Emt comparison

Emergency Medical Transport: A Juxtaposition of Houston and Istanbul Matthew J. Stampfl, AEMT [26 April 2013]

112 ambulance driving emergency

HFD crew loading a patient into an ambulance

Created for Global Urban Lab Rice University: School of Social Sciences & Kinder Institute for Urban Research

Table of Contents Table of Contents .................................................................................................................. 1 Executive Summary ............................................................................................................... 2 Report ................................................................................................................................... 3 The Issue........................................................................................................................................3 The Research..................................................................................................................................3 The Findings ...................................................................................................................................3 Means of Transport:.............................................................................................................................. 4 Differences in Urban Layout .............................................................................................................................4 Knowledge of Transport Options......................................................................................................................5 Walking/Privately Owned Vehicles (POV) ........................................................................................................6 Public Transit/Taxis...........................................................................................................................................6 Ambulances ......................................................................................................................................................6 Air Medical Transport .......................................................................................................................................8

Care provided en route: ........................................................................................................................ 9 Comparative EMS systems ...............................................................................................................................9 Public/Private ambulances .............................................................................................................................11

Implications .................................................................................................................................11 What the results mean: ...................................................................................................................... 11 What do we still need to know: .......................................................................................................... 12 Concluding thoughts: .......................................................................................................................... 12

Acknowledgments ............................................................................................................... 13 Bibliography ........................................................................................................................ 13

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Executive Summary Emergency medical transport is an integral part of a modern healthcare system but its practice varies greatly around the globe. The fundamental processes of emergency medical transport may be broken down into two aspects: the means of transportation used and the care that is provided while en route to definitive treatment. In seeking to explore these dimensions, Istanbul and Houston make a compelling pair for analysis, given their vastly different urban layouts and healthcare systems. Houston’s health system may be considered highly developed, possessing as it does the largest medical center in the world and one of the oldest air medical response teams, but it is also dysfunctional in terms of its exorbitant costs and obsession with liability. Istanbul provides universal medical coverage for its citizens but its health system, especially in emergency medicine, is still attempting to attain to higher standards of care. As this report will detail, significant differences exist between the emergency medical transport in Houston and Istanbul in areas such as the training of various levels of providers, the degree of decision-making assigned to dispatchers, and the obligation of an ambulance to provide transport. Further research remains to be done, however, particularly with regard to the patient outcomes obtained under each system and their long-term sustainability.

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Report The Issue What would you do if a loved one in your home suddenly collapsed, apparently from a heart attack? Most likely you would seek for a way to rush them to the hospital. Enter emergency medical transport, what we often experiences as whirling sirens and speeding vehicles, an essential component of modern healthcare systems.

Emergency medical transport may be defined as the means of movement through which a person suffering from an acute medical condition or status seeks definitive care. That movement may occur by ambulance, privately owned vehicle, public transit or other means. Emergency medical transport can be vital for time-sensitive conditions such as myocardial infarctions (heart attacks), strokes, and multisystem trauma from a vehicular accident. Emergency medical transport is a relatively new phenomenon and one that differs greatly in practice around the globe. Indeed, the concept of emergency medicine as a distinct discipline has only existed for around 60 years and its spread worldwide has occurred even more recently. For instance, the first ambulance service in Turkey began operation in 1986 (Musa). Emergency medicine is far from monolithic across the globe, and emergency transport is often a key area of distinction between countries. Two broad schools of thought exist on the optimal way to provide emergency medical services: Anglo-American and Franco-German. The former, which is used in the United States, relies on emergency medical technicians (EMTs) and/or paramedics to rapidly transport a patient to an emergency department while the latter, Turkey’s approach, involves physicians providing care out in the field to a greater degree. Of course, those categories can serve to obscure as much as they reveal about the systems under consideration. Delving deeper into how emergency medical transport varies between Houston and Istanbul, particularly regarding the means of transport used and the care provided en route to definitive care, is far more illuminating and may serve to identify possible improvements in the practices of both systems.

