An insight into Iceland’s Emergency Medicine and Pre-Hospital Care systems
Dr Ross Archibald, ST6 Emergency Medicine, South East Scotland Deanery
This Fellowship has allowed me to obtain a timely insight into Iceland’s pre-hospital care system, which is undergoing development at the same time that Scotland’s trauma and pre-hospital care systems continue to expand and develop. Like in Scotland, the isolated communities, challenging geography and harsh weather conditions of Iceland mean that a robust pre-hospital and retrieval network is a vital component of the heath service.
The second week of my time in Iceland began with a couple of days working alongside a paramedic team in Selfoss, a small town around an hour’s drive east of Reykjavík through some lovely mountainous scenery. The day began with a paramedic handover in a large shared emergency services base, which houses fire, ambulance, police and search and rescue operations. Owing to the relatively small population and the service demands in Iceland, it is common that emergency services share headquarters. This lends a number of advantages including the development of close working relationships and good understanding between personnel from different agencies, as well as reducing overhead costs.
Before attending to our first call out, I had a chance to have a tour of the base and gain familiarity with the vehicles and equipment in use, thanks to Bergur, an Emergency Medical Technician (EMT). Selfoss has two ambulances, both used for all levels of call out priority. They are fitted in a similar configuration to ours, with a few kit differences. Portable ventilators, advanced airway equipment including a video laryngoscope and intubation drugs are carried. This is principally due to the remoteness of some of the jobs, long transfer distances and limited medical cover available locally, although the need for pre-hospital intubation is infrequent. They also carry IV fentanyl and IV ketamine, the latter of which is often used for analgesia and is the go-to pre-hospital anaesthesia drug.
There was an impressive standard of facilities available within the emergency services headquarters (this turned out to be a recurring theme!). There was a big staff room and kitchen with barbeque-equipped balcony looking over the River Ölfusá, numerous comfortable sleeping rooms, in addition to a fully equipped gym and sauna! The staff were clearly well looked after and morale was high. Outside of clinical and general duties, staff were encouraged to relax during downtime. I got to see their multi-agency major incident and conferencing room just before we headed out on a range of calls. The majority of patients were taken to the small hospital in Selfoss, with one requiring transfer to Reykjavík.
Owing to the long transfer distances in this rural and sparsely populated part of the country, paramedics here need to be fairly autonomous and are sometimes called to assist with unwell patients in the local community hospital, which often has only junior medical cover. Where required, paramedics can also call for medical support in pre-hospital decision making. However, some of these situations may be out of the comfort zone of the local rural GP or community hospital junior doctor, so this an area which has been proposed for development, which I will touch on later. Another current issue is in relation to transitioning the paramedic working pattern away from their traditional 12-hour shifts to 8-hour shifts. This initiative has been introduced at a governmental level and there appeared to be mixed opinions about it, particularly in relation to work-life balance.
The training structure and educational opportunities for paramedics in Iceland differ somewhat to our own. Most paramedics initially undergo training to basic EMT, then intermediate EMT level in Iceland. To be certified to paramedic level however, trainees must currently study abroad. This is usually in the US, where a full-time paramedic diploma is generally 10 months in duration from intermediate EMT level. Some also go to the UK or Norway, where the training is longer but results in a bachelors degree. A full paramedic qualification in Iceland is in development but has not yet implemented.
Next week, my insight into Iceland’s ambulance system will continue when I spend time with the paramedics in Reykjavík, as well as learning about the call handling and dispatch system. A big thanks to everyone in Selfoss for making me welcome.
After this it was back to Reykjavik for an aeromedical weekend on call with the National Medical Director for Pre-Hospital Emergency Services, Dr Viðar Magnusson. This began at the headquarters of the Icelandic Coast Guard, whose hangar houses three big Eurocopter 225 Super Puma helicopters. In Icelandic fashion, these aircraft serve multiple roles, including coast guard, search and rescue and aeromedical operations, as well as civilian activities. The Coast Guard helicopter crew also operate in multiple roles – I observed the navigators and mechanics also operating as winchmen and found that all crew were trained to EMT level and able to provide support to the doctor on board.
Iceland is sparsely populated, with challenging terrain and in many places, limited road access, making the Coast Guard helicopters invaluable for certain time critical pre-hospital and retrieval work. Activations can be made by rural doctors or paramedics, either through a direct conversation with the Coast Guard helicopter doctor or via the dispatch desk operator in Reykjavík. Given the centralisation of tertiary care and the numerous small airports dotted around the country, the other key component of aeromedical operations in Iceland is fixed-wing aircraft, which I will talk more about in Part 4. At present, there are in the region of 800 fixed-wing missions and 130-160 helicopter missions per year nationally.
