An insight into Iceland’s Emergency Medicine and Pre-Hospital Care systems
Dr Ross Archibald, ST6 Emergency Medicine, South East Scotland Deanery
I have been very fortunate to be able to spend the final few weeks of my emergency medicine training in Iceland, thanks to the Robin Mitchell Fellowship. I was awarded the Fellowship last year, giving me an invaluable opportunity to explore Iceland’s emergency medicine (EM) and pre-hospital care systems. I hope you enjoy reading about my observations, experiences and reflections during this unforgettable attachment.
The Robin Mitchell Fellowship was set up in memory of Dr Robin Mitchell, an Edinburgh-trained EM physician, who died from pancreatic cancer in 2010. Outstanding as a clinician, educator and leader, Dr Mitchell had an influential and accomplished career in EM and pre-hospital care both in Scotland and New Zealand. For the last decade, The Robin Mitchell Fellowship has been awarded biennially to one EM trainee in Scotland in order to pursue a 4-6 week placement in an alternative environment, with the aim of advancing their clinical experience and expertise.
The idea to travel to Iceland for the Robin Mitchell Fellowship was sparked following my brief insight into the county’s EM and pre-hospital systems during a visit in 2019. I couldn’t wait to come back and it was clear that I could learn a lot from a longer clinical placement and comparison of our respective systems.
Iceland is an island nation situated just south of the Arctic Circle. It is the most sparsely populated country in Europe, with an area 1.3 times the size of Scotland, but home to only 360000 inhabitants, over 60% of which live in the capital Reykjavik. Perhaps Iceland’s most striking features are its stunning landscapes and abundant natural wonders, ranging through volcanoes, waterfalls, geysers, mountain ranges, fjords, hot springs and large areas of uninhabited desolation.
Iceland and Scotland share a number of challenges in achieving equality of access to emergency care, including harsh, variable weather conditions, mountainous terrain and isolated rural populations. We also face similar EM-specific issues with increasing complex elderly presentations, overcrowding and exit block, as well as balancing training and service provision.
The health care system in Iceland has a structure similar to other Nordic countries, with the majority of services provided by the government. Private clinics also provide a significant proportion of patient care, but this is mostly funded by a government-run universal health insurance program.
Although Iceland has a medical school since 1876, opportunities for postgraduate specialty training have been relatively limited, with the majority of Icelandic physicians having gone abroad for their specialty training, mainly in other Nordic countries but also in the US, the UK and other countries. Most Icelandic doctors trained abroad move back home to practice, resulting in a system which benefits from a wide range of experience and approaches. Among the Nordic nations, Iceland was the earliest adopter of EM as a specialty, where the first emergency physician was licensed in 1992.
Since then, EM training in Iceland has undergone a hard fought process of evolution. A key step in growing the specialty was the creation of a two-year residency program in 2002, based on a curriculum produced by the Icelandic Society for Emergency Medicine. This training program has since been redeveloped, with the Icelandic Directorate of Health recently approving a six-year EM training programme based on the Royal College of Emergency Medicine curriculum and examinations. All but 6 months of this programme can be completed in Iceland. There are currently 13 core EM trainees, 5 higher specialty trainees and 18 consultants (14 FTE) in the country.
EM trainees continue to be encouraged to do part of their training abroad, as this is felt to be an important component of becoming a fully trained specialist. My attachment in Iceland also presents an opportunity to establish a link between our respective departments and set up a regular exchange of trainees, thereby enriching future EM training both in Scotland and Iceland. I look forward to working on this once I am back home.
After an uncertain wait, the recent travel restrictions fortunately relaxed just in time for my attachment to go ahead in June/July 2021. I arrived in Reykjavik after an eerily quiet air travel experience and spent a bit of time getting my bearings before meeting some of the emergency department staff who would be my colleagues over the next few weeks. I made the most of the good weather that weekend by running some of the picturesque forest trails just outside the city. Visiting during the short Icelandic summer also gave a chance to experience the midnight sun, which takes a bit of getting used to!
My clinical attachment began with a few shifts in the emergency department (ED) at Landspítali, Iceland’s National University Teaching Hospital. Located in the centre of Reykjavik, it is Iceland’s main healthcare facility, with around 700 beds. It operates a wide range of clinical services and is where 70% of Iceland’s children are born. Landspítali’s ED sees around 70000 attendances per year and is split across two floors. The ground floor comprises two cubicle areas for major presentations (A for higher acuity and B for lower acuity), as well as four interconnected resuscitation bays, two specialty rooms and an eight-bed clinical decision unit. The upper floor is used for minor adult and paediatric trauma presentations, with a separate city hospital site taking medical paediatric presentations.
