a plea for croatian trauma system

4
Injury, Int. J. Care Injured 44 S3 (2013) S3–S6 Introduction In Croatia, 4.3 million citizens are unevenly distributed over 21 counties, with an average population density of 75.8 persons per km2. The rate of natural increase is negative and the population trend demonstrates aging. Measured by GDP per capita, Croatia is considerably behind the EU average. The unemployment rate is high, and economic indicators are currently negative. Consumer prices show a significant increase in health care and energy prices. More than a third of Croatian citizens are at risk of poverty and social exclusion. 35% of Croatian territory refers to the sea with 1244 islands, among them only 48 are permanently populated. During summer season, seaside is overcrowded with more than 11 million tourist which puts addiotional pressure to the organization of health care. During the past ten years, the third leading cause of death in Croatia was due to external causes of injury and poisoning (ICD-10 code: V00-V99, W00-W99, X00-X99, Y00-Y99). 1 In 2010 standardized death rate (SDR) was 52/100,00 0 (EU average: 36/100,000). 2 Top causes were falls (36%), suicide (26%) and traffic accidents (17%). Children and young people (0-39 years) mostly die due to road traffic accidents, middle-aged (40-64 years) due to suicide, and elderly (+65 years) due to falls. 1 In 2010, SDR due to road traffic accidents in Croatia was 9.59 (EU average: 5.97). 2 Basic health insurance is compulsory and carried out by state governed Croatian Institute for Health Insurance. Supplementary and private health insurance is voluntary. There are three levels of care. Primary health care is provided by general practitioners (i.e. family doctors), gynecologists, pediatricians (for infants and preschool children only), dentists, occupational medicine and pharmacists, mostly on the basis of concessions or in private practice. Health facilities at the secondary level are owned by counties. These include rehabilitation centers, clinics and small hospitals. Tertiary level comprises 11 university clinics, all but one owned by the state. More than one half of the university clinics are located in the capital city. Capital city has less than 20% of the total population in Croatia. Pre-hospital setting In Croatia, the term “emergency medical service” (EMS) is constrained exclusively to the provision of medical aid in pre- hospital setting, although emergency departments in hospitals also function. In this narrow term, EMS is considered as a part of primary health care owned by counties, even tough it is controlled and paid by the state insurance fund. There are four lines of treatment: - Fully equipped ambulance car with EMS physician, registered nurse and driver (Team 1) - Fully equipped ambulance car with two EMS nurses (Team 2) - General practitioners on call, mainly in rural areas. Official estimates suggest that 4/5 of population is covered by EMS, and the remaining 1/5 by general practitioners. 1 - Immobile, but non acute patients are accompanied by EMS driver in an ambulance with basic equipment. This kind of health service is in the process of separation from EMS. Croatian counties differ significantly in total area and population density. For example, Zagreb has population 1,232 KEYWORDS Croatia trauma trauma care trauma system ABSTRACT This paper provides an insight into Croatian health system with special focus on trauma care. The current situation is explained from a domestic point of view, but an independent review by foreign observers is also included. Fragmented approach to the treatment of injured patients in Croatia should be replaced by networking of health care componenets into a unique chain of help. The concept and five methodological steps in the development of a succesfull trauma system are presented. A good start is definitely a reorganization of existing knowledge on the basis of internationally licesed courses and the adoption of trauma registry as a standard for future discussion. Individual components of the trauma system can not be separately “optimized” so clinical and financial decisions should be planned exclusively on the integral level. © 2013 Elsevier Ltd. All rights reserved. A plea for Croatian trauma system Tonisav Antoljak a, *, Ivan Dobric a , Bore Bakota b , Tomislav Zigman a , Daniel Rajacic a , Tin Ehrenfreund a a Department for Traumatology and Bone & Joint Surgery, Clinics for Surgery, Clinical Hospital Center Zagreb, Zagreb, Croatia b Department for Surgery, General Hospital Karlovac, Karlovac, Croatia * Corresponding author at: Department for Traumatology and Bone & Joint Surgery, Clinics for Surgery, Clinical Hospital Center Zagreb, Zagreb, Croatia E-mail address: [email protected] (T. Antoljak). 0020-1383/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. Contents lists available at SciVerse ScienceDirect Injury journal homepage: www.elsevier.com/locate/injury

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Page 1: A plea for Croatian trauma system

Injury, Int. J. Care Injured 44 S3 (2013) S3–S6

Introduction

In Croatia, 4.3 million citizens are unevenly distributed

over 21 counties, with an average population density of 75.8

persons per km2. The rate of natural increase is negative and the

population trend demonstrates aging.

