Opinions - FREQUENTLY ASKED QUESTIONS

Frequently Asked Questions

Q1. Who made the SMURD system functional, generally speaking? Where else in the world is it working?

Q2. Which are the system's components? Where does it work, how many employees are there (doctors, assistants, paramedics, drivers, etc.), how many vehicles, how many helicopters / planes (if any)?

Q3. When did you launch the system in Romania - the history, details?

Q4. Who finances in Romania the SMURD?

Q5. Which are the advantages that SMURD brings, by comparison with the traditional ambulance service? What is the system's efficiency - seen cases, costs / efficiency reports?

Q6. Which are - if any - the disadvantages of the SMURD system?

Q7. Why do you think that the Ambulance Service is fighting against the national coverage of the SMURD? A detailed answer, if possible!

Q8. How true do you think the expression "competencies theft" is (also consider the "war" rouge vs. blancs in France)?

Q9. From the professional point of vue, are both you and your service appreciated by the Ambulance Service? They only "accuse" you're hyperintervening, a damaging fact for the patient's health. How do you comment?

Q10. They say that in your area the system is working very well because:
a. You have a smaller and less populated area to cover;
b. You have the "backup" of the Ambulance Service. For this reason you practically can't fail. How do you comment?

Q11. Do you presently have the legal possibility of hiring physicians, medical assistants, on a competitive basis? Can you be financed by contracts with the National Health Insurance Agency?

Q12. If there would be an initiative that the city - generally speaking - be "covered" by the Ambulance Service and the rest of the country by SMURD, how would you react?

Q13. In order to improve the activity of the Health and Family Ministery, there are initiatives of founding a new section for the coordination of emergency medical services. Do you consider these intentions of Minister Dr. Daniela BARTOS as being a hostile act against the expansion of SMURD?

Q14. If presently the Firemen are a military structure subordinated to the Interior Affairs Ministery, the forecasts are that in up to 2 years, the Firemen to become "civilians", under the direct management of local Mayor's Offices. How do you think SMURD will be financed then?

Q1: Who made the SMURD system functional, generally speaking? Where else in the world is it working?

- The model of the Mobile Emergency Service for Resuscitation and Extrication is based on the mainly European model, where the hospital in cooperation with other institutions such as the Fire Departments, sends a resuscitation unit to attend the critical cases regardless of their nature. The integration with the Fire Departments has very important logistic, financial and operative implications, especially in cases requiring complex interventions and technical assistance, like extrications. This system which sends a hospital physician in a resuscitation mobile unit with a paramedic team from the Fire Department started in Germany in the late 50's, and it was implemented in France in the 60's. Presently, this system involving both the hospitals and the Fire Departments is working in France, Germany, Luxembourg, Denmark, Finland, Belgium, a part of Norway, a part of Austria, a part of Spain; in Spain there are functional one ambulance service and a system similar to SMURD, called SAMUR, recently founded in Madrid in 1996, as part of the Civil Protection. The system is about to be implemented in countries like Poland and the Czeck Republic. In the US, although the physicians to not take part in pre-hospital emergency care, most of the pre-hospital emergency medical services are integrated in the Fire Department Units. The latest example is the decision of New York's Mayor Giuliani in 1995, which has integrated the pre-hospital emergency medical service (EMS) in the Fire Department structure, as result of a study which has demonstrated that by integration a more efficient system will be working at lower costs. To be mentioned here that the model implemented in Mures and other counties is not an accurate copy of a system from another country; it is more both the European and american models adapted to the realities and necessities of Romania. Our experience in this matter is of more than 10 years.

Q2: Which are the system's components? Where does it work, how many employees are there (doctors, assistants, paramedics, drivers, etc.), how many vehicles, how many helicopters / planes (if any)?