The Research I conducted a literature review of articles relating to emergency medical service (EMS) and emergency medicine in Houston and Istanbul. EMS research is somewhat uncommon but Houston is a major focal point for it due to the presence of the Texas Medical Center, the largest medical complex in the world. For instance, a classic study that eventually led to the discontinuation of the pneumatic antishock garment was conducted in Houston (Pepe). Fewer articles exist for Istanbul, and much of what does exist is in Turkish. The literature collected was often technical and narrowly focused so it was analyzed for general principles that could be extracted. In-person interviews were conducted with emergency medical physicians and other officials in Istanbul to gain background knowledge about the functioning of emergency medical transport. These interviews were structured from an interview guide but spontaneous questions were also employed extensively to probe interesting topics that came up in conversation. Finally, reports published by the Houston Fire Department as well as my personal experience with Rice EMS in Houston were instrumental in that portion of the research.

The Findings For accessibility, the findings of this report are broken out into the two primary research foci: the means of transport used and the care provided en route to definitive treatment.

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Means of Transport: Differences in Urban Layout

A considerable part of the appeal in juxtaposing the emergency medical transport of Houston and Istanbul is the immense disparity in the cities’ physical layout. Houston is a sprawling metropolis with a defined “car-culture,” boasting massive highways and multiple beltways. In contrast, Istanbul packs its far larger city population (13.8 vs. 2.2 million) into a roughly equivalent area (Istanbul Metropolitan Municipality). Furthermore, Istanbul’s history extends back well before the advent of the automobile, a reality reflected in its scheme of narrow, clustered streets. Few of Istanbul’s highways have more than six lanes while in Houston 12 or more lanes is not uncommon. However, Istanbul possesses a far more developed public transit system than does Houston. These physical and infrastructural differences pose alternative sets of transportation challenges for the two cities.

The extent of public transit in Istanbul and Houston is markedly dissimilar. Houston has a single metro rail line that extends for 7.5 miles and a fleet of 1,230 buses (“An Overview”). As mentioned above, Houston could be said to epitomize America’s car culture and is laid out in such a fashion that traveling without a car is a serious inconvenience. Istanbul possesses 2,768 buses and over 230 km (143 mi) of various types of rail (“Istanbul 2020”). Both cities are likely to continue to see rapid population growth and consequently have plans to bolster their public transportation system. Houston plans to add 30 miles of light rail as well as 40 miles of Bus Rapid Transit (BRT) routes and additional High Occupancy Vehicles (HOV) lanes (“An Overview”). Meanwhile, Istanbul has its Integrated Urban Transport Master Plan (IUAP), which includes the Marmaray project (connecting the European and Asian sides of the city with the deepest submerged rail tunnel in the world) and an expansion to 266 km of rail network by 2018 (“Istanbul 2020”). Indeed, Istanbul’s city government perceives the movement towards additional public transit like rail and BRT as a key part of improving the effectiveness of its emergency medical transport (Istanbul Metropolitan Municipality). Nevertheless, tax incentives and HOV lanes to discourage cars have not been implemented as they could be (Goymen).

Interestingly enough, despite the disparities in their road networks, the primary EMS agencies of Houston and Istanbul have broadly similar goals for their overall response times.

Houston Fire Department (HFD) aims to have advanced life support (ALS) on scene within eight minutes on 90% of calls (“Houston Fire”). Meanwhile, the ambulances of Istanbul’s 112 service (named for the Turkish emergency medical care number) also have a goal of an eight-minute response time, although it is acknowledged that they do not always achieve that goal (Açiksari).

However, HFD seeks to have basic life support (BLS) or first responders on scene within four minutes, a goal that may not be feasible in the context of Istanbul (“Houston Fire”). Transport times to the hospital are another key indicator of the effects of congestion on emergency medical transport but unfortunately it is difficult to acquire the necessary empirical data from the agencies involved. Anecdotal evidence from Turkish emergency medical physicians at multiple hospitals (American Hospital and Dr. Sadi Koacek Research and Training Hospital) indicates that the number of patients who come into the emergency department is highly correlated with traffic conditions (Selek, Açiksari). Rush hour traffic was described as producing a sharp drop in the number of patients arriving. Presumably similar effects may be observed in Houston, although the increased number of highway lanes available may ameliorate traffic’s impact to some degree.