Measured by GDP per capita, Croatia is considerably behind

the EU average. The unemployment rate is high, and economic

indicators are currently negative. Consumer prices show a

significant increase in health care and energy prices. More than a

third of Croatian citizens are at risk of poverty and social exclusion.

35% of Croatian territory refers to the sea with 1244 islands,

among them only 48 are permanently populated. During summer

season, seaside is overcrowded with more than 11 million tourist

which puts addiotional pressure to the organization of health

care.

During the past ten years, the third leading cause of death

in Croatia was due to external causes of injury and poisoning

(ICD-10 code: V00-V99, W00-W99, X00-X99, Y00-Y99).1 In 2010

standardized death rate (SDR) was 52/100,00 0 (EU average:

36/100,000).2 Top causes were falls (36%), suicide (26%) and traffic

accidents (17%). Children and young people (0-39 years) mostly

die due to road traffic accidents, middle-aged (40-64 years) due

to suicide, and elderly (+65 years) due to falls.1 In 2010, SDR due

to road traffic accidents in Croatia was 9.59 (EU average: 5.97).2

Basic health insurance is compulsory and carried out by state

governed Croatian Institute for Health Insurance. Supplementary

and private health insurance is voluntary. There are three levels

of care. Primary health care is provided by general practitioners

(i.e. family doctors), gynecologists, pediatricians (for infants and

preschool children only), dentists, occupational medicine and

pharmacists, mostly on the basis of concessions or in private

practice. Health facilities at the secondary level are owned by

counties. These include rehabilitation centers, clinics and small

hospitals. Tertiary level comprises 11 university clinics, all but

one owned by the state. More than one half of the university

clinics are located in the capital city. Capital city has less than

20% of the total population in Croatia.

Pre-hospital setting

In Croatia, the term “emergency medical service” (EMS) is

constrained exclusively to the provision of medical aid in pre-

hospital setting, although emergency departments in hospitals

also function. In this narrow term, EMS is considered as a part

of primary health care owned by counties, even tough it is

controlled and paid by the state insurance fund.

There are four lines of treatment:

- Fully equipped ambulance car with EMS physician, registered

nurse and driver (Team 1)

- Fully equipped ambulance car with two EMS nurses (Team 2)

- General practitioners on call, mainly in rural areas. Official

estimates suggest that 4/5 of population is covered by EMS,

and the remaining 1/5 by general practitioners.1

- Immobile, but non acute patients are accompanied by EMS

driver in an ambulance with basic equipment. This kind of

health service is in the process of separation from EMS.

Croatian counties differ significantly in total area and

population density. For example, Zagreb has population 1,232

K E Y W O R D S

Croatia

trauma

trauma care

trauma system

A B S T R A C T

This paper provides an insight into Croatian health system with special focus on trauma care. The

current situation is explained from a domestic point of view, but an independent review by foreign

observers is also included.

Fragmented approach to the treatment of injured patients in Croatia should be replaced by networking

of health care componenets into a unique chain of help. The concept and five methodological steps in the

development of a succesfull trauma system are presented. A good start is definitely a reorganization of

existing knowledge on the basis of internationally licesed courses and the adoption of trauma registry

as a standard for future discussion. Individual components of the trauma system can not be separately

“optimized” so clinical and financial decisions should be planned exclusively on the integral level.

© 2013 Elsevier Ltd. All rights reserved.

A plea for Croatian trauma system

Tonisav Antoljaka,*, Ivan Dobrica, Bore Bakotab, Tomislav Zigmana, Daniel Rajacica, Tin Ehrenfreunda

aDepartment for Traumatology and Bone & Joint Surgery, Clinics for Surgery, Clinical Hospital Center Zagreb, Zagreb, CroatiabDepartment for Surgery, General Hospital Karlovac, Karlovac, Croatia

* Corresponding author at: Department for Traumatology and Bone & Joint

Surgery, Clinics for Surgery, Clinical Hospital Center Zagreb, Zagreb, Croatia

E-mail address: [email protected] (T. Antoljak).