- The main system generally includes an integrated resuscitation unit with medical and paramedical personnel from the hospitals and the Fire Departments and volunteer paramedics. There is also the extrication unit with employed firemen and on military duty personnel.
In Mures County, the system includes an integrated resuscitation unit run by an emergency specialist or by an AIC specialist from the Emergency Department, the rest of the team consisting of a fireman paramedic driver and other two paramedics, of whom at least is an older and more experienced paramedic. The personnel we refer to as "paramedics" include medical assistants trained in emergency medicine as well as non-medical emergency-trained personnel, such as the firemen. There is also in Mures County an on-call crew on the helicopter and two first-respondant units in hold of semiautomatic defibrilators, within the Civil Fire Group, in Ibanesti and Sovata. Therefore, in our county, at the level of the Tg. Mures City there are a resuscitation mobile unit, an extrication mobile unit, a helicopter as well as two first-aid mobile units, placed in towns distant from Tg. Mures, units which are not covered by the ambulance service. To all those we might add the fast-intervention mobile unit of the emergency physician on call as well as the special emergency mobile unit of the coordinating physician. We are currently working together with the local authorities to set up at least other 4-6 First Respondant units in various towns, situated far away from the Ambulance Service or from SMURD. This year we set up and started operating the Integrated Emergency Dispatch, financed by the Switzerland Government, Minister of Health of Romania and the Tg. Mures City Hall. This dispatch will cover for all the emergency services including the Fire Department and the Police, remaining equally distant from the interest of different institutions and having as sole preocupation the well-being of the citizen.
In Mures, the number of physicians that work at SMURD and the Emergency Department is of more than 20 physicians, which includes the emergency and/or anaestesyology specialists, general medicine specialists with emergency competence as well as residents in emergency medicine and anaestesyology and intensive care (AIC); the number of medical assistants is 16 with full-time employment in the Emergency Department, then there are 3 drivers and a medical assistant, employed by the Fire Department to work on the resuscitation mobile unit and there are other 3 drivers and 6 men on military duty to work on the extrication mobile unit. To all these we must add a number of over 60 volunteers trained in emergency and first-aid who work in the Emergency Department and on the resuscitation mobile unit. Our team also includes the air crew from the Utilitary Aviation Bucharest that have lent us the helicopter.
For the rest of the counties that have this system functioning (Cluj, Craiova, Timisoara, Oradea, Arad, Sibiu, Piatra Neamt, etc.), the minimal crew is one resuscitation unit per county and one extrication unit.

Q3: When did you launch the system in Romania - the history, details?

- The launching of the system in Romania has started with an attempt at Cluj, cooperating with the Ambulance Service. The high amount of resistance from the Ambulance Service Union has made me, after six months of efforts, to move to Tg. Mures, where, with the support of Professor Dr. Mircea CHIOREAN, chief of the AIC Clinic, we started by cooperating with the Ambulance Service. The first intervention was made on September 23, 1990. Shortly after the day we launched the system in which an equipped unit left the hospital to meet the Ambulance Service unit, we were given a resuscitation mobile unit from Germany. We have tried to have this unit be driven by the Ambulance Service's drivers but unsuccessfully, so then we tried with volunteers, with the Red Cross of Tg. Mures. We kept on going this way until October 1991 when we found the best way, which was the combination between our system and the Fire Department. In this way, the Firemen took over the driving of the mobile unit, providing also a garage and room for the crew. In 1993 we founded the first resuscitation room within the Mures County Hospital with help from the Royal Edinburgh Hospital and the Firemen of Glasgow have donated the first extrication unit in Romania also providing the necessary training. In 1994 was created the first service for emergency admittance, based on the American and British models, with the support of the colleagues in Scotland and of the BBC. It is also to mention that in 1993 the first SMURD following the Tg. Mures model was created in Oradea, being soon followed by a second one in Sibiu. In 1994 appeared SMURD Cluj, and so on, the implementation continuing in the other counties. In 1994, the first extrication unit was donated to Bucharest, with the kindness of our colleagues in Scotland. In 1997, with a program of the British Government were founded in cooperation with SMURD other three resuscitation rooms in Timisoara, Craiova and Constanta and in Timisoara and Craiova were shortly created the Resuscitation, Emergency and Extrication Services, covered by AIC specialists, cooperating with the Fire Department, taking after the Mures model of SMURD. In August 1999 the air coverage was set up initially on a cooperation with RomGaz and now, since August 2000, on a cooperation with the Utilitary Aviation. Therefore we can say that the model implemented in Mures and copied successfully in other counties, at various levels, is a model which combines the European model with the American one, in pursuing the integration of the emergency medical assistance at all it's levels and taking whatever is applicable from every system.

Q4: Who finances in Romania the SMURD?

- The hospitals (on the medical side) and the Fire Departments (on the logistic side) are the main financing sources. In Mures we can add to that: the local authorities (especially the First Respondant units and the new integrated dispatch 112), the population (in 1998 the people have donated the amount of 183,000 DM used to buy the resuscitation unit currently in use), the donations coming from companies and institutions as well as donations from other countries. Our system remains at a national level a public service with no financial interest.