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Such delays pose a significant obstacle for emergency medical transport, and both systems have various measures in place to deal with this issue. In Istanbul, a recent innovation has been the introduction of EDS (translates as electronically controlled systems) lanes reserved for emergency vehicles.

These exist on major roads, often claiming one of the three lanes available. However, given Istanbul’s congestion, the temptation for other vehicles to abuse the EDS lanes is Figure 1: EDS Lane in Istanbul considerable. A network of traffic cameras exists to enforce the restricted use of the EDS lanes by capturing images of the license plates. The owners of vehicles who misuse them are subject to fines. This technical infrastructure was not in place when the lanes were first deployed, though, and consequently a culture of impunity was established. While conducting research in Istanbul, our group certainly spent a fair deal of time in EDS lanes (as Figure 1, taken over the bus driver’s shoulder, suggests). Professor Goymen of the Istanbul Policy Institute recapped the situation nicely by sharing a Turkish saying: “Rules are there to be broken. Otherwise they have no use” (Goymen). Even after the traffic cameras were activated, the effectiveness of the system was hampered by the delayed nature of the punishment as drivers received their fine long after the infraction occurred. A campaign is currently underway to address these difficulties. The fines are relatively steep at 200 to 300 dollars and an email system is being established to inform drivers of their fines in a timely fashion. Imprisonment is also being mooted as an option for continual abuse as some wealthy Turks may find the convenience of the EDS lanes worth the cost of the fines. In spite of the struggle to reserve the lanes, Turkish physicians did indicate that the lanes were reducing transport time (Açiksari).

Another technique used to help ambulances struggling with congestion in Istanbul is the availability of physician response teams. If an ambulance should be stuck in traffic with a patient in poor or rapidly deteriorating condition, it can request for physician backup. Emergency medical physicians will respond in an ambulance to meet the patient en route to the hospital and provide the required stabilizing care while continuing transport. Alternatively, both Houston and Istanbul map traffic conditions from cameras, but Istanbul integrates the information with its ambulances to avoid getting them stuck in jams (Açiksari). In Houston, one of the primary tools for confronting lengthy transport times or congested freeways is air medical transport, to be discussed later in this report. Istanbul also incorporates air medical transport, but to a lesser degree, at least for initially transporting patients to hospitals. One other HFD response to congestion is its employment of “Squads” in order to reduce its ALS response time during high call volumes. These units consist of two paramedics in a non-transport vehicle that responds to calls but hands the patient off to a BLS ambulance for transport unless ALS care is required so the Squad can return to service more quickly (“Houston Fire”).

Knowledge of Transport Options

A factor easy to overlook in the process of choosing a means of emergency medical transport is the necessity for a person to be aware of an option before it can be selected. In the United States, the ubiquity of 911 makes it seem inevitable that people know that they can call to request an ambulance. Indeed, 911’s cachet is enough that some nations like Australia, where there is a strong US media influence, have to emphasize what their own emergency numbers are to prevent their citizens from defaulting to 911 (“Using Other Emergency Numbers”). The novelty of Istanbul’s 112 number (it entered use in 1993) means that it cannot take that kind of 5|Page

awareness for granted and instead has to strive to ensure its citizens know their options. That lack of awareness means that the basic instinct of most Turks is to bundle a sick or injured person into the nearest car to take to the hospital. A further complexity existing in Istanbul is the presence of multiple emergency numbers. As noted, 112 is for the ambulance service, but 155 summons police, 110 calls the fire brigade, and there are several other minor numbers.

Fortunately, a project has been underway since 2005 to replace all of the existing numbers with 112 in order to create a unified emergency response number. Promotion of 112 as the sole emergency number will include celebrating 112 day, advertising campaigns, a promotional DVD, social media, and activities directed towards tourists in the airports (“Turkish 112”).

