General Capital – Mexico City (DF) Land Size – 1,972,550 km2 Population – 1,103,263,388 (2005 census) Language(s) – Spanish (Official)
“One might argue that the lack of data in Mexico indicates a poor quality of EMS available to the public, but this ignores many valuable services EMS provides in most societies without significant data recording them” (Peralta, 109).
“Improvements in prehospital care, potentially, could have a larger impact on overall mortality from trauma than would hospital-based improvements” (Arreola-Risa, 318)
Mexico City (Peralta, 104-5)
“Emergency medical services in Mexico City were developed without clinical or administrative standards and without proper planning” (Peralta, 105)
No regulation, standardized medical protocols, or medical guidance
Official Mexican Norm (NOM) – attempt by Health Secretariat to regulate activity of EMS providers in Mexico City
Established conditions under which agencies must provide care, including air and ground transport.
Norm does not implement specific requirements for:
Pt care documentation
Other key system components
Scope of training/Field Practices delegated to EMS providers, allowing them to establish own criteria for care based on selected standards
Limits accountability for government and providers
Norm clearly addresses:
Role of Medical Direction
Operative requirements for services
Remains vague and imprecise in other areas, including:
Medications that can be administered
Does not address key performance indicators or administrative requirements
Lack of data on evaluation and/or transportation of Pt’s in Mexico City
Researchers cannot study conditions in which Pt’s were transported/treated, and then relate data to Pt outcomes/In-hospital evaluation
“Much controversy still exists regarding the true benefits of advanced versus basic levels of care” (Peralta, 105).
[acc_item title=”EMS System Model”]
Anglo-American Model and/or
Organizational System developed in last decades, especially in aftermath of ’95 Mexico City earthquake
Studies have identified organizations that provide care without properly qualified/trained personnel (May be true throughout all of Mexico)
Number of EMS providers available to serve Mexico City exceeds needed numbers adequate to provide efficient care
Approximate 10 private org’s offering EMS in Mexico City
>100 voluntary org’s
No responsible org to control or regulate provider org’s
Several sources for population’s health care financing
60% – Social Security Medical Services – 60%
Provided by gov’t programs: IMSS and ISSSTE
20% (approx.) – Federal Secretary of Health
10% (approx.) – Private physicians/hospitals
10% (approx.) – Unfunded except for care at indigent hospitals
Red Cross: Public donations
[acc_item title=”Levels of Care”]
Physicians occasionally staff ambulances
Typically for interfacility transfers from private clinics
Education and Training
Technicos en Urgencias Medicas (TUM – Emergency Medical Technicians)
300 – 600h
Many receive “virtually no training, especially among the wide range of volunteers who supplement the pre-hospital care system” (Garcia-Rosas, 442)
Mexico City (Peralta, 107)
Multiple institutions offer EMS training in Mexico City (similar across country)
Nationaly Polytechnic Institute
National Autonamous University of Mexico
Basic-level training curricula tends to be similar in scope and format
However, programs are often registered with different gov’t agencies
Voluntary EMT registry recently created by Federal District Ministry of Health (Mexico City)
Three recognized levels of EMS training/care
Subsequent evaluation process (written and practical)
50.9% passed Basic; no data from remaining levels
Monterrey, San Pedro, Santa Catarina (Arreola-Risa – Prehosp Disaster Med)
“In each case, half or more of the personnel only had on-the-job training consisting of skills and knowledge they learned from colleagues during their daily work without any formal education and training courses.”
San Pedro: 30%
Santa Catarina: 20%
“At baseline, virtually none of the personnel had any type of trauma-related, in-service training, such as participation in [PHTLS] or [BTLS]”
All services comprised of approx. 50% paid staff and 50% volunteers
Educational levels impact ability of students to understand/utilize future training
Often delegated to individual EMS Provider
Mexico City (Peralta)
No supporting evidence of existence of off- or on-line medical protocols.
All medical direction efforts depend on availability of physician who will take responsibility for clinical care provided by prehospital team.
Unlikely to guide field treatments since there is no evidence of field protocols and/or requirements for clinical competencies
The responsibility to define and measure response times and to collect data, belongs to each EMS provider” (108)
No established standard for city
Providers define this metric – if they define it all – based on criteria that apply to their own expectations and needs and not to those of patients they serve.
Since there are no legal requirements for RT’s, and no need to comply or even measure RT’s, it is possible that they are not collecting this data.
Collecting RT data does nothing w/o interpretation, and if it is not used for quality management, assurance and improvement
Varies: Typically provided by private hospital, if at all
“The country has yet to institute a national system such as exists in the United States and Canada, so the receipt of calls for an emergency ambulance service is often delayed, slowing patients’ arrival at the Emergency Department” (Garcia-Rosas, 442)
“080” – former number in selected areas
“Now replaced with several different numbers to call the police or public ambulances; the Red Cross ambulance service has its own number” (Garcia-Rosas, 442)
1986 – First EM residency at General Hospital of Balbuena, Mexico City
1991 – rapid expansion of trained EM MDs begins when Mexican Institute of Social Services (IMSS) initiates “a network of Emergency Medicine residencies, accepting 150 residents per year throughout México into 3-year programs” (Garcia-Rosas, 442)
2004 – 14 Emergency Medicine residency programs in México (Garcia-Rosas, 443)
Arreola-Risa C, Mock C, Herrera-Escamilla AJ, Contreras I, Vargas J: “Cost-effectiveness and benefit of alternatives to improve training for prehospital trauma care in mexico.” Prehospital and Disaster Medicine 2004;19(4):318-25.
Arreola-Risa C, Mock CN, Lojero-Wheatly L, de la Cruz O, Garcia C, Canavati-Ayub F, Jurkovich GJ: “Low-cost improvements in prehospital trauma care in a Latin American city.” The Journal of Trauma: Injury, Infection, and Critical Care 2000;48(1):119-24.
Garcia-Rosas C, Iserson KV: “Emergency Medicine in México.” The Journal of Emergency Medicine 2006;31(4):441-5.
Peralta LM “The Prehospital Emergency Care System in Mexico City: A System Performance Evaluation.” Prehospital and Disaster Medicine 2006;21:104-11.