital, patient volume, and, especially, staffing. At Dokuz Eylul University Hospital, where Turkey's first emergency medicine residency training began, eight final-year medical students, two off-service first-year residents, and three nurses care for 30 to 45 patients during a typical day. The students work 24-hour shifts every 3 days during their 2-month rotation. A single faculty attending physician is responsible for patient care, medical education, and administrative issues, leaving the students and residents unsupervised for large parts of the day. The residents and students seek help from consultants (senior residents in other departments) in about 70% of cases. Only 30% of patients are seen and released by the primary student/resident team. A second university hospital across town, Ege University, operates quite differently because many residency-trained physicians have been retained by this older and much larger hospital. At the front desk, a nurse triages the patient to an appropriate area in the ED. Residency-trained specialists (senior residents at night) from general surgery, orthopedics, neurosurgery, otolaryngology, anesthesiology, internal medicine, and cardiology are assigned to the ED 24 hours a day to see patients sent to their area. Because no single physician is responsible for a patient's
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overall care, problems occur when a patient has a disease process involving more than one specialty. The ED director is a general surgeon, and the department has its own operating room, currently unused only because of a lack of nursing and technical staff. The third hospital in Izmir, a large government hospital, has an eight-bay area for initial evaluation by a general practitioner. About 20% of patients are treated and released from this initial area. The other patients are sent to various rooms along a large hall that are staffed by residency-trained physicians and senior residents from various specialties. All patient information, laboratory results, and physicians' notes are recorded by hand on a single 5x8-inch card. The city Children's Hospital has several rooms that function similarly to those in the government hospital's ED. The initial triage/routing decision, however, is made by a registration clerk or, occasionally, a nurse. The "emergency room" has two stretchers on which the pediatric resident evaluates very ill children only. It functions exclusively as a portal to the operating room or ICU. In smaller (50- to 100-bed) hospitals around lzmir, the "emergency rooms" (with two to three stretchers, a defibrillator, ECG machine, laryngoscope, ophthalmoscope/ otoscope, and suturing materials) are staffed by a physician and a nurse. No charting is done; the date, patient's name and age, diagnosis, and disposition are recorded in a ledger book. As the above examples illustrate, the current practice of emergency medicine in Turkey must overcome many shortcomings. The care given by current "emergency" physicians tends to be cursory and focused on directing the patient to a specialist, who may be located in the ED or elsewhere in the hospital. As a result, emergency care is often delayed until the arrival of the definitive care provider or consultant. Responsibility for the patient is often unclear when a patient presents with multiple problems. Specialty training in emergency medicine may help revolutionize this system. It is hoped that trained emergency physicians will obviate routine consultation in many cases, thereby facilitating the expedient resuscitation of the critically ill, and that they will add organization to the care of patients with multisystem problems. However, these physicians will have to operate within an already well-established infrastructure, and it remains to be seen whether a small number of specialty-trained physicians can significantly alter emergency medical care in this country.
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CURRENT PREHOSPITAL CARE
Turkey's emergency medical service system also is being greatly affected by the ongoing development of emergency medicine. Izmir has a fairly typical system. There are seven public health department ambulances in the city, each staffed by one general physician (without residency training) and a single untrained driver (usually recruited from the public bus system because these drivers are familiar with the small back streets of the older neighborhoods). No personnel or equipment standards exist for the public ambulances, although legal standards for private ambulances were passed in 1993. Private ambulances, usually used for hospital-to-home transfers, are staffed by drivers only. Of the seven public health department ambulances, which are divided among four ambulance stations, five are sparsely equipped with oxygen, a variety of spIints and bandages, and some basic airway equipm.ent. Backboards and cervical collars are generally absent and are rarely used. The remaining two ambulances, which were recently acquired, are modern and well equipped, with defibrillators and even otoscope/ophthalmoscopes and fetal Doppler monitors. More of these modern ambulances will soon replace their outdated prototypes, and the number of city ambulance stations will be expanded to 10. Ambulance personnel admit that it is rare to reach the scene of a traffic accident before patients have been removed from the scene by taxis and passing private vehicles. Although a central dispatch system does exist, ambulances must contend with the notoriously congested traffic. The resulting response times are understandably long, and this may help to explain the popularity of taxis in prehospital transport. It is hoped that the additional ambulance stations will help rectify this situation~ The level of education of the ambulance staff is an area of active concern to the small emergency medicine community. Neither the Ministry of Health nor any physician organizations (eg, a heart association) have made any effort to produce or import packaged resuscitation courses (eg, basic life support, advanced cardiac life support) for widespread dissemination. However, Turkey's first emergency medical technician class is now in session, and within a few years at least some ambulance services will have personnel specifically trained in prehospitaI care. A 1-week refresher course for the ambulance physicians was offered in April 1994, and a shorter course for the drivers will be carried out in the near future.
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The two new ambulances represent a strong start toward modernizing emergency medical service (EMS). Communications equipment necessary for hospital notification and medical control is being installed. Better-trained prehospital care providers using adequate equipment may help ensure better outcomes in persons requiring emergency aid. Interhospital transfer practices are also being examined. Turkey's current insurance system typically specifies a hospital at which care may be provided for a patient. Collecting compensation from a hospital with a different type of insurance (eg, if the patient was transported to the closest hospital) is often difficult. This has created a situation in which many patients, including the critically ill, are transferred from one hospital to another for financial reasons. Stories of deaths occurring during or shortly after such transfers abound. Efforts are under way to establish patient transfer protocols (such as calling the receiving hospital before sending a patient) under the auspices of Izmir's local health department. Improved communication and the establishment of standards for ambulance personnel and equipment should greatly improve the safety of these patient transports.
Reprint no. 47/1/66628 Address for reprints: KevinA Bresnahan,MD GeorgeWashingtonUniversity Departmentof EmergencyMedicine BuildingVV 2140 PennsylvaniaAvenue Northwest Washington DO20037
EMERGENCY MEDICINE AS A NEW SPECIALTY
The development of emergency medicine as a specialty in Turkey could change the delivery of emergency care in many ways. First, as EDs modernize, emergency physicians should practice and teach comprehensive care without the delays inherent in consultant-based systems. Second, emergency physicians should guide the development of Turkey's EMS system. However, how a small number of emergency physicians will be able to affect the current, well-established infrastructure remains to be seen. The residency program that began in the summer of 1994 at Dokuz Eylul University faces many challenges. The administrative and financial decision making rests with the Ministry of Health and the Higher Educational Council in Ankara, not with the university or any specialty board. For this reason, change is a slow and unreliable process. The four pioneer residents will begin without the benefit of a specialty board or standard curriculum guidelines. As more programs begin to form, we hope that a somewhat standardized educational experience will evolve and that it will encompass all of the skills needed to practice this challenging specialty.
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