Sirens and Lights

In St. Gallen, I met with a doctor who has really been one of the leaders of EM development in Switzerland, and particularly in his canton. It was really a fantastic meeting, including a tour of a small, but very well-equipped ED. We talked more about some of the thoughts brought up by physicians in Lausanne: the competition between specialities; the hesitance of people to accept new specialities; the role of money and power in the development of healthcare systems; precisely how different the cantons all are in their EM systems. One thing that I want to mention that he said to me is something that is relatively obvious, but I think still deserves mention: emergency medicine is an interesting specialty in that it serves in many ways to do the opposite of what most specialties do; rather than attempt to further focus care, it seeks to provide a more general perspective on healthcare. In the ED, a patient can come in with a problem that is vague and then be referred to those who can appropriately treat them. This contrasts to a patient with a problem going to the emergency area of a given specialty, getting a work up and possibly at the end of it, finding out that while they are cleared for a particular system/area, they still have whatever problem brought them to the hospital in the first place. Thus, they end up having to start over at the next specialty. Of course, there are general practitioners and family physicians who can help with this process, but it can still be redundant…

The other truly interesting idea that we discussed was the ways in which the different cantons in Switzerland developed their systems. They truly are completely unique in many regions, while the systems developed similarly in others. When I asked the extremely broad question on why he thought the systems have developed as they have, the doctor said quite frankly, “Luck.” In many ways, it depends on what the hospital has at the time of development in terms of equipment, resources (including human resources) and the roles that physicians from different specialties took on in the development of EM in their respective ERs. What I loved about this answer was that it reminds me in many ways of the comments that I’ve heard about India….while India is very far behind Switzerland in terms of technology, development, resources, etc., a similar situation exists in which the different city-states are just completely different. On a cultural note, several people I’ve met in Switzerland have commented that Switzerland isn’t really a country in the way that other countries are; the cantons are linked, but they are leagues apart in terms of culture, language, organization, etc. (much like India). The cantons here, too, are very hesitant to accept instruction from other cantons or even federally, it seems, as they are very protective of their autonomy. It’s incredibly interesting as a phenomenon because it means that instead of working together to develop an effective system, often each canton will develop a system for itself from scratch. This, of course, can kind of be a limitation for the speed of advancements in terms of structure, but also in regards to the establishment of EM as a specialty as there is not really a strong united front. I feel like there may be a lot of lessons for a place such as India to learn from the Swiss examples…and I wonder if there will be a similar pattern of development. I imagine yes, though there is much more outside interest in the Indian development by organizations such as AAEMI, and therefore may be more guidance and the like.

wow, it’s been a nutty past week. tomorrow is a holiday for Genève, and so WHO gave everyone a 4 day weekend…as a result, everyone is leaving the country it seems, for holiday or for work…so it’s just pure madness helping my boss prepare for a conference in Egypt and getting myself ready to (a) move apartments; (b) take my week long trip to Barcelona starting tomorrow; and (c) figuring out what I want to send home with a friend (love ya, beth!) to the U.S. in any case, i’ll post later today, i promise….but here’s an article on the heat wave casualties (which were MASSIVE) for France, which happens to be the country whose system of healthcare is one of the most revered in the world (including by WHO)… it’s in French, so sorry to all of you non-francophones…

