Brazil

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General

Capital – Brasilia

Land Size – 8,514,877 sq km

Population – 201,103,330

Language(s) – Portuguese (offical and most widely spoken language)


Prehospital Care


Overview

  • A combination of the Franco-German EMS system and the developing Anglo-American emergency medicine model, “creating a uniquely Brazilian approach to emergency care” (Tannebaum, 223)
    • Two divisions of Prehospital Care
      • Fixed locations
        • Basic Health Units
        • Family Health Program
        • Specialized Cllinics
        • Diagnosis & Therapy services
        • Non-hospital Emergency Care Units
      • Mobile Response
        • On-Scene Emergency Medical Response
        • Also provides psychiatric emergency assistance


History

  • SAMU Serviço de Atendimento Móvel de Urgência (Mobile Emergency Care Service)
    • 1995 – established after agreement with France to exchange technical information
    • Sept. ’03 – Launched nationwide by Federal Gov’t
    • 24hr/day, any location
      • Staffed by Physicians, Nurses, Nursing Assistants and Rescuers
    • 70 SAMU services established/operating in Brazil (Timerman, 357)
      • 320 towns in 22 states


EMS System Model

  • Franco-German model – providing care on-scene as well as en route
    • “[US-style] Paramedics do not exist in Brazil because Brazilian law precludes nonphysicians from performing intubation, defibrillation, and other … ALS procedures” (Tannebaum, 225)
    • “No standards governing qualifications of EMS physicians, except that they must hold a valid state license to practice medicine” (Tannebaum, 225)
    • 1 BLS ambulance per 100,000 – 150,000 inhabitants
    • 1 ALS ambulance per 400,000 – 450,000 inhabitants
  • Response Agencies
    • SAMU Serviço de Atendimento Móvel de Urgência (Mobile Emergency Care Service)
      • Major provider of EMS in Brazil
    • Mobile (private) Hospital Services
      • Scarce, but more prominent in urban centers
    • Fire Department
      • When EMS is not directly available
      • BLS only, online medical direction
  • Ambulance classification (Timerman, 357)
    • Type A: Transport Ambulance
      • Transport of Pt’s “in supine position who have no life-threatening problems. Also used for elective transport”
    • Type B: BLS Ambulance
      • Transport of Pt’s “with potentially life-threatening problems and those with undiagnosed problems.”
      • Can provide some medical interventions on-scene/en route
      • Staffed by Nurse Assistant & Rescuer
    • Type C: Rescue Ambulance
      • “Pre-hospital care for the victims of accidents of those in situations with difficult access (e.g., rough terrain, water, and heights).”
    • Type D: ICU-ALS Ambulance
      • “Provide care and transport for high-risk patients in pre-hospital emergencies and inter-hospital transfer”
      • Staffed by Physician and Nurse
    • Type E: Aeromedical Transport
      • “Fixed or rotary wings to attend and transport patients to and between hospitals”
      • Treatment, transport and rescue
    • Type F: Medical Transport Vessel
      • “Medically equipped boats used to carry victims through maritime or fluvial routes”
  • Puerto Alegre (Southern Brazil)
    • SAMU (& Fire Department)
    • Privatized Highway Services
      • Service funded by road tolls; Pt’s not charged directly
      • BLS ambulances placed 30km apart on private roads
      • ALS ambulances “staffed by relatively well-compensated physicians ($25 to $30 perhour)” (Tannebaum, 225)
      • “Load and Go”
    • Fully Privatized (non-highway) Services
      • Monthly insurance premium (approx. $10-15/month)
      • Uninsured can access at rate of $100-150/transport
      • MDs are “usually moonlighting residents or other physicians with no training in emergency care” (Tannebaum, 226)
    • High prevalence of ED arrivals by private transport (e.g, Taxi or bystander)


Lead Agency

  • Ministry of Health
    • Makes and enforces policies guiding SAMU services.
    • Hopes to establish SAMU in all Brazilian towns “respecting the jurisdiction of three administrative spheres (federal, state and municipal government)” (Timerman, 357)
      • 2006 – expected SAMU service in 1215 towns, serving population of 97m


Funding

  • Federal government-funded universal medical care: Sistema Único de Saúde (SUS) entitles population to public medical assistance – (since 1998)
    • 24.4% of population pays for full private medical assistance (Timerman, 357)

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Education & Training


Specialty Services


Dispatch & Medical Direction

  • Regulation Center
    • Communication Operators take calls (acting as medical regulation assistants)
    • Identifies nature of emergency and immediately transfer call to dispatching physician
    • Physician determines appropriate resource response
      • Can refer caller to public health center
      • Mobilize BLS and/or ICU-ALS ambulance
    • Physician in communication with public hospital and keeps track of bed availability


National Emergency Telephone #

  • 192 – common single access number, toll-free
    • Not universal (Bloem, 9)


Emergency Medicine & Emergency Care

  • Emergency Medicine not yet recognized as stand-alone specialty
    • Considered sub-division of internal medicine
  • 2002 – MOH issued “Portaria 2048” which outlined way for entire healthcare system to improve emergency care due to increasing injury victims and overcrowding of EDs (Bloem, 9)
  • 50% of medical school graduates do not get residency positions (Bloem, 9)
    • “These new physicians with minimal clinical training look for work in emergency departments”
  • 2008 – 2 existing Emergency Medicine residency training programs (based on American model) – (Bloem, 10)
    • Porto Alegre
    • Fortaleza, Ceará
    • Other programs in planning
  • Emergency hospital units (Timerman, 358)
    • Type I – located in small general hospitals
      • “First-level of care of only minor complexity”
    • Type II – located in medium-sized hospitals
      • “Able to provide emergency care of medium complexity”
    • Emergency Reference Hospital Units
      • “Able to provide emergency care at high levels of complexity”
      • Funded on basis of numbers and complexity of patients.

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Disaster

  • “Well-established multi-agency responses to complex emergencies that may include the military, fire department, police, highway patrol, and others working with the medical resources to rescue and treat victims” (Timerman, 357-8)
  • Fire Department
    • Can provide rescue and first aid for fire, drowning, flooding, collapse and catastrophe
    • Identification/Management of hazards on-scene
    • Perform complex rescues that health teams cannot
    • Can provide BLS care where direct medical assistance is not available via direct or remote medical supervision


Future Priorities

  • Expand general coverage of SAMU
  • Decrease response times between call and on-scene arrival
  • Recognize Emergency Medicine as stand-alone specialty
  • Make available/increase emergency courses for Physicians, Nurses and Health Technicians (e.g., BLS, ACLS, ATLS, PALS)
  • Provide widespread public access to defib education/programs


References

  • https://www.cia.gov/library/publications/the-world-factbook/geos/br.html
  • Bloem C: “Emergency Medicine in Brazil.” American Academy of Emergency Medicine 2008;15(6):9-11.
  • Tannebaum RD, Arnold JL, De Negri Filho A, Spadoni VS: “Emergency Medicine in Southern Brazil.” Annals of Emergency Medicine 2001;37(2):223-8.
  • Timerman S, Gonzalez MMC, Zaroni AC, Ramires JAF: “Emergency medical services: Brazil.” Resuscitation 2006;70:356-9.


Links

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