Walking/Privately Owned Vehicles (POV)

Many patients arriving at emergency departments travel by privately owned vehicles (POV). In some cases patients believe that their condition is not serious enough to merit ambulance transport or are deterred by the perceived cost of an ambulance. Or, as discussed above, it may not occur to the patient that taking an ambulance is an option. The owner of the vehicle used may vary from a family member to a friend to even a complete stranger who is willing to help. Walking tends to be a less common option as it may not be possible depending on the patient’s condition and it is only feasible for those within a certain radius of a hospital.

The neighborhood surrounding a hospital can be an influential factor in how patients arrive.

Istanbul’s American Hospital lies in a district characterized by narrow streets brimming with shops and is not at all conducive to public transportation so consequently the majority of its patients arrive by POVs (Selek). Our research group personally experienced the impact of the congestion in that area when we attempted to travel to the American Hospital by bus. We were making such slow progress that we ultimately got off and walked the rest of the way to the hospital.

Public Transit/Taxis

Taxis could be classified under POVs as they share many of the same characteristics.

However, the use of a taxi for emergency medical transport raises some interesting issues as the taxi driver is transporting a passenger who could potentially deteriorate over time and with whom the driver likely has no previous relationship. Another interesting line of questioning to be further probed is point of origin for journeys involving POVs or taxis. It appears plausible that emergency medical transport involving a taxi would be more likely to originate from a public space where a taxi could be easily hailed compared to a private location. Then there is public transit. It may appear to be an odd method to choose during an emergency but depending on the circumstances it may be the only affordable option available. As Istanbul seeks to move away from the automobile and towards public transport, such methods may be increasingly used, especially among lower socioeconomic groups lacking awareness of alternatives.

Ambulances

Ambulances are the prototypical means of emergency medical transport. They may be a part of either a private or public organization. Both Houston and Istanbul have one major governmental provider, respectively the Houston Fire Department (HFD) and the 112 ambulance service, and a number of private providers. Both public ambulance systems rely on a network of stations where the ambulances and crew wait before being dispatched. The Bosporus Strait divides Istanbul into its European and Asian sides and its public ambulances are split between the two sides roughly in proportion to population with approximately 105 present on the 6|Page

European side and 55 stationed in Asia. Each side has its own primary dispatch center but they are interlinked with one another and can take over the operations of the other if one were to go down (Ozucelik). In Houston, instead of distributing ambulances to minimize average response times, they are deployed according to fractal times. These are determined by breaking down response times by sectors of the city of Houston. This implies that areas with a higher call volume will have a greater number of units assigned to them, although all districts share the same response time goals (“Houston Fire”).

Private ambulances are an entirely different story, although they are subject to regulation by the health authority in both cities. In Houston, many of the private ambulance services work primarily in inter-facility transfers or shuttling patients from one hospital to another. For Istanbul, regulations make it difficult for private companies to own multiple ambulances, but they are involved in emergency transport to private hospitals such as American Hospital (Açiksari). The socioeconomic groups that use private compared to public ambulances tend to be wealthier in Istanbul (Tokyay). This is likely due to the additional cost and need for knowledge regarding the availability of private ambulances. In Houston, the use of ambulances in general appears to be more prevalent among poor segments of the population as their health tends to be worse and they have fewer alternatives for getting to a hospital. Of course, the near universal knowledge of the availability of ambulance transport is probably also an important factor in determining Houston usage patterns.

