Week 2 – SMUR
After a trip up to Paris last weekend for the marathon I felt back in the deep at the start of this week after a weekend of English! This week I have spent doing some filière courte, where there has been a lot of suturing to do. Other than that I have been shadowing the interns looking after patients in the “boxes” (a small cubicle which can hold two patients – there are 12 of these boxes). I was able to make myself useful explaining a patient’s situation (non-French speaker but their second language was English) to them and their partner.
Service Mobile d’Urgence et Reanimation (SMUR)
Yesterday I did my first shift with the SMUR team based in Aix, which was great. This is a prehospital emergency team consisting of a driver (fire fighter), consultant ED physician, a junior doctor, a nurse and usually a student nurse. But there was space for me as there was no student nurse yesterday. The driver and consultant are both on call for 24 hours and often get no sleep at all. SMUR is not to be confused with SAMU (le Service d’Aide Medicale Urgente), which coordinates the treatment and logistics of prehospital medical emergencies, i.e. deciding which team is sent to different patients.
The whole prehospital emergency medicine organisation is very different in France to the UK. The majority of evacuations to hospital are carried out by the Pompiers (fire fighters). My understanding is that generally speaking the Pompiers have limited medical training by comparison to UK paramedics (now a 3 year undergraduate degree), from what I have seen so far they have equipment to perform basic obs (pulse and oxygen saturation) and give oxygen. The Pompiers are able to evacuate most patients to hospital to receive treatment there, but when urgent medical intervention, help or monitoring during the journey is needed the SMUR team is called. The SMUR team is also called to major road accidents and suspected major medical emergencies, e.g. chest pain. There are also a whole subsidiary group of private ambulances offering the same service, so they are all in competition.
Having had some experience shadowing paramedics in the UK I noticed some subtle differences in the way the services operate. In the UK the driver has an onboard computer and the operator at the call centre is able to upload the location, route, clinical details to that system to the paramedics can see it. In comparison in France we used a tomtom satnav to navigate. However, one thing that I found could be really useful in the UK is that the French consultant had a dedicated SMUR smartphone with a SMUR app. This synchronised with the control centre and showed details of the patient on it. She was able to write contemporaneous notes on it in most cases (unless required to be directly involved in patient care), which were available to the control centre and could be printed off on arrival at hospital for the receiving team. A lot more practical than trying to write on the move in an ambulance and saving time on arrival writing out the sequence of events on paper.
One patient we were called to see yesterday was a 70-year-old lady with chest pain who had had stents fitted for chest pain 2 weeks previously, but left hospital against medical advice due to the death of her husband. The SMUR team arrived a few moments before the Pompiers, myself and the junior doctor took the stairs and the others took the lift. Unfortunately the lift got stuck with 6 people in due to the weight, so after the intern and I eventually found the patient’s flat we assessed the patient. The ECG showed signs of lateral ischaemia, and a new onset atrial fibriliation with fast ventricular response. She received some IV diltiazem (to increase coronary blood flood, lower blood pressure and to try to treat SVT) and was taken to the intensive cardiac care unit at a near by private hospital (or clinique in French), where she had been a patient a few weeks previously.
The last patient we saw before heading to get some sleep was a comatose diabetic man on insulin who had a blood glucose of 18mg/dl (1.0mmol/L UK units), after giving a lot of IV glucose he started to wake up, it was amazing to see how quickly and effectively it could be reversed, but also to consider how dangerous or even fatal hypoglycaemia can be if missed or misdiagnosed. Over the night we weren’t called out once between 10pm and 8am, which I’ve been told is a rarity!