REPORT FROM SPAIN: The Andalusian Approach

Emergency management and response guidelines vary somewhat among Spain’s 17 regions and two autonomic towns – i.e., Ceuta and Melilla in Northern Africa. In Andalusia, for example, civil protection and emergency management are the responsibility of the Andalusia Internal Affairs Ministry (Consejería de Gobernación). Because of the variations mentioned above, a coordination center has been established in each province to receive all calls placed to the European Emergency phone number (112). Although this approach can be used to activate the emergency fire and medical services, those services also have their own emergency numbers – fire departments and emergency medical services (EMS) agencies, for example, can be reached through the numbers 085 and 061, respectively.

The Public Company for Health Emergencies of Andalusia (EPES in Spanish) was created in 1994 by the Andalusian Government’s Regional Health Ministry (Consejería de Salud). The ministry’s goal was to deliver emergency healthcare assistance to communities throughout the entire region of Andalusia, primarily by using the 061 emergency services number. The Andalusian EPES is headquartered at the Andalusian Technology Park in Malaga and now operates eight services in the capital cities of Andalusia.

EPES’s mission is to provide effective and efficient Accident & Emergency (A&E) healthcare services to address citizens’ demands and expectations. To do so, it implements plans and programs with community participation in a combined effort to tackle Andalusia’s top-priority health problems.

There are neither paramedics nor emergency medical technicians (EMTs) in Andalusia – nor, probably, in the rest of Spain. However, EPES can deploy several types of resources. Most of those resources are allocated to mobile Intensive Care Units (ICUs), each of which is staffed with a TES (Spanish for Health Emergency Technician, loosely similar to an EMT-Basic) who is in charge of driving the ambulance and transporting a patient, a nurse, and a doctor.

Some Andalusian cities, such as Malaga and Seville, have adopted the use of ECAs (Spanish for Advanced Coordination Teams) – which are, basically, ambulances staffed with both a nurse and a TES. After a victim’s/patient’s vital signs, electrocardiograms (EKGs), and nurse’s assessments have been sent to the coordination center, a doctor decides what course of action should be taken. In mild-injury cases in which patients must be transported to a hospital or health center, BLS (Basic Life Support) ambulances staffed by two TESs can be very useful.

Mass-Casualty Incidents & CBRN Capabilities Responses to mass-casualty incidents also come under the EPES’s jurisdiction. For that reason, EPES has a Logistic Support Vehicle available, in each province, stocked with not only the medical equipment needed but also an inflatable tent that can be used as an advanced medical post.

EPES also is in charge of the decontamination of patients at the scene of a HazMat (Hazardous Materials) or CBRN (chemical, biological, radiological, or nuclear) incident. To prepare for these types of incidents, decontamination stations have been deployed in four of Andalusia’s eight provinces: Huelva, where one of the biggest chemical factories in Europe is located; Seville, which has the largest number of HazMat transport vehicles in Spain; Granada, which covers eastern Andalusia; and Cadiz (which has not only an important petrochemical factory in its southern area but also three major naval/military facilities: the U.S. Naval Station in Rota; a United Kingdom base in Gibraltar; and a Spanish Navy base – also in Rota).  An additional station in Seville houses the EPES headquarters, and also is used for training and exhibition purposes.

Each of the four decontamination stations is equipped with an inflatable, semi-rigid, fire-resistant tent that is supported by five polyester pneumatic arches. Each tent also is fitted with two doors and eight windows – four on each side – and is built to resist both heavy snow and strong winds. To create a more comfortable atmosphere for the injured, each tent: (a) Is equipped with a heater and air conditioner as well as a water heater; and (b) Contains a waste cistern that can hold a large quantity of contaminated water.

Three Lines, Many Providers, and No Time Lost Operationally, each tent can sustain three different decontamination lines: one for ambulatory females; a second one for ambulatory males; and a third one (in the middle) for non-ambulatory patients. In the two “walking” lines, EPES providers guide the contaminated patients through the decontamination process. After undressing (or being undressed), the patients go through two different showers, followed by a cleaning stage, and are then dried and dressed.

In the non-walking line, a large pantographic tray is used to move both the stretchers and the patients while two providers shower and clean them. At the end of the tray – i.e., in the so-called cold zone – two providers take the decontaminated patient and his/her stretcher either to an ambulance or to the advanced medical post.

Because all of these resources are managed by the Medical Services rather than the police or fire departments, as is customary elsewhere, the EPES can provide a medical approach throughout the entire decontamination, prehospital care, and transport processes. Here it should be noted that, although the decontamination procedures are still under development, the primary objective is still to deploy the available resources in three zones.

In the hot area, one or two medical providers – wearing totally encapsulating chemical-resistant (Level A) protective suits fitted with self-contained breathing apparatus (SCBA) – perform a medical assessment, CBRN, and trauma triage, and administer basic support measures such as airway management and the administration of medical antidotes. Inside the station, other providers – wearing hooded chemical-resistant (Level B) protective suits with SCBA – take care of the patients during the decontamination process. Finally, yet other providers – wearing similar hooded chemical-resistant (Level C) protective suits with filtered masks (rather than SCBA) – dress the patients.

When the decontamination process has been completed, the patients are directed to the medical post. Because doctors and nurses are usually by that time deployed in the field, they can begin advanced life support, stabilize patients prior to transport, and even, if possible, discharge patients (both to reduce hospital surge and to allow hospital personnel to focus greater attention on the patients most critically injured).

Not incidentally, it also should be noted that EPES is now developing a “best practices” guide that could be used for a global response to CBRN/HazMat incidents. The capabilities mentioned above provide excellent opportunities for the best possible on-site care, but such care also requires optimal coordination, intensive planning, and continuous training.