Another fundamental aspect of ambulance transport is how the ambulance actually moves through the city, interacting with other traffic. Both Houston and Istanbul have regulations specifying what is permitted while driving “emergency.” The primary regulations on emergency vehicles in Houston are determined by the Transportation Code of the state of Texas. Per Title 7, Subtitle C, Chapter 546, emergency vehicles are permitted to travel through a red light after Figure 2: 112 ambulance driving emergency slowing for safety, exceed the minimum speed limit, and disregard regulations on the direction of traffic provided that the vehicle is on an emergency call and still exercises appropriate regard for the safety of all persons. Furthermore, Section 545.156 mandates that other vehicles yield the right-of-way when approached by an authorized emergency vehicle (“Texas Constitution and Statues”). Istanbul has broadly similar regulations including permitting traveling through red lights, the use of higher rates of speed, and the requirement for other vehicles to yield. Ambulances in both cities are equipped with lights and sirens to signal their presence and declare when they are driving emergency. However, their usage of them varies slightly. Houston ambulances will respond to calls with lights and sirens but then drive a noncritical patient to the hospital as normal traffic without lights or sirens. A critical patient, though, will be transported emergency to the hospital as safely as possible, a tricky proposition for the EMTs treating the patient during the transport. Istanbul’s ambulances will always use their lights but largely do not use their sirens, reserving them for some critical responses. Given the nature of Istanbul’s streets, the ambulances also use their expanded privileges with discretion, realizing that the time gained is often not worth the additional risks of operating aggressively in the cramped streets of the city (Açiksari).

Despite the caution that ambulances attempt to use while driving emergency, they are still predisposed to being involved in traffic accidents. Indeed, while conducting the research for this 7|Page

report, I was actually witness to an accident caused by one car bumping into another while attempting to move out of the way of an HFD ambulance driving emergency. A retrospective study of all collisions involving HFD EMS vehicles in 1993 found that 86 occurred in HFD’s 180,000 vehicular responses. Furthermore, 17 people were transported to the hospital following an EMS collision. Interestingly, ambulance drivers with a previous history of collisions were correlated with the number of persons transported to the hospital (Biggers et al.). It is also worth noting that the collision that I witnessed would not have merited inclusion by this study’s criteria, as it did not directly involve the ambulance. While numbers for ambulance crashes in Istanbul were not available to me, one of the physicians I spoke with indicated that the 112 ambulances attempt to minimize their use of high speeds due to the increased propensity for accidents (Açiksari) A special challenge in Istanbul is the tight streets ubiquitous to many of the historical districts of the city. In some areas, a car has difficulty maneuvering, to say nothing of an ambulance. Two key factors in mitigating that difficulty is the use of drivers who are accustomed to navigating the streets and smaller ambulances. Ambulance drivers receive special training and certification in both jurisdictions. Global Positioning Systems (GPS) are quite helpful in assisting ambulances in finding addresses. Other complications occur in the next aspect of ambulance transport: getting the patient to the ambulance.

In comparison to Houston, Istanbul is old and densely populated. Accordingly, many of its buildings are tall but rely on stairs instead of elevators, which can be a problem when a patient is unable to walk, necessitating the use of a stair chair (pictured) to extricate the patient.

Figure 3: Stair chair at a Fenerbahçe football match

Once the patient is securely in the ambulance, the next question is where they should be transported. In Houston this is a decision made by the ambulance crews in consultation with the patient’s wishes. Guidance from protocols lays out general principles that crews interpret (Persse). For Istanbul, the crew sends in a patient report over the radio to dispatch and dispatch decides where the patient should be taken. A major difference from Houston is the ability of ambulance crews to refuse to transport a patient for whom they feel transport is not indicated, even if the patient wants to go to the hospital by ambulance (Açiksari). One final dissimilarly is that the larger size of Houston’s ambulances allows them to transport two patients at once, something that happens commonly with motor vehicle accidents.

Air Medical Transport

Air medical transport refers to the use of helicopters and fixed wing aircraft in emergency medical transport. Houston was actually a pioneer of air medical systems with Memorial Hermann Life Flight being the second air medical ambulance system established in the United States. It remains the only hospital-based air ambulance system in Houston. The capabilities of the system include the ability to respond to most areas within a 150-mile radius of Houston within 15 minutes with one of its six helicopters, each of which has the capacity to transport two patients (“Life Flight”). Prominent constraints are the dependence on weather conditions in order to fly, the cost of the service, and the inherent dangers of helicopters, particularly in marginal weather conditions. One characteristic of Houston that helps to promote the use of air medical transport is the broad highways, which can be rapidly closed off to provide a suitable landing zone if required. Istanbul also has an air medical transport including 40-some helicopters and 8|Page

fixed wing aircraft (Goymen). However, Istanbul’s topology makes it difficult to land helicopters in the field and many hospitals do not have helipads so patients must be landed nearby and then transferred by ambulance to the hospital (Açiksari).

