Operating a National Emergency Medical Service Network

The mission was organized and executed by the Red Magen David, the Israeli equivalent to the International Red Cross, and sponsored by MASHAV, the Centre for International Cooperation of the Israeli Ministry of Foreign Affairs. The intensive three-week training mission was conducted by two senior Red Magen David personnel: Nathan Kudinsky - manager of the First Aid Training Department, and Chaim Rafalowski - director of the Emergency, Hazardous Materials and Drills Department.

While Chile does not presently suffer from terrorism, it struggles (as does much of the world) with the critical problem of serious traffic accidents and is situated in a region characterized by the threat of natural disasters - earthquakes, volcanic eruptions, tasumi tides and other phenomena.

Steps to establish a national EMS began two years ago at the personal initiative of Dr. Alfredo Mizrachi - a paediatrician from the capital city of Santiago and expert in a paediatric intensive care. Mizrachi equipped and staffed a special mobile unit for evacuation of children from traffic accidents to the Roberto del Rio Hospital where he works - a service that was later expanded to cover the whole city. Subsequently appointed special EMS advisor to the Chilean Minister of Health, Dr. Mizrachi visited Israel in the summer of 1996, after touring EMS models in the United States and Europe. The trip precipitated the Chilean request for Israeli assistance, particularly with MCIs (multi-casualty incidents) - a neutral terms which translates in human terms into horrific accidents and major catastrophes - at the hands of man or nature.

What prompted Chile to seek assistance from Israel?
Founded in 1936, the Red Magen David is an old established organization with a wealth of experience in MCIs, but it is also quite unique. The Israeli system has integrated aspects of both American and European EMS systems: American mobile units are staffed by paramedics ("rescue squads") whose role is to extend urgent care and bring the ill or injured person to a hospital as rapidly as possible; European mobile units (SAMU - Emergency Medical Services, the French model) are headed by a physician and stay at the site of the incident as long as necessary, before transferring the ill or injured to a hospital.

"Our paramedics rarely operate without an attending physician like in Europe, but the curriculum is based on the US approach - with the aim of rapid evacuation," said Rafalowski. "The American system has been modified by the Red Magen David to fit Israeli realities," he clarified. For instance, working with limited resources, there are not paramedics in all mobile units; ambulances operate on two levels - most of the fleet provide basic life support, while only some are intensive care vehicles.

Israel, due to its special situation, has developed a system that integrates operation of emergency services - medical, fire-fighting, law enforcement and others - for fuller coordination and cooperation in responding to MCIs. Moreover, the Red Magen David is a national organization. Thus, it can offer others a model and longtime experience in handling emergencies in both urban and rural settings - while elsewhere most EMS setups that can send training teams to other countries are local organizations with a narrower mandate.

Natan Kudinsky notes that there is also a departure in "personality" from the American and European EMS systems: Israelis tend to be innovative in many areas of endeavour rather than working strictly by the book - partially an outgrowth of national character, partially a product of necessity and limited budgets, he says. Thus, substitutes for expensive equipment not always available due to on-site conditions or short supply have been improvised.

All these factors singular to Israel make the Israeli EMS system particularly suitable for countries operating under far from ideal conditions - from both a medical and budgetary standpoint.

Rafalowski and Kudinsky stated that during the courses they became aware of other similarities: "The American system is very structured." For instance, ambulance and fire-fighting services are administered by the same director, and designation of authority in the handling of an emergency is mandated by law. "In Israel, as in many other countries - including Chile, these functions are not specified - a source of lack of clarity and competition which can lead to confusion if operations are not coordinated. Chile was in need of an emergency response system that can function well in the absence of clear delegation of authorities - making the Israeli model particularly suitable."

"Chile and Israel may be worlds apart geographically, but they very similar in national personality traits," commented Rafalowski. Like Israelis, among Chileans relationships are less formalized than in Europe and North America and preparation more fluid - lacking detailed pre-planning, resting on last-minute organization depending heavily on informal networking and esprit de corps to achieve the best results.

Moreover, Israelis have learned to make-do with what is available. He gives the example of treatment of spinal and neck injuries: Lacking special equipment in every evacuation vehicle, Israelis have designed low-cost but effective substitutes.

The Red Magen David mission carried out three one-week intensive introductory programs to the Israeli model: The first, in Santiago, focused on integration of all emergency services; the latter two - held in two small cities - Antofagasta in the north and Chillan in the south - focused on practical skills in emergency situations.

In the capital - where a fledgling EMS setup already operates - the two Israeli instructors concentrated on integration of emergency services in responding to an MCI. Among the 27 participants in the course were senior representatives from the Ministry of Health, the emergency medical service system (SAMU), the fire department, the police department, airport emergency unit, relevant municipalities, and guests from other regions in Chile.

The first two days were devoted to presentation of the Israeli model and the third day to a review of the Chilean experience with MCIs. The last two days of the course got down to the nitty-gritty: On day four the participants were presented with two scenarios and requested to draw up a plan for dealing with the situation: 1. a crowded public bus on its way into the capital plows into a building which subsequently is set afire, and 2. a railroad accident in an isolated outlying area of the country.

"This was the first time that all the relevant emergency services sat down together to address such a situation," disclosed Rafalowski. The last day was devoted to simulation of an integrated response with personnel from various emergency units - all told some 60 on-site personnel in addition to the 27 course participants - including establishment of a forward command post and simulation of management of the rescue and evacuation in an integrated manner. The simulation created such interest that the Minister of Health, the Mayor of Santiago and other authorities paid a visit.

The other two courses were held in the areas of the country where SAMU networks still have to be established. These two course focused on practical training for medical personnel (doctors, nurses) from Antofagasta and Chillan as well as outlying areas - in on-site techniques of patients and casualties in need of immediate attention.

Four days of the course were dedicated to instruction in techniques and procedures used in Israel with the fifth day devoted to simulation of a serious road accident - with emphasis on extrication of casualties, classification of injuries and on-site treatment - including techniques developed in Israel to deal with emergencies situations and a limited supply of specially-designed but inexpensive equipment. Thus, for instance, the participants learned a "rolling blanket" technique, based on an ordinary blanket and special triangles of cloth, for safely moving casualties with neck or spinal injuries and an effective pressure dressing that can be improvised anywhere.

In addition to emergency medical services, Israel has the ability to provide others with inexpensive frameworks that are nevertheless effective in real-life situations. Ideally, if an ambulance can't arrive in 8 minutes, one should add more ambulances, but not every country has the resources to opt for such a "deluxe" solution. Israel augments its own limited resources through a network of trained volunteers equipped with beepers or walkie-talkies who live or work in a particular vicinity of city and rural areas - designed to be first-responders until emergency units can arrive at the scene of an incident. Moreover, the Israeli approach holds that professional personnel should mobilize passing pedestrians at the scene of an incident to aid them in administering first aid, which in an MCI can literally save lives.

The Israeli blood bank system is also unique, added Rafalowski. In many western countries blood banks buy blood; in Israel blood donors are attracted with a different incentive: each donor is rewarded with "insurance" for their family - a supply of blood should they need it for any reason (an operation, an accident) during the year following the donor's visit to the blood bank. This allows the blood bank to maintain a level of supply capable of dealing immediately with an MCI, without having to call in donors off the street.

The three-week Red Magen David mission to Chile was the first international cooperation project in which the Red Magen David has participated, concluded Nathan Kudinsky, "The experience was a successful one. We realized the goals we set for ourselves and the courses were positively received by participants in the host country. If other countries believe they can benefit from the Red Magen David model, we would be glad to assist," he said.