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Ambulance
August 2012 - Issue 3 | Volume 9

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Thijs Gras Letter from Amsterdam to Lisbon

GREEN LANES Speed Up Ambulance Care

Ambulance Todays Dutch Ambulance correspondent, Thijs Gras, was recently invited to take a brief look at life in
Portugals ambulance service. Below Thijs reports on what he learnt during his four day whistle-stop tour and looks
forward to a more thorough examination of an EU ambulance system that, despite the countrys own severe
budgetary constraints, is using all its resources to improve prehospital clinical care levels and position its ambulance
delivery in the best possible position within its wider healthcare system
Your Dutch correspondent was
invited to Lisbon in late June to give
a presentation about the Dutch
ambulance system.This invitation
woke precious memories of very nice
holidays spent in Portugal in 1979,
1986 and 2002. Apart from lovely
sunshine, very nice people and a
beautiful landscape, all these
memories contained elements of
ambulances.
The first trip was with my parents. We
rode in a few days in a Citroen 2 CV all the
way through France and Spain and entered
Portugal in the North, riding towards the
coast. In the village of Mangualde, the Fire
Service was celebrating its 50th anniversary
and the village was packed with marvellous
fire engines and ambulances both old and
new. We took a lot of pictures for my fire
fighting family. The 1986 trip was with three

friends, this time heading for Faro where

one of my friends had a very nice and
beautiful girlfriend. Now I was already an
ambulance-addict myself so, apart from the
fire engines, I took quite a few ambulance
pictures. I still remember some of them,
such as an old red Mercedes or the Peugeot
404 with an external holder for glass
infusion bottles (air-cooled!).

During the holiday in 2002 I spent with my

own family and I was surprised to hear a

familiar Dutch three-tone ambulance siren

on the streets of Nazare, on the Western
coast. It inspired me to visit the local fire
station which was very nice. In that year I also
saw a few vehicles with INEM on the side,
but I was not able to dive deeper into their
system.
And then, last April, quite probably out
of a very beautiful blue Portuguese sky, a
letter dropped on my doormat inviting me
to give a lecture about the Dutch system
since I was considered to be: the
Netherlands leading expert on the history
of your ambulance service. This rang a bell:
it was the formulation your kind editor
Declan Heneghan used to introduce me to
the UK readers of Ambulance Today in the
august 2011 issue Lets Go Dutch. Soon
afterwards I learned that they found me on
the internet, yet again thanks to Ambulance
Today!
Apart from the lecture for the national
Portuguese Nurse Association, I offered to
give a sort of workshop about the Dutch
ambulance service, along the lines of a
presentation I gave for Ambulance Today. This
extra offer made me feel a little more at
ease with my request to get a glimpse of
the Portuguese system and maybe even to
ride along.
It could not have gone better. I flew to
Lisbon on Wednesday and arrived just as
the Portuguese soccer team was playing
their first half against Spain in Euro 2012.
I hoped to bring the luck I brought to the
Danish team 20 years ago, but during our
dinner we saw Portugal losing the semi-final.
A slight stain on an otherwise spotless visit.
The next day I surprised the audience
with a short but carefully coached and

This edition of Ambulance Today goes out to all 25 Dutch Ambulance Regions courtesy of Procentrum

PROCENTRUM - LEARN TO FEEL THE DRIVE www.procentrum.eu

August 2012 | Ambulancetoday

37

Thijs Gras Letter from Amsterdam to Lisbon

rehearsed two minute speech in

Portuguese to start my presentation (this
was entirely thanks to a colleague of my
wife who was kind enough to translate my
Dutch into impeccable Portuguese). Polite
as they were, they even said they could
understand me. This meeting also gave me a
glimpse of new developments in Portuguese
nursing where they have expanded their
programs on emergency care and intensive
care, even in the basic nurse training. I also
learned of the Via Verde (green lane), named
after a lane on the toll road especially for
driving through without having to stop for
payment. They implemented since 2005 a
system for four patient categories where
time was of the essence to get them fluidly
and quickly to the hospital. These categories
were trauma, CVA, ACS and sepsis. That
evening we went to a restaurant to enjoy
the food and wine of the Alentejo, a region
considered to be poor and poorly
populated, but rich in these traditions and I
absolutely loved it!

recent years replaced nurses in the control

room.The technicians work with a special
priority dispatch system which was developed
in Portugal. It has only very recently been
implemented and, at the time of my visit, was
not yet fully fulfilling its needs: too often a
doctor was called to the scene risking a
doctor not being available for really urgent
cases. Besides, personnel were complaining
that they received less information now

because specific information about the

situation was generalized by the system. Also
crews in the field (mostly fire fighters)
sometimes missed the guidance of a nurse
(who were from 2007-2010 also part of the
CODU-team) in handling cases on their own
(which they sometimes have to do).
The CODU cooperates well with another
healthcare institution in Portugal, Sade 24.
This is a phoneline they set up which is
modelled on a similar health information
line provided by the National Health Service
in the UK which is also staffed by nurses. The
CODU-operators pass calls for advice to
them and sometimes receive calls from the
Sade 24-nurses about cases where an
ambulance is needed.
In Lisbon the CODU of the INEM has two
other specialties: Firstly, they host the
Poisoning Information Centre, which is open
to the public but only via telephone - and
to healthcare professionals and which is
staffed by a doctor. And secondly, they have
the CODU-Mar or CODU which offers
practical help and advice especially for
people and their crews on sea in the waters
of Portugal who find themselves faced with
an acute health problem. After this I visited
the museum of the Fire Brigade (which