Care provided en route: Comparative EMS systems

As for the second primary thrust of my research question, analyzing the relevant EMS systems in a comparative manner appears to be the most promising approach to considering the care provided to patients en route to definitive care. The first aspect of the care provided by EMS is determined by the dispatch or response model used. That may appear to be a strange claim but the type of response determines what resources are available for the care of the patient. Houston currently uses what it calls an All-Hazard response model. The basic concept is dispatch triages emergency calls according to their apparent seriousness and issues that seem minor in nature are first sent the nearest available unit, which arrives on scene and determines whether additional resources are required. This policy places the decision about the degree of response needed in the hands of the first HFD unit on scene instead of the caller. Medical emergencies that appear to be serious such as difficulty breathing or a cardiac arrest still provoke an immediate ALS and ambulance response (“All-Hazard Response”). This policy has met with controversy in some cases where a serious incident did not immediately receive an appropriate ambulance response, and has been modified since its inception to permit the first responding unit to upgrade the response before they arrive on scene if necessary (Pinkerton). Istanbul’s dispatchers, who all have medical training and include physicians, have an even more difficult call to make, as they can decide whether a response will be sent at all. If a patient calls in with what appears to be a frivolous complaint lacking merit for ambulance transport, the dispatcher may refuse to send an ambulance and instead recommend that the patient proceed to the hospital by other means. It is difficult to imagine such a policy in the United States, considering the potential liability and the use of dispatchers without medical training, but this approach does carry the boon of avoiding tying up ambulances with trivial calls, as often happens in the United States.

The next layer to be unpacked in determining the care provided by EMS is the levels of personnel they have available, including their training. Houston Fire Department has two levels of providers: emergency medical technicians (EMTs) and paramedics. EMTs have completed 280 hours of training and possess registration with National Registry of Emergency Medical Technicians (NREMT) and are certified by the Texas Department of State Health Services.

Paramedics generally complete a 2-year associates degree to be registered and certified (“What is EMS”). All EMTs and paramedics with HFD are also certified as firefighters. HFD staffs its BLS ambulances with two EMTs and its ALS ambulances with two paramedics (“Houston Fire”). Three levels of providers exist within Istanbul’s 112 services: technicians (ATTs), paramedics, and physicians. The ATTs have two years of training following high school while paramedics have a four-year university degree as well as ATLS, ACLS, and APLS (Advanced Trauma/Cardiovascular/Pediatric Life Support) training. A national practical program exists as well as a national certification program. Physicians who ride out on ambulances have more than 6 years of schooling as well as additional training in ACLS and other protocols (Açiksari).

Another dimension of the care rendered is the equipment available. Although, as one physician correctly pointed out, treatment quality is harder to achieve than just having the right 9|Page

equipment, possessing the proper tools is still a necessary condition for optimal patient care (Selek). The basic equipment used is fairly standard across Houston and Istanbul’s ambulances. Defibrillators, electrocardiogram monitors, ventilators, suction units, oxygen tanks, stretchers, and backboards are common to both services (Ozucelik).

More invasive equipment such as supplies for intravenous cannulation and endotracheal intubation are also seen with both as well as basic medications such as D50 (50% dextrose Figure 3: Inside of a 112 ambulance solution in water). Greater variation may be seen with more advanced medications such as cardiac drugs but it is difficult to comment, as I was unable to obtain access to the 112 protocols. Houston ambulances do tend to carry more equipment that 112 ambulances by virtue of their greater size providing more space to store supplies.