0020-1383/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.

Contents lists available at SciVerse ScienceDirect

Injury

j our na l homepage: www.e lsev ie r.com/ loca te / in ju r y

Page 2: A plea for Croatian trauma system

S4 T. Antoljak et al. / Injury, Int. J. Care Injured 44 S3 (2013) S3–S6

people/km2 and Licko-senjska County only 10 people/km2.

During 2010, one EMS team covered nearly 10,000 people and

each of them had 2,687 interventions in average. The average

medical transportation time was 49 minutes and 45 seconds.

Under special conditions, army facilities can be activated for

emergency medical air transportation and in 2011 there were

1,387 flights totally. Boat transfer is also available on inhabited

islands, but the means of transportation are rather inappropriate.1

Couple of years ago, specialization in EMS for physicians

was introduced in Croatia, but without a clear vision whether

it should be pre-hospital or hospital based profession. Senior

physicians, former GP’s, were promoted to the status of a

specialist, but without any formal examination, and the younger

ones started their residency mainly in hospitals.

Hospital setting

A total of 29 acute hospitals are participating in trauma

network. Each of them carries the responsibility for a certain part

of the country on equal basis though they vary considerably in

human capacity and equipment. In other words, the accreditation

process in Croatia has not started yet, although the government

agency was established few years ago. Due to the lack of

corresponding specialists, hospital emergency departments

still functions in fragmented sections. All together, this causes a

clear inequality of initial trauma care, depending on geographic

location of injury.

Review from abroad

Thanks to MATRA funds, two projects were accomplished

during 2008 and 2009 in cooperation between Croatian ministry

of health on one side, and Dutch ministry of foreign affairs, Dutch

ministry of health and Dutch Association of trauma centers on

the other. These projects were: “Developing Croatian Trauma

System through open communication” and “Empowering the

professional through networks”. A high delegation of Dutch

experts visited Croatia several times with objectives to gain

insight into present trauma care in Croatia and to assist in the

policy development of future Croatian trauma system.

In a written report to Croatian government it was clearly

stated that present level of trauma care in Croatia is not up to the

standards of EU. It was strongly advised to the Croatian Ministry

of Health to improve this situation and create equal access to

trauma care throughout Croatia.

Besides this core finding, few other problems were

highlighted:

- Heterogeneity in human resources, training and equipment

- Absence of group goals, methods and priorities

- Discoordination among health care segments, especially

between pre-hospital and hospital setting

- Unawareness of unique chain of help in trauma care

- Lack of objective data (trauma registry)

- Lack of leadership in decision-making

From Croatian point of view, the following remarks from

Dutch colleagues are worth mentioning:

- Personal attitudes prevail instead of written protocols,

guidelines and standard procedures

- Discussions are dominated by individual opinions whose

acceptance depends on the position of the debater in the

hierarchy

- Changes are hard to achieve because health care professionals

do not tend to accept ideas from other professionals,

institutions or trauma care segments. They call upon the

government to take some action and use formal power to

overcome these shortcomings as if they are still functioning

in the centralized system they once had.

- The government is taking initiatives, but until now not in a

coordinated and concerted manner. It takes time for plans

to be implemented and after that additional time is needed

to check the programs in health care practice. Unfortunately,

plans in Croatia are already changed or stopped before

they become really effective because of changing political

priorities or shortage in funding. Both the government and

health care professionals are consequently frustrated.

Steps to be taken

Trauma system is an organized, coordinated effort in a defined

geographic area that delivers the full range of care to all injured

patients, and which is integrated with the local public health

system.3 According to the definition, key components of the

system are: pre-hospital care, acute hospital care, rehabilitation

and public health measures. Under circumstances of sharp

division am ong these links, the main challenge is to connect

all of them into a firm chain of help to injured people using

communication and coordination activities as well as ongoing

evaluation processes.

Four premises are essential:

1. Saving life is of highest importance, not reducing disability

2. Injury is not a simple sum of individual diagnosis, but a

complex condition/illness causing a reaction of the whole

organism

3. Due to the complexity of injury, trauma patients require

multidisciplinary treatment

4. Definitive treatment of injured people should be carried out

not in the nearest, but in the nearest competent hospital.