Q5: Which are the advantages that SMURD brings, by comparison with the traditional ambulance service? What is the system's efficiency - seen cases, costs / efficiency reports?

- For the critical patient, the advantages offered by SMURD are that this integrated system brings the competence of the hospital with also, if necessary, the competence of Firemen, in the shortest time possible, where the patient is, in this manner transferring the emergency room at the patient's location. The crew is led by an emergency or AIC physician, specially trained and experienced. The crew is destined to cover only critical emergencies, otherwise being on hold, not usable in other activities such as house calls, as seen in many Ambulance Services. The cases taken are medical, cardiological, neurological, toxycological or traumatic, with the requirement that they are code red cases, cases with real vital or imminent danger. For instance, in 2000 the resuscitation unit has taken 2,300 cases (an average of 6-7 cases per 24 hours), of which there were 262 traumatisms and polytraumatisms in car crashes, 273 traumatisms and polytraumatisms of another nature, 102 cardio-respiratory resuscitation attempts of which 36 patients were resuscitated in prehospital and then moved to the Emergency Department, this showing a percentage of 35%, the rest of the cases being medical, cadriac, toxic and other emergencies.
As of the cost/effciency quota I can say that out of the resuscitation crew only the physician is paid by the County Hospital, the driver of the unit being a fireman. The fuel, maintenance, etc. are covered by the Fire Department and by the local authorities and the supplies are covered by the hospital. So, 80% of the funding coming from the sanitary system allocated to the resuscitation unit are for pharmaceuticals and materials and only the remaining 20% are allocated to pay the physicians, compared to the high 60% the Ambulance Service spends on pay-cheques and administrative expenses. Therefore, from the patient's point of vue, the cost/efficiency quota is a lot higher for a SMURD unit where most of the funds are destined directly to the care and treatment of the patient In Mures, the costs for the resuscitation crew, consisting of at least 4 people, for the sanitary system is lower or equal to the costs of an ambulance crew consisting of 3 people and where the expenses, over 60% of them are destined to administrative and not medical purposes.

Q6: Which are - if any - the disadvantages of the SMURD system?

- There is no such thing as a perfect system, with no downsides. SMURD has the disadvantage of it's complexity and requires an integrated coordination, well planned and followed-up and requires not only an inter-disciplinary cooperation but also an inter-professional cooperation in most cases. SMURD currently relies on the confidence the population and on the confidence of local authorities in certain areas, so if this system is unable to keep it's high standard it could be severely affected from every point of vue, by comparison with the Ambulance Service, which has guaranteed financing regardless of it's performance. To SMURD, this could be a downside, but this turns into great advantage for the patient. I'm sure there could be found other disadvantages, but they do not affect the patient in any way.

Q7: Why do you think that the Ambulance Service is fighting against the national coverage of the SMURD? A detailed answer, if possible!

- Basically, I think that we're dealing with the unjustifiable fear of change. Unfortunately, a small group of people insist in claiming that if SMURD is created then they would lose their jobs, which is not true, since SMURD will never be able to cover all the necessities and neither the Ambulance Service will. Another issue is the fear for the impact upon the direct interests of persons holding management positions in their attempt to obtain a monopoly over the emergency pre-hospital care. Maybe there are other issues but I think that the ones who should answer this question are the colleagues at the Ambulance Service. There is one thing I wish to state firmly and this is if the patient's interest was the number one subject in this conflict, things would have been solved since the beginning. Unfortunately, the patient's interest is the last thing to be considered, every time.

Q8: How true do you think the expression "competencies theft" is (also consider the "war" rouge vs. blancs in France)?

