1. 1 TRACK H Developing EMS in Bulgaria and Promoting Emergency Medicine as an Independent Specialty Dr. Assen Geshev - Center for Emergency Medicine and Accidents - Stara Zagora, Bulgaria Prof. M. Milanov MD – National Institute for EM – Sofia Maxim Gaidev MD – Ministry of Health

2. 2 Bulgaria is situated in the south - east part of Europe, and in the eastern part of the Balkan Peninsular. Country information

3. 3 General Information Territory - 110 993,6 km2 Population - 7 973 671 Capital - Sofia Official language - Bulgarian Political system - Parliamentary Republic Population - Demographic data: (01.03.2001): Population - 7 973 671 Men - 3 888 440 Population in towns - 5 500 695 Population growth - (%) – 5,1 Socio-economics - The economy in 2001 Actual growth of GDP (%) 5,8 GDP (thousand Lvs) 25 453 649 GDP per capita (USD) 1459 Budget surplus (% GDP) - 1,1

4. 4 Country information Burden of disease Life expectancy – 71.5 years Major causes of morbidity and mortality Ischemic heart disease and Cerebrovascular disease Health care system GPs – all over the country Regional hospitals with basic wards only and small number of beds 28 county hospitals 5 university hospitals Several centers of national significance Financing –by state budget and by NHIF, a small number of private hospitals and medical centers Medical education 5 Medical Faculties 6 years of study 4-5 years residency programme according to specialty Medical Specialty Board certification mechanism - still not introduced

5. 5 EM specialty status In 1996 Emergency Medicine is declared an independent specialty by Ministry of Health. A national residency programme based in the National Institute of Emergency Medicine was developed and carried out in five Academic Medical Centers The first admission exams were carried out in 1997. The duration of the programme is four years. During this time the resident has to pass 8 theoretical terms with an exam at the end of each. Final specialty exam by the National Examination Committee at the end of the residency programme Special attention is paid to anesthesiology and intensive care, cardiology, toxicology, pediatrics and surgery.

6. 6 Residency Programme in EM Anesthesia and Intensive Care 9 weeks Pediatrics 9 weeks Surgery8 weeks Cardiology7 weeks Neurology and Neurosurgery5 weeks Toxicology4 weeks Orthopedics and Traumatology4 weeks Obstetrics and Gynecology4 weeks Pulmonology4 weeks Psychiatry 1 week Ophthalmology2 weeks Organization of EM1 week Urology 2 weeks Burns2 weeks Gastroenterology1 week Total practice 64 weeks

7. 7 Bulgarian Association of EM Physicians In 1999 Bulgarian Association of EM Physicians was founded The main goals of the association are: To unite all the emergency physicians To work on the public image of EM To promote standard protocols in EM To support physicians in their qualification and scientific research To support public education and training in EM To help international collaboration in EM

8. 8 EM System information Both Pre-hospital and In-hospital emergency care is provided by 28 CEMA. Emergency care is a state policy and is totally funded by Ministry of Health. At present time the national system for Emergency Medical Care consists of: 28 centers for emergency medicine 1507 doctors and 2532 nurses 186 branches for emergency medicine 92 mobile intensive care units 251 mobile medical units 50 transport units 50 emergency departments 136 emergency sectors

9. 9 EM System information Structure of CEMA administrative unit dispatch center = regional coordination center emergency department mobile intensive care units mobile medical units transport units

10. 10 Dispatch Center (regional coordination center) It is based in the administrative center of the county. It has a computerized system for registering and recording the phone calls on the unified emergency number 150 and creating a data base of all missions on which mobile units are sent. Radiocommunication system was at first introduced. Through the years with the development of mobile technologies, and having in mind the geographic characteristics of the country the system was doubled by GPS with voice modules providing bi-directional communication. Thus the communications between ambulances, emergency departments and dispatch centers became safer. The dispatchers in these centers are nurses supervised by a physician 24 hours a day. Neither special training or requirements are needed for the dispatchers, nor any protocols are followed.

11. 11 Mobile units are three types mobile intensive care unit – crew - consist of a physician, a nurse and a driver. qualification - both the physician and the nurse have passed courses for ACLS, APLS and ATLS. The driver has accomplished a course of BLS and helps the medical staff. equipment - the ambulances are large vans, equipped with standard resuscitation drugs, cervical collars, backboards, monitors, defibrillators, perfusion pumps, respirators and communication devices. The mean response time for such a unit is 3 to 9 minutes. These units are usually sent to traffic and industrial accidents or to patients at high risk.

12. 12 Mobile units are three types mobile medical unit crew - consists of a physician and a driver. qualification - the physician has passed courses for ACLS, APLS and ATLS and the driver has accomplished a course of BLS and helps the medical staff. equipment - the ambulances have the same design and are equipped as mobile intensive care units. These units are dispatched to patients who are not in life threatening situation and resuscitation won’t be needed. The mean response time for such a unit is 6 to 12 minutes.

13. 13 Mobile units are of three types transport unit crew–a driver who has accomplished a course of BLS obligations - provides emergency transport of bioproducts and blood, and specialists between hospitals.

14. 14 Emergency Department It is a part of the Emergency Center and not of the hospital. The emergency departments can use the diagnostic facilities of the hospital – laboratory, X-ray, CT scanner. In major cities these departments usually have: room for resuscitation and intensive care – equipped with monitors, respirators, defibrillators, ECG- machines and variety of emergency drugs. trauma room – where surgical activities are run, such as sutures, immobilizations, extraction of foreign bodies. some departments have specialized pediatric sectors

15. 15 Challenges To overcome the use of ED as a round a clock GP To introduce National Standards in EM To intoduce the credit system in Certification doctors in EM

16. 16 Comparative Analysis of Bulgaria’s EMS FeaturesUnderdevelopedDevelopingMatureBulgaria Specialty systems National organization Residency Training Board Certification Official specialty status No Yes No Yes Academic EM Specialty Journal Research Database Subspecialty training No Yes No Yes Yes, clinical No Patient Care System EM physicians ED director Prehospital care Transfer system Trauma system Other physicians Private car No EM residency trained EM physician, EMT No EM residency trained EM physician, EMT Yes EM residency trained EM physician, EMT Yes

17. 17 Summary The number dialed for a medical emergency is 150. It is well known and easy to dial from everywhere. The usage of one tier system providing a physician at the scene is a guarantee for an on-time highly qualified help and gives a great chance of survival. Absence of protocols does not unify the activities carried by the emergency physicians not only at the accident scene but at the ED as well. The absence of a special training, standard protocols and requirements needed for the dispatchers is lowering the effectiveness of their work. It leads to a high percentage of non emergency cases and more expenses. Less then 1% of the population is trained in CPR and for any type of emergency help. The community is not familiar with what to expect from the ED..

18. 18 Summary Educating more people how to behave in emergency situations and well managed public relations will be the next step ahead Educating more people how to behave in emergency situations and well managed public relations will be the next step ahead. All the emergency services – Fire Department, Police and EMS have different emergency numbers and the delay caused by having to dial different numbers in emergency situation has been shown to delay the response times of ambulances, police and fire department. On the other hand being under different supervision all three emergency services do not work in team. Making emergencies a teem effort and teaching firemen and policemen how to act as first responders will help us in fight for our patients. A better payment and ways to fight the everyday stress in our work will help too..