Following international experience,3–7 a trauma system should

be developed using five steps:

1. Reorganization of existing knowledge of health care

professionals

2. Development of standardized trauma units

3. Organization of trauma centers through intrahospital

integration of health care capacities

4. Organization of trauma system through coordination of

health system with other public services

5. Promulgation of trauma system as a factor adding to social

stability. This is of particular importance in Europe, because

injuries affect mostly less privileged people.8,9

Injuries are life threatening conditions which occur suddenly

and unexpectedly. For this reason, their treatment should have

the highest priority, above all other emergencies in medicine.

Even more, treatment of injuries requires teamwork which

implies demonstration of high quality of common knowledge

under stress.

Problem of postgraduate education has already been recog-

nized in developing countries.10–14 In at least one of them,

Trinidad, a regular institution of internationally licensed courses

has been documented to lower the mortality rate of trauma

victims.15–17

Without any doubt, health care staff in Croatia has a

respectable amount of knowledge. However, this knowledge is

accumulated in postgraduate period on an individual basis and

according to personal preferences, and it is largely financed on

own expense. Therefore, it is of uneven quality and very often

fragmented.

In Croatia, a key component of improvements in trauma care

should be optimising training using internationally licensed

courses. This provides the following priorities:

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T. Antoljak et al. / Injury, Int. J. Care Injured 44 S3 (2013) S3–S6 S5

1. Determining the minimum of common knowledge in trauma

care

2. Establishing clear priorities in treatment of injured persons

3. Installation of evidence based medicine (EBM) as the only

correct way in treatment of acutely injured people

4. Teamwork training

5. Licensing and relicensing of health care staff based on

professional standards rather than on academic knowledge.

Regarding this issue, the situation in Croatia is currently

not encouraging. Surgical Society, the principal professional

association, is not interested to introduce ATLS because of

high initial costs. Croatian Resuscitation Council has recently

started with ETC, but the courses are rare and expensive for an

individual. Starting from 2004, over 2000 doctors and nurses

completed ITLS training and the course has been well received.

On the other hand, ITLS is designed for pre-hospital setting, not

for hospitals, so it can not be the only part of the didactic core of

the future Croatian trauma system. Finally, Croatian Institute of

Emergency Medicine started in 2011 with some kind of education

sponsored by World bank. Since this effort is designed according

to personal preferences of the leaders, it does not address the

need for standardized education based on EBM.

Next to reorganization of knowledge based on internationally

licensed courses, a good start for the Croatian trauma system

would be data collecting in a single trauma registry. When

presenting the analysis, in should be born in mind that adverse

outcomes are not always a reflection of poor medical care. The

imprefection of the system causes the majority of mistakes,

rather than the individual.18

The second step in the development of the trauma system

is the organization of the trauma unit (TU). This is not an

observation room, not an operation theatre for elective surgery

and there are no regular patients. Spatially it can be an integral

part of the emergency department (ED) or separately organized

entity.7 Whichever option is chosen, trauma unit must be the

only admitting area in the hospital for the treatment of acutely

injured people. Due to the ongoing emergency procedures, key

criteria for construction and equipment should be efficiency,

affordability, simplicity and visibility.

Procurement and arrangement of equipment is the easy

part, but the real challenge is building trauma teams7. Trauma

team is a multidisciplinary, trained and organized group of

health care professionals who take the full responsibility for

emergency trauma patients.19 This goes well beyond the usual

procedures such as diagnosis and initial stabilization of vital

parameters.20 Important features of teamwork are: dedication

and commitment, complementary skills, mutual trust and

timely fulfillment of agreed tasks. Completing ATLS or ETC is a

prerequisite for teamwork in the trauma unit.

Some of the responsibilities of a team leader are: data collection

from pre-hospital service, setting priorities in the diagnosis

and treatment, the interpretation of patient data, coordination

of intra- and inter-hospital transfer, communication with

consultants and primary triage during disaster management.20

Although an anesthesiologist, general surgeon or EM specialist

can be nominated as a team leader, for Croatian circumstances

we strongly advocate trauma surgeons. During war in Croatia

1991-1995 they have proven their value and we do not support

recent merging of trauma surgery with orthopedics as suggested

from EU.

