EMS Around the World: A Profession In Its Infancy

Editor’s note: This is the first in a new bimonthly column profiling EMS systems around the globe.

Poland’s national emergency medical service was founded with an enabling act passed in 2006 and last updated in 2015. This article profiles the example of the provincial emergency station in Gorzow Wielkopolski, which fields two types of rescue crews and is Poland’s first fully functioning centralized medical dispatch center. 

Gorzow Wielkopolski is a town in western Poland, the largest in Lubuskie region, situated on the River Warta about 60 km from the border with Germany. Emergency medical services operate from a provincial emergency station managed by Dr. Andrew Szmit, a specialist in emergency medicine, anesthesiology, and intensive care, as well as a regional emergency medicine consultant. The region has approximately 170,000 residents. The jurisdiction has six fixed-duty ambulances; four have specialized crews with doctors, and two have basic crews (two paramedics), but all can provide ALS-level care.

The legislation governing Poland’s national emergency medical service determines the organization’s rules, functioning, financing, and provision of education. The system’s objective is to ensure that any person in an emergency will be provided with health assistance. Supervision and control are exercised by the government. The minister responsible for health oversees the system throughout the country, and the provinces (the Polish equivalent of counties) are supervised by provincial governors using a national EMS regional action plan. 

The Polish system for delivering emergency medical care includes hospital emergency departments (known by the acronym SOR) and both emergency medical (ZRM) and air-medical (HEMS) rescue crews. Emergency crews provide triage and basic stabilizing treatment for those in emergencies, then transport them to emergency departments. 

The EDs also provide assistance to any person who believes their health is in danger without any referral. Triage separates those who face immediate health hazards from those who do not require immediate attention. 

EMS crews (locally ZRM) provide services in case of prehospital emergencies. Their “S” teams include at least three persons authorized to carry out medical emergency treatment, including a physician and nurse or paramedic. The physician will be a specialist in the field of emergency medicine or one who has work experience of at least 3,000 hours in the medical profession—on the SOR, ZRM, HEMS, or at a hospital emergency department.

The nurse will hold a specialist title or specialize in the field of emergency nursing, anesthesiology and intensive care, surgery, cardiology, or pediatrics. They also complete qualifying courses in emergency nursing for anesthesiology and intensive care, surgery, cardiology, and pediatrics, and have at least three years’ work experience in hospital EDs or specialty wards.

The Paramedic Profession

The occupation of paramedic appeared in Poland in the 1990s, replacing the professions of “first-aid worker” and “stretcher carrier.” Its goal was to prepare professional medical staff to assist patients in emergencies involving health or life.

In Poland licenses are required of doctors, pharmacists, nurses, and even some medical-related professions, but paramedics are not licensed. They practice skills obtained in the course of training, on the basis of a diploma that confers certain qualifications. The job can be performed by any person with full legal capacity, adequate health, fluent Polish, and suitable qualifications. At the moment the educational path includes higher education that lasts three years or specialization in emergency medical services. 

Paramedics may practice in the form of an employment or civil/legal contract. It is controversial that they must document further training in the form of service courses and self-study; at least 200 education credits must be scored within five years, including at least 120 for participation in the course and passing an examination. 

The professional paramedic in Poland is to protect persons on accident scenes and also perform medical-rescue activities outside the system—e.g., when working in hospital wards and other centers of wider health service; these activities are defined as healthcare services other than medical-rescue.

Medical-rescue activities carried out by Polish paramedics involve medical evaluation of the patient and determining appropriate interventions, if any. They conduct CPR to current standards. Their skills, tools, and equipment include:

• Tubes (oro- and nasopharyngeal), face mask, laryngeal mask and tubes, and equipment for airway suctioning and conicopuncture if necessary. 
• Oxygen and breathing/ventilation assistance, including face mask, one-way valve and breathing bag, and ventilator. Endotracheal intubation in direct laryngoscopy in cardiac arrest can be accomplished through the mouth or nose, without the use of muscle relaxants and while running ventilation replacement. 
• Performing manual defibrillation based on the ECG, implementing automated defibrillation, monitoring of respiratory function, noninvasive cardiovascular monitoring, percutaneous electrical stimulation of the heart in bradyarrhythmia, performing cardioversion for tachyarrhythmia, and obtaining and evaluating ECGs.
• Peripheral vein cannulation of upper and lower limbs and the external jugular vein, intramedullary access using a kit. Administration of medications by intravenous, intramuscular, subcutaneous, intratracheal, oral, rectal, inhalation, and intramedullary routes. Pressure pneumothorax decompression by puncture of the pleural cavity, downloading venous and capillary blood for laboratory tests. 