- The "competencies theft" is a term used by those who would not admit that the saving of a life cannot be monopolized by one category of people or by an institution. This term is created against the implication of Firemen in providing first-aid. As I have said before, the emergency medical assistance is offered at various levels starting with the basic first-aid and ending with the highest level. The Firemen are a part of the fast intervention structures and they should be trained and they should become competent including the basic emergency assistance and semiautomatic defibrilation. In fact, this is not the Firemen's right, it's the patients' right to have competent intervention crews regardless of their nature or provenience. If we consider the number of Military Fire Units in the country, which is over 230, to add there the number of Civillian Fire Units, which is of more than 500, and we compare these numbers with the relatively small number of ambulance stations we will understand why we should train the Firemen to provide emergency medical assistance up to a certain level. This is the only way to cover the national needs in a short period of time and without any huge financial implications. Within SMURD no competencies are stolen when it is about the mobile resuscitation unit since in the crew there is always a physician on board to perform the medical act. The war mentioned above, in France, is limited mostly to Paris, where conflicts started between the Firemen who have fully independent resuscitation units, operating with military physicians separated from the hospitals, them being the red ones, and SAMU or the emergency medical assistance which is mainly the hospital service providing pre-hospital care. This was avoided in the Mures model since the physician comes from the hospital and the Firemen with the hospital work integrated, not separately. There is to mention that in France there are no public ambulance services. All their ambulance services being private, including house-calls, the emergencies are handled by the Firemen and the hospitals. In the rural areas there is no conflict as in Paris, there is a much better cooperation and a higher level of integration. In Paris, however, we should mention that there are more than 190 Fire Intervention Units, the majority operating semiautomatic defibrilators. These crews are supported by the 8 resuscitation units with Firemen physicians, by a certain number of resuscitation units from SAMU and a number of first-respondant unit of the French Red Cross and French Civil Protection. There are more than 70 departure points of those units in Paris!!!!!!!!

Q9: From the professional point of vue, are both you and your service appreciated by the Ambulance Service? They only "accuse" you're hyperintervening, a damaging fact for the patient's health. How do you comment?

- In Mures I can firmly state that we are appreciated by the Ambulance Service, especially if we admit that we are usually called on a serious case involving an employee or a relative of an employee of the County Ambulance Service.
The accuse of hyperintervention is created by people who do not fully understand, from a medical point of vue, the purpose for certain maneuvres and emergency procedures. Our crew proceeds only in the full respect of international protocols and procedures, with no exaggerations and no improvisations. So, a SMURD crew will not wait for a patient in respiratory insufficiency to turn apneic for proceeding to the intubation, there are well known criteria to proceed on such a patient with the intubation without any further delay, avoiding serious consequences. Unfortunately, this direct and somewhat more invasive approach in misinterpreted as hyperinterventions, by those who are not used to the handling of critical cases and have not enough training to do so. Our statistics show that appreciatively 15% of the patients assisted by the resuscitation unit have required endotracheal intubation, percentage comparable to similar crews in Norway, Germany and France. Out of the intubated patients results show that around 50% have required one form of medication, sedation or induction; in order to perform an intubation advanced knowledge is required, in the fields of anaestesyology and intensive care. A retrospective study we conducted in 1998, in which we compared, using our computerized database, the survival rate of a critical patient, in the first 4 hours, brought in the Emergency Room by a SMURD crew, and this rate is 3.4 times the rate of the Ambulance Service, patients' conditions being comparable. Even more, around 50% of the patients brought to the Resuscitation Room by the Ambulance Service have required an immediate endotracheal intubation after their arrival, compared to SMURD's average of 17%, the rest being already intubated in pre-hospital. So it seems that our "hyperintervention" is better for the patient then the "hypointervention" which obviously leads to a decrease of the survival chance.

Q10: They say that in your area the system is working very well because:
a. You have a smaller and less populated area to cover;
b. You have the "backup" of the Ambulance Service. For this reason you practically can't fail.
How do you comment?

- This cannot be true. If we take the Mures County for an example, where we have 630,000 people living, of which 200,000 live in Tg. Mures, having as a service a single mobile resuscitation unit and a few first respondand crews and emergency crews from SAJ and the Civillian Firemen, in an area where the distances can be over 60-70 km, we cannot be talking about easier work conditions. In fact, we never thought about functioning without the Ambulance Service and we have never stated that there isn't any real cooperation between the two services. SMURD is complementary to the Ambulance Service, and is not a replacement. Actually it is easier to cover a smaller but more crowded area than an entire county. If currently the Ambulance Service has 6 departure points in Bucharest, let's think of the efficiency they would have if they accepted to add the Firemen' other 16 points of departure, with no additional costs. Our statistics show that more than 30% of the interventions of SMURD's mobile resuscitation unit were made in the rural areas and if we add to that the First Respondant s' missions, then the percentages are equal between city andrural areas, but worth mentioning is that the First Respondant Crews arrive in a much shorter time to the patient than other crews.

Q11: Do you presently have the legal possibility of hiring physicians, medical assistants, on a competitive basis? Can you be financed by contracts with the National Health Insurance Agency?

