Macedonia has universal public health care coverage. Acute and emergency patient care is provided in different care environments based on the medical complaint and resource proximity. While emergency medicine and well organized emergency departments (EDs) are an essential component of any developed health care system, emergency medicine as a specialty is relatively non-existent in Macedonia.A system assessment regarding presence, availability and capacity of EDs was completed from 2013-2015, based upon assessments of 21 institutions providing emergency care and information provided by the Ministry of Health. This assessment establishes a benchmark from which to strategically identify, plan and implement the future of emergency medicine in Macedonia.In general, emergency departments - defined by offering acute care 24 hours per day, 7 days per week - were available at all general and university hospitals. However, care resources, emergency and acute care training, and patient care capacity vary greatly within the country. There is limited uniformity in acute care approach and methodology. Hospital EDs are not organized as separate divisions run by a head medical doctor, nor are they staffed by specialists trained in emergency medicine. The diagnostic and treatment capacities are insufficient or outdated by current international emergency medicine standards and frequently require patient transfer or admission prior to initiation.Most of the surveyed hospitals are capable of providing essential diagnostic tests, but very few are able to do so at the point or time of presentation. While emergency medical services (EMS) have improved system-wide, emergent care interventions by EMS and within all hospitals remain limited. Further system-wide acute and emergency care improvements are forthcoming.

Improvements in emergency response can help prevent deaths and life-changing injuries in road collisions. However, emergency response has not been getting a fair share of attention in terms of research, best practice exchange and measures in the European Union. The aim of the Revive project is to map Emergency Medical Service (EMS) and Fire and Rescue Service (FRS) practices in the EU28 and raise the profile of both EMS and FRS on the national and European political agendas.

The Revive project aims at improving post-crash care provided by EMS and FRS in order to mitigate the consequences of road collisions. One of the key outcomes of the project is to have established an international network of experts, researchers and practitioners in the field of post-collision care and emergency response. Lastly, the Revive project has contributed to promoting the need for EU-wide action on tackling serious road traffic injuries.

Injury is a major cause of premature death and disability worldwide. Most existing injury control strategies focus on primary prevention – that is, avoiding the occurrence of injuries or minimizing their severity – or on secondary prevention – providing adequate medical response to enhance treatment and thereby minimize harm following an injury. In many instances the prompt provision of emergency care and rapid movement of injured victims from the scene of injury to a health-care facility can save lives, reduce the incidence of short-term disability and dramatically improve long-term outcomes. Unfortunately, the capacity to provide this basic level of medical care does not exist in many parts of the world.

Abstract:

The emergency medical healthcare system outside hospital varies greatly across the globe - even within the western world. Within the last ten years, the demand for emergency medical service systems has increased, and the Danish emergency medical service system has undergone major changes.

Therefore, we aimed to provide an updated description of the current Danish prehospital medical healthcare system.

Since 2007, Denmark has been divided into five regions each responsible for health services, including the prehospital services. Each region may contract their own ambulance service providers. The Danish emergency medical services in general include ambulances, rapid response vehicles, mobile emergency care units and helicopter emergency medical services. All calls to the national emergency number, 1-1-2, are answered by the police, or the Copenhagen fire brigade, and since 2011 forwarded to an Emergency Medical Coordination Centre when the call relates to medical issues. At the Emergency Medical Coordination Centre, healthcare personnel assess the situation guided by the Danish Index for Emergency Care and determine the level of urgency of the situation, while technical personnel dispatch the appropriate medical emergency vehicles. In Denmark, all healthcare services, including emergency medical services are publicly funded and free of charge. In addition to emergency calls, other medical services are available for less urgent health problems around the clock. Prehospital personnel have since 2015 utilized a nationwide electronic prehospital medical record. The use of this prehospital medical record combined with Denmark’s extensive registries, linkable by the unique civil registration number, enables new and unique possibilities to do high quality prehospital research, with complete patient follow-up.