After being kitted out with a flight suit, boots and helmet for the days ahead, I was given a rundown of the relevant helicopter essentials by the Chief Technician, Jon (namely how to operate the seat belts, communication system and how to get out of the side windows!). I then became familiarised with the medical kit that would be on board. There were kit bags for drugs, airway and trauma equipment, a portable monitor, a Lucas mechanical CPR device, a video laryngoscope and a portable ultrasound device. Blood products are not carried on board the helicopter at present. Should this be required, the police are requested to bring blood to the scene, which can have an impact on the promptness of administration.
Although impressive aircraft capable of flying in adverse weather conditions and carrying multiple passengers or patients, the 225s are not specifically designed and configured for medical use. This results in a few ergonomic issues for medical teams to deal with. These include the loading and securing of patient trolleys, optimal placement of monitoring equipment and the ease of access to medical kit bags, which are stowed behind a removable panel at the rear of the aircraft.
Next, I attended a pre-mission brief, where the pilots, navigator, winchman (in this case also the Chief Technician) and medical staff gather to discuss flight timings, routing, weather, potential hazards and contingency plans. I found out that the first mission for the day involved participating in a simulation being filmed for a documentary about the care of stroke patients in Iceland! This involved us flying to pick up our patient around 100km away before taking them to hospital in Reykjavík, during which several photographers were filming every stage of the patient journey and capturing some dramatic action shots of the crew. I found out that this would later be aired on Icelandic TV, so apologies in advance for any terrible acting or looking like a spare part!
Our medical activations included a capsized boat in a remote lake in the Highlands region (fortunately the occupants had managed to return to shore when we arrived on scene), and a drowning-related cardiac arrest (the patient survived, largely thanks to bystander CPR). Due to the recent downturn in tourism, the demand on Iceland’s aeromedical service has been relatively low, but this is expected to increase again soon. The Coast Guard helicopter was also tasked with transporting some scientists to the currently erupting Fagradalsfjall Volcano on the Reykjanes Peninsula in south west Iceland. I was able to ride along, for which I’m very grateful as we ended up flying over an otherworldly scene of black lava flows and venting gases, before deftly landing on a small rocky hilltop in the middle of all this. An experience I will never forget!
It was interesting to hear about some of the plans and aspirations for Iceland’s pre-hospital services from Dr Magnusson. These are all driven by a central aim of improving the overall quality and timeliness of pre-hospital care, as well as the equality of access to emergency and critical care for patients living in the remote areas of the country. A key part of this is the implementation of a national helicopter emergency medical service (HEMS), together with a dedicated helicopter. As one would expect, this is no small feat, requiring commitment from government and the wider health service for funding and support. In addition to this is the need for more pre-hospital trained medical staff able to balance pre-hospital work with other professional commitments, alongside the challenges of maintaining competencies in relatively low volume service.
One of the issues facing the service at present is whether to have staff stationed in the Coast Guard base during their shifts. Currently, crews are on-call from home, meaning that if there is an activation, the pilots, mechanic, navigator, winchman, doctor and ground staff all make their way to the base. As Reykjavik is a fairly compact city, travel times are not long, but this does inevitably lead to a delay in getting airborne and on the way to a patient. The current time from activation to take off is typically around 40 minutes. There was some discussion around this following one of our activations, where it would have been desirable to minimise response time. It seems likely that the service will transition to having on-call staff stationed in the base during their shifts, but this will of course require additional financial support from the government, at a time when there are other competing health care developments.
One of the other areas to be addressed is the viability of re-distributing Iceland’s centralised helicopter resources, in order to improve medical responses in more remote areas. Currently all the Coast Guard helicopters are based in Reykjavík. One solution to improve response times and access would be have the available aircraft distributed evenly across the country (in a similar fashion to Scotland’s Emergency Medical Retrieval Service). This of course throws up issues of cost, staffing and infrastructure, with no clear and easy solutions. It is recognised that telemedicine will play an increasing role in providing decision support to remote medical staff in Iceland, although a system for this and who will staff it has not yet been determined.
An ongoing area of development has been the standardisation of Icelandic pre-hospital care through the implementation of protocols for drugs and procedures. In addition to this, a new electronic tablet-based paramedic documentation system is being developed by one of the EMT staff (the existing system is still paper-based). It is hoped that this will be much more user friendly and will assist with data capture. Another very recent development has been the addition of a response car in the Reykjavík area. Although not yet formally in service, it is envisaged this may be used by an advanced paramedic or doctor to provide pre-hospital support to paramedic crews during more challenging scenarios.
After a really interesting and memorable few days, I’m looking forward to the coming week, where I will be spending more time on the Coast Guard helicopter and with Reykjavík’s ambulance service.