Yesterday was probably the coolest day I’ve had in a while. As I mentioned, I went to Lausanne and spent the entire day (from 7 am to 7 pm) hanging out there with the ambulance crew. I walked into the Emergency Department (Urgences) and was handed an official uniform of the ambulance crew to wear for my day as an observer! Very exciting. Basically, the Swiss system is a little bit of a mix of the two most prevalent models of EM, the Franco-German and the Anglo-American, though it certainly leans heavily on the Franco-German side. The major difference between these two types of EM is that in the FG model, doctors are put on ambulances and generally they spend a lot more time treating the patient on site (sometimes upwards of an hour) rather than getting them to the hospital immediately for treatment. There’s a lot of discussion over which system is better, though I recently heard of a Canadian study that showed that in the end, there is no significant difference in outcomes (I’m looking more into that). Many countries have chosen to adapt their systems to whichever aspects of the models suit them. In any case, in Lausanne, they have a system where ambulances with paramedic types called “ambulanciers” go out on ambulances to calls. If the call requires or seems like it might require more treatment, a S.M.U.R. team is dispatched as well, including a physician (médecin) and an ambulancier (I spent part of the afternoon at the 144- their 911- call center, so I got to see how they make the decisions on who goes where, etc.). The S.M.U.R. vehicle is this little fluorescent yellow station wagon full of supplies. Paramedics here undergo extensive training (3 years), but are more limited than paramedics in the U.S. as to what they can do…the doctors do more. Because of the meshing of systems, most calls take less than 20 minutes to get patients to a hospital, but some do take longer if the physician is treating for a while. I also really want to emphasize that Switzerland is made up on 26 different cantons, and each canton has its own system of EM. While they have commonalities, it’s better to view them individually…this discussion here is only about Lausanne, which is in the Vaud canton.

I was shadowing the a physician and a paramedic, Anne-France and Fred, on a S.M.U.R. team. Very exciting day! I spent the morning at a call where two cars hit each other head on. I’ve never seen an accident that bad before, so it was definitely a little frightening, but very interesting. It was a classic example of how much can be done on the field in Lausanne…they had stabilized the patient and were ready to transport him, but then he started to crash, so we pulled over for 10 minutes to treat him. There’s also a helicopter system, as I explained before (REGA) and so I got to see some of their traumas come in to the hopsital as well…another car accident, and probably the messiest trauma I’ve ever seen. Unfortunately, I didn’t get to see all of it as we were leaving for another call…. Those were the highlights, though. In addition, I spent part of the afternoon meeting with a physician who in charge of prehospital services (SMUR and REGA). It was a great opportunity to discuss the development of EM in Lausanne, which has only truly been occurring over the last 4-10 years. EM is not seen as an individual specialty in Switzerland. In fact, in order to be an EM physician, you have to do a regular specialization (usually anaesthesia or internal medicine) and then sub-specialize in emergency medicine. Doctors involved in SMUR and REGA are normally in their subspecialization. The doctors on REGA usually are the ones who have a stronger background in anaesthesia than those on SMUR.

As everywhere, the main hindrance to development certainly seems to be money… as the demand for EM services in Lausanne is rising, there’s a need to further develop these services (though they are certainly well developed already!), however there is a little opposition from other specialties, as well as of course from those controlling the money! EM ends up taking away patients (read: money) from other areas, and it’s not particularly lucrative as a specialty itself, so it’s a bit of a problem. However, there seems to be a lot of confidence that the developments will come, that Switzerland is just always a little behind when it comes to development. EM should and will be its own specialty sometime in the near future.

The last part of the afternoon was spent in a meeting with all of the prehospital care physicians where they just exchange stories and experiences of their recent work….cool cases, interesting situations, problems faced and mistakes made. Heard some cool stories, but this entry is long enough already! In the end, I came back to Geneva full of information, having practiced a lot of French (all day in French…woohoo!) and truly energized despite having woken up at 5:15 am to get to Lausanne in time!

As I’m heading to Berlin all weekend and need to get my project for WHO done soon, I probably should get back to work… more farewells tonight. I swear, half of my social life is good-bye parties…