Poison and sardines:

Next day a visit to the control room was
scheduled in the morning.This control room
is operated by the INEM, which stands for
Instituto Nacional de Emergncia Mdica
(National Institute for Emergency Medicine).
This is a government organization, set up in
1981, that supervises and partly delivers
ambulance care in Portugal.The control room
is called CODU: Centro de Orientao de
Doentes Urgentes (Centre for the Judgement
of Urgent Patients).There are four of them
covering the whole of Portugal, staffed by
Technicians and Doctors. An interesting
feature is that there are also psychologists
available in the control room and they can
speak with callers with psychiatric or
emotional problems.The Technicians have in

This edition of Ambulance Today goes out to all 25 Dutch Ambulance Regions courtesy of Procentrum

PROCENTRUM - LEARN TO FEEL THE DRIVE www.procentrum.eu

38

August 2012 | Ambulancetoday

Thijs Gras Letter from Amsterdam to Lisbon

housed a most interesting litter) and then it

was time for my presentation in a school for
nurses.
The day ended with a very nice meal in
Alfama: freshly roasted sardines and a nice
cold beer. We then escorted a nurse to the
hospital where he had to start his night
shift (he of course had restricted himself to
Cola) and he gave me a tour of its busy
Accident and Emergency department. They
are tightening the bonds between the

prehospital phase and the clinical phase in

Portugal. In rural areas a lot of hospitals
have an ambulance with both the vehicle
and the driver supplied by INEM - but they
have to provide a nurse for in the back. This
nurse works also in the A&E-department
so he (or she, of course) can offer ALSlevel care (infusion, medication, intubation
etc.). This way the nurses keep their clinical
experience sharp while providing a high
level of care outside the hospital especially in those regions where an
emergency doctor is not so easy to access.
It was quite busy, but I was very pleased to
see good equipment, dedicated staff and
also a good level of care.
Pregnant:
My last day started at 8.00 with a shift on
the VMER (Viatura Mdica de Emergncia e
Reanimao), a vehicle for emergency
medicine and resuscitation. This is a vehicle
staffed by a doctor who is accompanied by a
nurse who also drives the vehicle. It is sent to
situations where an advanced medical care
need has either been identified or is
anticipated. They can put up IVs, give
medication and so on and back up BLS-units
with technicians of the INEM. In the outskirts
of Lisbon and surrounding cities and villages
fire fighter crews provide the basic care and
the transportation.
We had four runs. None of them very

spectacular, and in two cases the value of the

doctor was questionable because he could
not do very much. In one case we had to
drive about 25 miles to a pregnant lady
because the system advised ALS. This left
quite a big region poorly covered with ALS
for a period of time, so this is perhaps
something to be evaluated. In one case by
coincidence another pregnant lady with
hypotension - the doctor put up an IV and
accompanied the patient to the hospital in a
fire service ambulance. There is some
criticism about this system and they are
trying to figure out ways to make it cheaper
while maintaining the quality. Nevertheless,
this was very interesting for me because it
gave me a glimpse of their prehospital care
practices.
My last visit was to a helicopter base
outside Lisbon where one of the five HEMShelicopters of Portugal was situated. My
good friend Pedro Vasconcelos was on duty
as a nurse and had had a busy day: they had
one primary call for an accident in the
countryside with a severely injured man and
when they arrived at the nearby hospital to
further stabilize before taking him into the
helicopter, they found a woman in the A&Edepartment with a GCS of five, so they also
intubated her and took her along with the
man in the helicopter to the university
hospital in Lisbon.
Lets Go Portuguese:
As I hope you can tell, I found this a most
interesting visit which left me wanting to
learn a great deal more about the
Portuguese ambulance system. Ambulance
Today editor, Declan Heneghan, has already
suggested that we should look at working
with our Portugese ambulance colleagues to
research and publish a Lets Go Portuguese
special edition in the very near future so
please keep an eye out for this within the
next twelve months.
Finally, I would like to thank all my
Portuguese friends, especially Pedro
Vasconcelos, Joo Loureno, Luis Ladeira, Inz
Elvas, Helder Ribeiro and Tiago Amaral for
what they did for me. I also thank the
coordinating doctor Ana Lufinha and the
nurse Carlos Miguel Rocha and doctor
Ricardo Dias, the crew of the VMER of the
Hospital S. Francisco Xavier and the INEM in
Lisbon for their hospitality and the
Associao Portuguesa de Enfermeiros for
inviting me to their conference.
If you would like to give your views
on this article feel free to email
Thijs Gras at: th-gras@hetnet.nl

This edition of Ambulance Today goes out to all 25 Dutch Ambulance Regions courtesy of Procentrum

PROCENTRUM - LEARN TO FEEL THE DRIVE www.procentrum.eu

August 2012 | Ambulancetoday

39