The protocols are extremely important as they determine what types of care are in the scope of practice for each level of provider and under what circumstances that care may be administered. In Istanbul, ATTs have a scope of practice broadly akin to that of Advanced EMTs (AEMTs, not part of HFD’s model) in the United States. This means that they can perform intravenous cannulation (IVs), intubation, and provide some basic medications such as D50 in addition to simple procedures like splinting or immobilization on a backboard. Furthermore, they may also obtain electrocardiograms, which is generally not done by AEMTs. Paramedics are capable of providing many more medications, including the cardiac drugs (Açiksari). Houston’s EMTs are restricted to providing basic life support, noninvasive procedures, and a few selected drugs. Paramedics in Houston perform invasive procedures including more advanced ones like needle chest decompression for a tension pneumothorax (collapsed lung) and administer a large number of potent drugs such as fentanyl, a painkiller (Persse).

Beyond the dimensions of the care the protocols stipulate, the question of authorization to perform that care is critical for actually understanding how the protocols are translated into practice. The time at which a protocol should be followed is laid out by listing the signs and symptoms that ought to be present for the patient to be treated under that particular field impression. In Houston, provider discretion mostly emerges from the decision of which protocol or level of severity to follow, as the protocol proscribes treatments in a detailed manner. In order to exceed what the protocols mandate or even to carry out some treatments included in the protocols, it is first necessary to contact medical control. Medical control consists of physicians who provide remote on-line (protocols would be considered off-line) guidance for emergency personnel in the field. They can authorize specific deviations from the protocols, provide support on the treatment of a difficult case, or provide the legal authority for a patient refusing care against medical advice (Persse). Istanbul’s system relies much more heavily on the written protocols and provider discretion. There is nothing in the protocols that the emergency personnel must first obtain on-line permission from medical control to do, and in a situation where the EMTs or paramedics believe it to be necessary they may even exceed the protocols, although they will be called upon later to justify their actions. Medical control is available as a resource if the emergency personnel should need them but there is no requirement to contact them if the situation is urgent. Indeed, one of the Turkish emergency medical physicians with whom I spoke thought it was ludicrous to be mandated to contact medical command in an exigent situation, as their personnel have already been cleared to work within the written protocols and the physicians 10 | P a g e

trust their judgment (Açiksari).

One other facet of care is the maintenance of patient records. Sometimes perceived as just paperwork, these reports can be vital in ensuring continuity of care for a patient. HFD generates electronic medical records for their patients using Toughbook laptops that are especially designed for field use (“Computers & Tablets”). Istanbul presently uses paper medical records but within a few months they will be moving over to an iPad-like system on their ambulances, which will have the capability of sending an electrocardiogram to the hospital for a physician to analyze (Açiksari).

Public/Private ambulances

Thus far, the discussion of care provided has restricted itself to public ambulance services. That is not to imply that private ambulances are not significant care providers, although they are generally less involved in initial emergency medical transport (and not at all within Houston city limits). As private EMS providers are not governmental organizations, their regulation is a crucial issue in understanding them. Houston’s regulations regarding private ambulances have historically been quite lax and that has led Figure 5: Private ambulance on standby to frequent abuse of Medicare’s reimbursement system, with at a Fenerbahçe football match patients receiving nonemergency transports to and from routine healthcare visits. As of 2011, there were 397 private EMS organizations in Houston’s Harris Country (there are more than 500 now), of which 333 were under review by Medicare for billing irregularities in the previous year (Langford). Conversely, Istanbul’s private ambulances are overseen much more strictly by the ministry of health, with requirements stipulating the kinds of equipment and personnel required (Tokyay). They are not dispatched from the public system but efforts are currently underway to develop a protocol to integrate them into the 112 system during disasters as the Istanbul has the right to appropriate them in such situations. The private personnel have the same training as the 112 staff and they are required to have physician oversight (Açiksari). According to director of emergency medicine at American Hospital, the private ambulances tend to do better than 112 in areas like establishing patent IV lines but 112 ambulances have been improving over the years (Tokyay). Equipment and vehicles are similar between the public and private services. Dispatch for private ambulances occurs from their own dispatch centers or from private hospitals. The patient is transported according to wishes or to nearest capable hospital and the cost varies by distance with the base cost being around $150. In comparison, an ambulance transport in Houston can easily cost over $1000. American Hospital relies on private ambulances for many of the patients who arrive in its emergency room (Tokyay). One other role for private ambulances in both systems is providing stand-by coverage at private events such as the Fenerbahçe football match pictured.