Having a well-equipped, well-operating trauma unit does not

make a shift from regular hospital to a trauma center.7 Actually,

trauma centers are verified acute hospitals where emergency

trauma patients have the priority over all other patients. Intra-

hospital integration of all necessary medical specialties needs to

be implemented in practice as they provide complete, coordinated

and efficient care to all injured people 24h/7 days. Besides,

trauma center should have developed systems for education,

injury surveillance, data collection and quality improvement.21,22

Good communication and cooperative relationships should be

maintained with other hospitals in region as well as transport-

and by pass-agreements.21,22 Coordination with other public

services is also required. These standards are hardly to achieve

without a lots of commitment from hospital administration.7

Most important point is that there is no need to build new,

special hospitals for trauma centers. All that is needed is to

reorganize the existing capacities upon new principles. Almost 14

years ago EU has announced a network of trauma centers along

major transport corridors to maximize the safety of passengers.

Each of these trauma centers should cover a population up to one

million people.23

A trauma center does not make a trauma system7. Main

feature of a good trauma system is to link prehospital, hospital,

rehabilitation and public-health efforts in a solid, uninterrupted

chain of trauma care.

In Croatia, pre-hospital EMS transports patients to the

nearest hospital. As well known, this can significantly decrease

the transport time in large, densely populated cities but might

have negative implications for in-hospital mortality, as centers

without adequate resources might be receiving patients for

which they are unprepared.24 On the other hand. the general

principle of a good trauma system in pre-hospital setting is to

identify and manage any life-threatening injuries, and then to

transport the patient to an appropriate facility as soon as possible

to receive definitive treatment.25–28 Any delay in the transport

time or delay in the ongoing treatment of life-threatening

injuries may jeopardize the common goal: saving as many lives

as possible. Therefore, we do not advocate “Stay & Play” or

“Scoop & Run” phylosophy in pre-hospital trauma care, but “Run

& Play”. We believe that ITLS in Croatia provides sufficient basis

for the achievment of this standard, so we strongly recommend

this course as a mandatory part of education of pre-hospital

personnel in Croatia, both doctors and nurses.

Although without EBM support on this issue, there seems

to be a trend in EU towards integration of pre-hospital teams

in hospital ED’s in order to increase the quality of trama care in

the field and to reduce costs.29,30 If this is true, then the nurses

should take over considerable responsibility in pre-hospital

setting. This process has already been started in Croatia through

activities of Croatian Institute of Emergency medicine (Team 2).

As monitoring parameters are not well defined, the future of this

project will depend again on the political will of the goverment.

For now, the introduction of paramedics in trauma care in Croatia

is not an option.

Particularly in the case of road traffic accidents, there is

no doubt that lay bystanders can play a crucial role.23 Besides

some actions like rapid extrication from a burning vehicle or

establishing a contact with emergency services, lay bystanders

need to be able to secure a free airway in unconsious victim

and to treat immediately major bleeding. This is particularly

important to reduce preventable deaths. The presence of gloves

in the car to protect the bystander during these actions is

desirable. Even more, there is no evidence to suggest that first

aid kits being made available in cars would help. In this sense,

we suggest a shift from the current targets of teaching of first aid

for drivers towards more modern knowledge. Basic ITLS would

be a good choice.

The need for transportation of injured persons to the nearest

competent hospital has been emphasized several times. In

other words, some hospitals in Croatia will be passed by in

the future trauma network due to lack of human resources or

Page 4: A plea for Croatian trauma system

S6 T. Antoljak et al. / Injury, Int. J. Care Injured 44 S3 (2013) S3–S6

equippment. They will lose some of their importance, and

probably part of their income, while some other hospitals will

be increasingly burdened so they will ask for more money. We

agree that accreditation is an extremely delicate process with

a lot of political implications, but it has to be done. Because of

the potential impact on the survival and invalidity of trauma

patients, action between professional organizations and the

government must be coordinated and presented to the public on

the basis of clear and agreed information.

Finally, each trauma system has to be tailored to fit local

circumstances, but the program is effective only when it involves

the whole chain of help in trauma care, not just individual

links. Therefore, option advocated by Croatian Institute of

Emergency medicine is not satisfactory, because it relies just on

improvement of pre-hospital services. Mere question remains

what will be the trigger point that will bring together the

government, professional health care associations and citizens in

order to build a new organizational structure on the principles of

cooperation and goodwill as well as with respect to knowledge

and experience from abroad.