Abstract
Although much is known about EMS care in urban, suburban, and rural settings, only limited national data describe EMS care in isolated and sparsely populated frontier regions. We sought to describe the national characteristics and outcomes of EMS care provided in frontier and remote (FAR) areas in the continental United States (US). We performed a cross-sectional analysis of the 2012 National Emergency Medical Services Information System (NEMSIS) data set, encompassing EMS response data from 40 States. We linked the NEMSIS dataset with Economic Research Service-identified FAR areas, defined as a ZIP Code >60 minutes driving time to an urban center with >50,000 persons. We excluded EMS responses resulting in intercepts, standbys, inter-facility transports, and medical transports. Using odds ratios, t-tests and the Wilcoxon rank-sum test, we compared patient demographics, response characteristics (location type, level of care), clinical impressions, and on-scene death between EMS responses in FAR and non-FAR areas. There were 15,005,588 EMS responses, including 983,286 (7.0%) in FAR and 14,025,302 (93.0%) in non-FAR areas. FAR and non-FAR EMS events exhibited similar median response 5 [IQR 3-10] vs. 5 [3-8] min), scene (14 [10-20] vs. 14 [10-20] min), and transport times (11 [5.,24] vs. 12 [7,19] min). Air medical (1.51% vs. 0.42%; OR 4.15 [95% CI: 4.03-4.27]) and Advanced Life Support care (62.4% vs. 57.9%; OR 1.25 [1.24-1.26]) were more common in FAR responses. FAR responses were more likely to be of American Indian or Alaska Native race (3.99% vs. 0.70%; OR 5.04, 95% CI: 4.97-5.11). Age, ethnicity, location type, and clinical impressions were similar between FAR and non-FAR responses. On-scene death was more likely in FAR than non-FAR responses (12.2 vs. 9.6 deaths/1,000 responses; OR 1.28, 95% CI: 1.25-1.30). Approximately 1 in 15 EMS responses in the continental US occur in FAR areas. FAR EMS responses are more likely to involve air medical or ALS care as well as on-scene death. These data highlight the unique characteristics of FAR EMS responses in the continental US.

Abstract
The cost of ambulance services is very high for patients. A patient who uses an ambulance can expect to pay hundreds of dollars for even the most basic ambulance service. There are many reports of patients receiving basic medical care in an ambulance and being charged extremely high costs as if their injuries were more serious. The problem is that the service levels of EMS systems are not diversified enough to isolate costs. The financial burden of preparing to handle major incidents and managing ambulance vehicles and equipment increases the cost of basic ambulatory services.

Abstract
Trauma pain represents a large proportion of admissions to emergency departments across Europe. There is currently an unmet need in the treatment of trauma pain extending throughout the patient journey in emergency settings. This review aims to explore these unmet needs and describe barriers to the delivery of effective analgesia for trauma pain in emergency settings. A comprehensive, qualitative review of the literature was conducted using a structured search strategy (Medline, Embase and Evidence Based Medicine Reviews) along with additional Internet-based sources to identify relevant human studies published in the prior 11 years (January 2006–December 2017). From a total of 4325 publications identified, 31 were selected for inclusion based on defined criteria. Numerous barriers to the effective treatment of trauma pain in emergency settings were identified, which may be broadly defined as arising from a lack of effective pain management pan-European and national guidelines, delayed or absent pain assessment, an aversion to opioid analgesia and a delay in the administration of analgesia. Several commonly used analgesics also present limitations in the treatment of trauma pain due to the routes of administration, adverse side effect profiles, pharmacokinetic properties and suitability for use in pre-hospital settings. These combined barriers lead to the inadequate and ineffective treatment of trauma pain for patients. An unmet need therefore exists for novel forms of analgesia, wider spread use of available analgesic agents which overcome some limitations associated with several treatment options, and the development of protocols for pain management which include patient assessment of pain. Funding: Mundipharma International Ltd. Electronic supplementary material The online version of this article (10.1007/s40122-018-0101-1) contains supplementary material, which is available to authorized users.

A collection of European standards in medical training

Abstract
The ambulance-planning problem includes operational decisions such as choice of dispatching policy, strategic decisions such as where ambulances should be stationed and at what times they should operate, and tactical decisions such as station location selection. Any solution to this problem requires careful balancing of political, economic and medical objectives. Quantitative decision processes are becoming increasingly important in providing public accountability for the resource decisions that have to be made. This chapter discusses a simulation and analysis software tool ‘BartSim’ that was developed as a decision support tool for use within the St. John Ambulance Service (Auckland Region) in New Zealand (St. Johns). The novel features incorporated within this study include the use of a detailed time-varying travel model for modelling travel times in the simulation, methods for reducing the computational overhead associated with computing time-dependent shortest paths in the travel model, the direct reuse of real data as recorded in a database (trace-driven simulation), and the development of a geographic information sub-system (GIS) within BartSim that provides spatial visualisation of both historical data and the results of what-if simulations. Our experience with St. Johns, and discussions with emergency operators in Australia, North America, and Europe, suggest that emergency services do not have good tools to support their operations management at all levels (operational, strategic and tactical). Our experience has shown that a customized system such as BartSim can successfully combine GIS and simulation approaches to provide a quantitative decision support tool highly valued by management. Further evidence of the value of our system is provided by the recent selection of BartSim by the Metropolitan Ambulance Service for simulation of their operations in Melbourne, Australia. This work has led to the development of BartSim’s successor, Siren (Simulation for Improving Response times in Emergency Networks), which includes many enhancements to handle the greater complexities of the Melbourne operations.