Emergency Departments Get Eased Rules on Patient Care

Here I am at the Children’s Hospital in Lausanne… I’ve had a fantastic past 24 hours. I arrived here yesterday morning and just did a little exploring of Lausanne (they have a gorgeous cathedral and a park/museum dedicated to the Olympics) before meeting up with a pediatric trauma surgeon here. As it was an “academic” day for him, I spent the afternoon with him being introduced to various doctors both here and at the main Lausanne hospital. I took tours of the emergency departments in both locations and just asked lots and lots of questions about the ED, insurance in Switzerland, as well as prehospital care (i.e. ambulances). On our way between hospitals, this doctor took me to a REGA station. REGA is one helicopter service used to transport patients and medical services rapidly and safely. As it turned out, there was a call (an “intervention”) just 2 minutes after we walked in, so we got to see them prepare to take off to contribute to efforts to rescue someone who had disappeared in the Rhône, a major river in Switzerland. I took some photos of the helicopter departing, which I’ll post later. Overall, very cool. This morning, I’ve just been doing more shadowing, and found out that it’s been arranged for me to do a ride along on the S.M.U.R. (like EMS…it’s an ambulance service here) with a physician in the first week of September. I am very very excited about that, as I wasn’t sure if it would be possible for me to get on ambulances. Now if only I could find a way to get on one of those helicopters….. ;). Ah, well, I won’t try to push my luck!

The other very nice part of yesterday was that I was lucky enough to be able to stay as a guest with the doctor at his house in the countryside (it’s only 10 minutes from Lausanne…I love how easy it is to be someplace so peaceful and beautiful, but know that the city is nearby if you should need or want anything). The house was absolutely incredible…it’s on a farm and all you can see are mountains and cows and grass. I can’t imagine a more beautiful place to live….the family and I ate dinner outside, and I kept getting distracted by the incredible view. What impressed me most, though, was just talking to a family that has spent significant time abroad. Lately, I’ve been a little anxious about the idea of returning to rural PA for medical school (for those who don’t know, I’m currently deferring a year at Penn State College of Medicine in Hershey, PA), so it’s nice to see people who have so very successfully spent time abroad studying/practicing medicine, even with kids. While I’ll be spending the better part of the next 4 years (well, after this one) in Hersehy, I’ll have a chance to go abroad later…

ok, more later!

**continued**
sorry that entry ended so abruptly…it was lunchtime! i’m back in Geneva now, doing some work at WHO to make up for my time away. as i was saying, it was very comforting realizing that my opportunities to travel won’t stop the instant that I have other obligations. Seeing how mature and aware the kids in this family are (as well as adorable with their french/english/american accents) made me realize how beneficial experiences like living abroad can be for everyone, even if it involves a lot of change and adaptation…

I also meant to write more about the differences of living in Switzerland versus the U.S. (or at least PA, as the doctor I was visiting worked in Philadelphia and we reflected mostly on Switzerland versus Philadelphia)… one of the topics of discussion for us was the approach to education in the two areas. Here in Switzerland, education is seen much more as a means to an end, I think. Students aren’t encouraged as often to explore opportunities such as grants to do research or travel, and it seems as if these opportunities just don’t exist to the same extent if at all. While I firmly believe that even in the U.S., only people who actively seek these opportunities usually come across them and take advantage, they’re still much more readily available here. However, I think the path here is also much more prescribed: this is what you do to be a doctor, go do it. The difference is that in the U.S. you’re sometimes expected to do much more on your own before you can embark on that path. In discussing how that influences you in the end…well, I’m not sure that we came to any conclusions, but I think we both (and the other people we were discussing this with at the hospital) agreed that it is certainly very nice to feel so free to explore as a student and to be able to get so involved.

if you’re interested in my impressions on Swiss EM so far….well, I’m working on how I want to phrase things thus far, but I’ll try to get back to you ASAP.

WOOHOO! submitted my IRB on Wednesday. wish me luck that all goes well with that….

weekend plan: Mont Blanc in Chamonix, France. I think this is the last mountain on my list for a while :P. we’ll see how hiking goes with my stupid all bruised and swollen leg (was a little too aggressive at football practice Monday…oops..the coach kept telling me he could tell i was from philadelphia )…

i miss ritas water ice and soft pretzels. i miss the NY Times crossword puzzles.

ok, back to work.