Conflict of interest

All authors declare they have no conflicts of interest.

References

1. National Health Development Stategy 2011-2020, Sept. 2012.

2. European health for all database, WHO Regional Office for Europe,

Copenhagen, Denmark, July 2012.

3. American Trauma Society: Trauma System-Agenda for the Future. 2002.

4. United Nations, General Assembly, 1 August 2003: Global Road Safety Crisis.

Report of the Secretary-General.

5. Advanced trauma life support for doctors. Instructor course manual, 6th ed.,

American College of Surgeons, Chicago; 1997.

6. SMARTRISK, Health Canada, Emergency Health Services Branch Ministry of

Health: The Economic Burden of Unintentional Injury in Canada; 1998.

7. Michaelson M. Building a Trauma System-The Rambam Medical Center

Experience. Trauma Care 12(2), Fall 2002.

8. La Flamme L. Social Inequality in Injury Risks. Knowledge Accumulated and

Plans for the Future. Sweden, Karolinska Institutet, 1998.

9. La Flamme L. Explaining socio-economic differences in injury risk. Injury

Control and Safety Promotion 2001;8(3):149-153.

10. Civil IDS. Trauma care - a team sport in the 21st century. Injury, Int. J. Care

Injured 2007;38:5—6.

11. Mock CN, Quansah R, Addae-Mensah L, DonkorP. The development of

continuing education for trauma care in an African nation. Injury, Int. J. Care

Injured 2005;36:725—732.

12. Dai K, Xu Z, Zhu L. Trauma care systems in China. Injury, Int. J. Care Injured

2003;34:664–8.

13. Civil IDS. Good trauma care doesn’t happen by accident. Injury, Int. J. Care

Injured 2005;36:689—690.

14. WHO: Prehospital Trauma Care Systems, Geneva 2005.

15. Ali J, Adams R, Butler AK, et al. Trauma outcome improves following the

advanced trauma life support program in a developing country. J Trauma

1993;34:890—8.

16. Ali J, Adams R, Stedman M, et al. Advanced trauma life support program

increases emergency room application of trauma resuscitative procedures.

J Trauma 1994;36:391—4.

17. Ali J, Adam RU, Gana TJ, Williams JI. Trauma patient outcome after the

Prehospital Trauma Life Support program. J Trauma 1997;42(6):1018-21.

18. Performance Improvement Subcommitteeof the American College of

Surgeons Committee on Trauma. Trauma performance improvement.

Reference Manual. Jan 2002.

19. State of California, Emergency Medical Services Authority. Chapter 7. Trauma

Care Systems, California, 2003.

20. Driscoll PA, Vincent CA. Organizing an efficient trauma team. Injury

1992;23:107–110.

21. West JG, Williams MJ, Trunkey DD, Wolferth CC Jr. Trauma systems: current

status — future challenges. JAMA 1988;259(24):3597-600.

22. Kortebeek JB. A review of trauma systems using the Calgary model. Can J Surg

2000;43:23-8.

23. European Transport Safety Council. Reducing the Severity of Road Injuries

Through Post Impact Care, Brussels 1999.

24. Roudsari BS, Nathens AB, Arreola-Risa C, Cameron P, Civil I, Grigoriou G et

al. Emergency Medical Service (EMS) systems in developed and developing

countries. Injury, Int. J. Care Injured 2007;38:1001—13.

25. Coats TJ, Goode A. Towards improving prehospital trauma care. Lancet

2001;357:2070

26. Kristiansen T, Søreide K, Ringdal KG, Rehn M, Krüger AJ, Reote A et al. Trauma

systems and early management of severe injuries in Scandinavia: review of

the current state. Injury 2010;41:444–52.

27. Mackersie RC. History of trauma field triage development and the American

College of Surgeons criteria. Prehosp Emerg Care 2006;10:287–94.

28. Sharma BR. Development of pre-hospital trauma-care system—an overview.

Injury 2005;36:579–87.

29. Council of the European Society for Emergency Medicine. Manifesto for

Emergency Medicine in Europe. European Journal of Emergency Medicine

1998;1:7-8.

30. Council of the European Society for Emergency Medicine: Manifesto for

Emergency Medicine in Europe, revision. European Journal of Emergency

Medicine 1998;5(4):1-2.