Implications What the results mean:

Despite the variation in the urban landscapes of Istanbul and Houston, lessons still may be gleaned from their respective approaches. Many of the most striking distinctions between how things are done in Istanbul compared to Houston are seemingly underlined by liability concerns.

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Potentially sensible reforms like refusing to dispatch ambulances to calls that are patently absurd are unthinkable in the United States because of liability concerns. It may be that reducing liability concerns could help to improve the care patients receive. Conversely, the lax approach taken by Texas and Houston towards private ambulance regulation appears quite odd considering the vital functions they are expected to perform. For Istanbul, questions may be raised concerning the correct degree of autonomy to afford non-physician ambulance personnel, given their lack of a medical degree, or its reliance on decision-making by dispatchers, who are necessarily deciding from afar.

What do we still need to know:

Patient outcomes produced under each system, in spite of their central nature in appreciating the effectiveness of emergency medical transport, were not possible to examine within the scope of this project. Agencies were reluctant to share the necessary data and length constraints for this paper precluded a thorough treatment. They remain a bright area for further research. Another intriguing question that this report has not been able to delve into is the degree of sustainability of each of these EMS models (and the broader healthcare systems to which they belong). Istanbul’s 112 service is provided free of charge at the point of care through various governmental insurance programs, which likely increases access to care (Goymen). While admirable, the average age in Turkey is currently 29, and as those demographics shift to an older population, Turkey may find it difficult to meet the growing burden of its prior fiscal commitments (Istanbul Metropolitan Municipality). In contrast, a ride in one of Houston’s ambulances is quite expensive, to the point of dissuading people from seeking necessary medical care in some instances. Paying for the system is accomplished through a strange mechanism in which everyone is charged the same high rates but only a fraction of people actually pay them, effectively subsidizing the cost for everyone else while still leaving a substantial burden to be picked up by taxpayers. And then there is the unsustainable trajectory of medical care expenses.

The distinctly different circumstances of Houston and Istanbul render the question of sustainability a particularly interesting one to ponder, as considering them in tandem helps to draw out some of their peculiarities. Finally, it would be most fascinating to extend the study of emergency medical transport beyond just Houston and Istanbul to see the similarities in other jurisdictions as well as what new perspectives and insights they have to offer.

Concluding thoughts:

Different models for emergency medical transport exist and conducting comparative analysis of those systems may led to insights that can be applied for the benefit of all. Although it may be infeasible to simply transplant ideas from one context to another, failing to at least study the varying approaches taken to emergency medical transport runs the risk of continuing to do things because that is how they have always been done, regardless of their efficacy. Recall that classical Houston study that discovered pneumatic antishock garments were basically useless despite their widespread acceptance across the nation (Pepe). A promising movement currently underway in EMS is called evidence-based medicine, which posits that medical treatments should be used because they have been proven effective in controlled studies. The point may seem obvious, but traditionally much of the care provided by EMS has lacked solid research support as to its effectiveness. Policy forms and structures may not fit as easily into such an approach but that should not mean that we do not aspire to discover best practices and seek to implement them. EMTs are fond of saying that their job is saving lives and good policy in emergency medical transport can help them achieve that.

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Acknowledgments I would like to express my grateful thanks for the assistance rendered on this project by people too numerous to fully list. My inspiration came from Dr. Bobby Kapur, who was also instrumental in helping me establish contacts in Istanbul. Dr. Ferudun Celikmen generously invited me to visit the European-side 112 call center in Istanbul. David Almaguer, Dr. Uğur Selek, Dr. Dogac Ozucelik, Dr. Rifat Tokyay and especially Dr. Kurtuluş Açiksari were vital interviewees whose answers to my questions made this work possible. Dr. Michael Emerson provided key guidance in the shaping of my research topic and the editing of this manuscript.

Finally, I would like to thank Ipek Martinez, Abbey Godley, and Dr. Michael Emerson for their guidance and supervision during our time in Istanbul.

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