During day time hours each floor of the ED generally has one consultant and often a HST or core trainee in EM, in addition to a small number of junior doctors and senior medical students. There were fewer doctors on shift than we are accustomed to, but this was balanced with plenty of nursing and support staff. Reflective of Icelandic society in general, the ED working environment was informal, with everyone on first name terms and no role-specific uniforms (which I found tricky to begin with). Specialty referrals were fairly informal, with some specialties like cardiology often coming to see patients on the basis of a patient being marked for cardiology input on the IT system, rather than requiring a phone referral. The ED staff had a comfortable and spacious staff room, well-stocked with fresh fruit and other food, as well as the ever present high-end free coffee machine!
During my shifts I felt very welcome and able to easily integrate as a registrar, despite very limited Icelandic. This was considerably helped by being paired with a final year medical student scheduled to do a “scribe shift”. During these, the medical student accompanies a senior doctor with a portable computer, doing all the documentation and ordering of tests in real time. I found it a very efficient way to work and was able to go from patient to patient relatively seamlessly. It also provided an opportunity to deliver ad-hoc teaching, something which can be challenging in a busy ED. Although many of the patients spoke fluent English, this was less common in the older patients, where the medical student’s skills as a translator became invaluable. Medical students appeared to enjoy these shifts, particularly where they were paired with a senior doctor keen on teaching. I think this is something we could certainly consider adopting at home. During their ED placements, students are also scheduled to do regular shifts where they see patients more autonomously and discuss cases with seniors.
The mix of presenting complaints was familiar: chest pain, breathlessness, collapses, head injuries, palpitations, mental health problems and complex frail patients with falls and confusion. And of course, after a particularly sunny Saturday evening, the inevitable alcohol and drug-related attendances were well represented! Ambulance crews would pre-alert the nurse in charge where necessary via phone and would send ECGs suspicious for STEMI ahead electronically for review on a big screen by a senior ED doctor, so that a decision on diverting to PCI could be made.
As in Scotland, Iceland’s EDs face increasing issues of overcrowding and exit block, particularly in relation to insufficient bed capacity and social care availability. There is currently no time standard in place in the ED in Iceland, with the average time from decision-to-admit to a patient leaving the ED sitting around 16 hours. As a result, the CDU here is generally full of “admitted” patients awaiting inpatient beds and it is not uncommon for patients to be on trolleys in the ED corridors for many hours and sometimes days. This is compounded by the familiar issue of increasing complex presentations in the frail elderly population, many of whom I saw during my shifts. These challenges appear to have caused a significant strain on the department in recent years, with resultant concerns for EM training, job satisfaction and job sustainability. Part of the solution may be on the horizon, with a bigger hospital in the pipeline.
There were plenty of nursing and clinical support around, all working efficiently and pro-actively. When seeing majors patients, I found they were almost always already on a trolley, changed into a gown with observations completed, usually in addition to bloods and an ECG. This allowed me to see patients quickly and focus on patient assessment, decision making and teaching. Patients were moved in and out of cubicles fairly promptly, helping to best utilise the limited cubicle space.
The IT system in use was impressive, with some very useful features, having been custom-developed and continually adapted with the input of the ED staff,. The user interface gives a familiar list view of the whole department on one screen, with most information such as observations, SBARs, jobs, results, referrals and pictures of the named nurse and doctor immediately viewable for each patient, rather than requiring separate page navigation. Patient discharge prescriptions were made electronically available immediately at any pharmacy, so patients could pick up their discharge medications without requiring a paper script. There was also the ability to easily instant message any staff member to ask them to do a job such as a repeat set of observations or adding a lab blood test, rather than requiring a phone call or finding the staff member. This was helped by plentiful computer availability for all clinical staff. It was impressive to see that the department was truly paperless, with all documentation, prescribing, and ordering and reviewing of tests done on the same computer interface. It was a great example of how a small scale custom-made IT solution can significantly benefit the running of an ED.
At the end of my first week I spent a day out on the ambulance with one of the city’s paramedic teams, and toured the shared emergency services headquarters. I will be doing more of this over the next couple of weeks, so will report back on this then. Overall it has been a very enjoyable and insightful first week in Iceland and I am very much looking forward to the rest of my time here!