In addition there is wound healing, stopping bleeding, immobilization of fractures, dislocations and sprains, and spinal immobilization with particular emphasis on the cervical (i.e., typical BLS). Paramedics can also assist with births outside hospitals, take temperatures, conduct triage, take protective measures to reduce the health effects of events, and prepare patients and provide medical care during transport.

They can also conduct certain interventions under medical supervision, such as endotracheal intubation in direct laryngoscopy in cases other than sudden cardiac arrest with the use of muscle relaxants; catheterization of the bladder; inserting gastric probes after securing the airway; assisting in minor surgical procedures (stapling wounds, etc.); and other medical procedures. 

Centralized Dispatch

The position of dispatcher plays a key role in the Polish emergency medical system. We call the dispatcher the “first rescuer,” who has first contact with the person requesting assistance. The dispatcher decides whether to send a medical rescue team or not; if not, they give instructions for further proceedings. The national EMS law specifies who can become a medical dispatcher and the job tasks involved.

Dispatchers collect information through procedures for answering calls and dispatching rescue teams. Interview algorithms contain questions and recommendations to support decision making based on best current medical knowledge. In Poland there are several guidelines for dispatchers, so the dispatcher chooses what’s appropriate or leaves it to the discretion of the “head,” who is responsible for proper functioning of the dispatch center. 

Regulations define dispatcher qualifications. A medical dispatcher in Poland may be a person who has at least a secondary education in the profession of nurse or paramedic and was trained in dispatching and has been employed for at least five years providing care at a hospital emergency department or emergency medical services in a hospital emergency department or department of anesthesiology and intensive care.

Like paramedics, dispatchers must undergo additional vocational training such as improvement courses and seminars. 

Command Support

Poland’s first SWD PRM (the command support system for the national emergency medical service) was introduced at our station, WSPR Gorzow Wielkopolski, on June 23, 2016. It initially included the disposal of six ZRM, but currently medical dispatch manages and has 17 ZRM in the city of Gorzow Wielkopolski, plus helicopter EMS (labeled as Lifeguard 24). 

SWD PRM functioning in our station consists of several modules:

• Administrator—This covers user rights management and regional ambulance data for particular administrators.
• Dispatcher—For receiving and managing requests from the emergency numbers, 1-1-2 and 9-9-9; direction of medical rescue teams in the areas of operation.
• Mobile—Receiving calls from the dispatcher on a tablet computer; completing departure documentation; creating medical documentation; updating ZRM statuses.
• Reporting—Reporting.
• Place of stationing—Starting and ending duty (system log-in and log-out), ability to take orders, ability to complete departure data.

The Ministry of Health has prepared a draft of changes to the rules governing the national emergency medical service. Among the changes it seeks is to remove private medical companies from the provision of emergency medical services and introduce motorcycle rescue crews for certain times of the day and year. The ambulances will have three-person crews but no doctors.

Conclusion

The occupation of paramedic is relatively young in Poland, but leaders intend to provide paramedics with a wider range of skills and increase their powers, making the profession increasingly independent. This will require constant improvement of their abilities, as they are responsible for the lives of patients. But in the rescue environment and other medical areas, views of the future often entail a medical system in which paramedics play a greater role.  

Robert Rajtar has 14 years of experience as a paramedic-driver and 9 as medical dispatcher for SOR in Gorzów Wielkopolski, medical rescue crews in Szczecin, and in Berlin, Germany. He currently works at the provincial emergency station in Gorzów.