Physician aids in overhaul of Tuscan emergency medical system
by Jacqueline Mitchell

Minutes after the Paris car crash that killed Princess Diana in 1997, ambulances arrived to tend to the severely injured. Later, when British and Americans learned that 52 minutes had elapsed before the princess was loaded into an ambulance and taken to a hospital, conspiracy theories piled up as fast as the flowers outside Buckingham Palace. Those 52 minutes may not have been evidence of a royal cover-up, but they do illustrate one important difference between Anglo-American and European emergency medicine.

Dr. Scott Weiner, an ER physician at Tufts, left for Tuscany in late January to continue his work helping the Italian province establish a standardized emergency medical care system. © Mark Morelli

In the United States and England, ambulances and EMTs serve to stabilize patients until they can be transported to well-equipped hospitals. In most of Europe, however, the ambulance itself is so well equipped, it is essentially a hospital on wheels. Because high-speed ambulance rides to the hospital are viewed as potentially life-threatening, physicians staff the ambulances and attempt to treat patients where they find them.

Insiders call the two schools of thought about ambulances “scoop and run” versus “stay and play.” That’s only one of the several ways Europeans and Anglo-Americans handle emergency medicine differently. It’s been hard to quantify which—if either—system works better.

Disaster preparedness
But after the 2001 terrorist attacks on the United States, when Italian officials in the province of Tuscany became concerned about disaster preparedness, they turned to a group of American experts, including Dr. Scott Weiner, assistant professor of emergency medicine at Tufts, to help streamline Italy’s emergency medicine system.

The Tuscan Emergency Medicine Initiative (TEMI) is a collaboration among the Tuscan Ministry of Health, the major universities in Tuscany, Harvard Medical International and physicians from the Beth Israel Deaconess Medical Center, where Weiner did his residency before joining the staff at Tufts and Tufts-New England Medical Center. TEMI’s main goal is to officially establish the specialty of emergency medicine in Italy.

While emergency medicine has been a recognized specialty in the United States since 1979, it is not a specialty in many countries, including Italy, where emergency rooms are staffed by doctors who specialize in other fields.

“The main problem is that the system is very inefficient,” says Weiner. “Since there is no unified body of knowledge they need to know, subspecialty consultants need to be present in the hospital 24 hours a day, and the quality of emergency care can vary greatly.”

Train the trainers
To standardize the quality of emergency care in the region, the first stage of the TEMI approach is to “train the trainers”—physicians who already work in emergency departments and will train future specialists. After a nine-month program of clinical rotations, weekly lectures and final examinations, the first group of 24 physicians—18 from the University of Florence’s major teaching hospital, Careggi Medical Center, and six from the surrounding community—graduated from the program last spring. These doctors, whom Weiner characterizes as the “future grandfathers of emergency medicine in Italy,” are now training the second group of physicians, who began the course last summer. Last September, the “train-the-trainers” program got under way at the major hospitals in Pisa and Siena, also in the Tuscan province. Additionally, TEMI has initiated a three-year master’s degree program in emergency medicine at Florence University, and six participants are currently enrolled.

The TEMI process is a highly collaborative one, Weiner says. “The unique part about working with Italy, compared to other countries, is that it’s a developed country with a sophisticated health delivery system and talented physicians,” he notes. “This is more of a sharing of ideas, not us telling them our ideas are better.”

The emphasis on sharing—not imposing—ideas is especially important in Tuscany, where regional pride and rivalries can run deep. And it’s not just American arrogance the TEMI program must guard against. In expanding to the cities of Pisa and Siena, the physicians confronted “politics in every nook and cranny,” Weiner says.

“The program had to start somewhere, and it just happened to start in Florence,” says Weiner. “That has been a problem in Siena, where they still haven’t gotten over wars from the 1400s.”

Rigorous certification
Another priority is to certify all the physicians already working in Tuscany’s emergency departments. When emergency medicine was undergoing the same evolution in the United States, physicians who logged 5,000 hours in a hospital emergency department and who passed a test became board-certified in emergency medicine. In Italy, the process is more rigorous. Physicians seeking certification will have to attend four hours of lectures per month, go through eight weeks of rotations in other specialties and then pass a test. In this way, the TEMI group hopes to standardize emergency care as well as lend credibility and prestige to those who practice emergency medicine.

At the end of January, Weiner headed back to Tuscany for three months to oversee the fledgling programs in Pisa and Siena while continuing to assist with the Florence-based program. Among duties such as administering mid-terms and final exams, supervising clinical rotations and hosting visiting American lecturers, Weiner is also responsible for assessing the success of the project

“I am working with surveys to determine if the doctors’ attitudes and aptitudes are changing during the process...to ensure they are learning from this method of instruction.”