- Of course we are entitled to hire personnel on a competitive basis. Actually, the Decision of the Ministry of Health no. 508 dating of July 1999 legally aknowledges the Emergency Department and the Mobile Resuscitation Units. All our professional personnel in Mures as well as the personnel workind for SMURD throughout the country is hired by legal competitive means. This issue was solved in Mures by the Direction of Health starting 1997/1998. As for the contracts with the National Health Insurance Agency, SMURD has no business operations whatsoever, this being, as a system, a component of the hospital. Therefore are still some difficulties in obtaining financing for the pre-hospital activity of the hospital. In Mures, in 2000, we were financed by the National Health Insurance Agency through the hospital. The main issue is the contract procedures, where momentarily the tendencies are to accept only the Ambulance Service and to leave SMURD, which is also a public service, without a clear solution. We hope these problems will be solved on-going.

Q12: If there would be an initiative that the city - generally speaking - be "covered" by the Ambulance Service and the rest of the country by SMURD, how would you react?

- I do not understand why anyone would do that. SMURD is destined to handle major emergencies, regardless if these are one meter or 10 kilometers away of the SMURD unit. If the distance should be too big to cover in due time, an intermediate unit is sent, belonging to the Ambulance Service or, following the Mures County model, belonging to the Civillian Fire Groups, which will provide the first-aid or emergency assistance until the arrival of the resuscitation unit or until the rendez-vous with it if the intermediate unit should begin the transportation. In 2000 the SMURD resuscitation unit has been on 2,300 cases of which 798 were in rural areas. If we add to those the missions handled by the First Respondant units of Ibanesti and Sovata, being under SMURD coordination, they have handled 980 cases in rural areas. The helicopter has taken over 150 cases in rural areas. Therefore we see no reason at all to split territories, because at the city's level there is a sophisticated resuscitation unit covering the entire county, and in the rural areas, locally, the first respondant units are beginning to get together, financed by the local authorities, especially in those areas where the Ambulance Service has no mobile units. It is important to mention that the SMURD First Respondant units in the rural areas are financed almost entirely by the local authorities and by the population, based on the Civillian Firemen Law that states first-aid as part of their mission.

Q13: In order to improve the activity of the Health and Family Ministery, there are initiatives of founding a new section for the coordination of emergency medical services. Do you consider these intentions of Minister Dr. Daniela BARTOS as being a hostile act against the expansion of SMURD?

- From what information I gathered from the statements made by the Ambulance Service Union's leaders, it was the founding of the National Ambulance Service, not the founding of a Direction of emergency medical assistance. In case they would be planning to found a new National Ambulance Service, this would be against the reformatory tendency and against the government program, which is focused mainly on decentralization. If we take a look at the organization of emergency pre-hospital care in Europe, there aren't more than 1 or 2 countries to still have such national services, these being non-representative for the European or international system. Since the Police and the Firemen are becoming decentralized, it would be absurd to centralize the Ambulance Service. Indeed this might negatively inflict on several counties where SMURD in functioning, as Mures County is and where there are local conventions with the Ambulance Service; these conventions could be negatively affected if the Ambulance would be under central Bucharest coordination.
Case being they were reffering to a direction for emergency medicine generally speaking, several issues will have to be cleared, the first one being it's relation with the General Direction for Medical Assistance, which cannot draw a line between the emergency medical assistance and all the rest of it's tasks. The second issue, if it is still to be founded, the new direction should cover the emergency medical assistance in it's whole, at all levels, and not only some segments, like the Ambulance Service does. If still this Direction will be founded, the person in charge of it should be equidistant between the problems of SMURD and the Ambulance Service, a good and skilled manager for this field generally and very familiar with the European and international systems, in order to follow the goal of developping an integrated system compatible with the European requirements.

Q14: If presently the Firemen are a military structure subordinated to the Interior Affairs Ministery, the forecasts are that in up to 2 years, the Firemen to become "civilians", under the direct management of local Mayor's Offices. How do you think SMURD will be financed then?

- It is very possible for the financing process to improve and the resources and the possibilities to grow. This was proven to work in the Mures County as a consequence of the implementation of the First Respondant units, which are financed by the local authorities. However, it is important to mention that, consequently to financial difficulties in covering the costs of the helicopter by the National Health Insurance Agency, the Mures County Council has initiated the project of covering the helicopter costs by the County Councils in our area. So, we do not think it will be bad for us, on the contrary, our financing will improve and the development possibilities will grow to a real reflection of our local needs.