CONFIDENTIAL PolHenrotte Thesis - EMRIC · dropped over the last decades, the number of disabilities attributed to RTA is assumed to rise ... known under the name “polytrauma”

Bachelor Thesis

Analysis of Cross-Border Trauma Care in Luxembourg and its

Greater Region

Name: Pol Henrotte

Student ID: I6075426

UM Supervisor: Dr. Thomas Krafft

External Supervisor: Marian Ramakers

Study: B.Sc. European Public Health

University: Maastricht University

Faculty: Faculty of Health, Medicine and Life Sciences

Date: July 1st, 2016

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Acknowledgment This thesis has been an exciting challenge for me at the end of the Bachelor of Science in

European Public Health at Maastricht University. I would like to take the opportunity to

express my gratitude to my supervisors who guided me with their knowledge and experience

through this project. My university supervisors Thomas Krafft and Eva Pilot and external

supervisor Marian Ramakers offered me a perfect mixture between space and guidance to write

this thesis. Moreover, I’d like to thank Samira Jabakhanji, Anja Sommer and Kim Worseling

for sharing their feedback, knowledge and experience with me during the thesis writing

process. Furthermore, I would like to thank the Luxembourgish institutions and experts for

participating in my study through interviews.

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Table of Contents 1 Introduction 6 2 Background 8

2.1 Pre-hospital trauma care 8 2.2 Trauma Care Standards 10 2.3 Regionalization 11 2.4 Luxembourg 12 2.5 Current State of BTCCE 13

3 Research goals and questions 14 3.1 Research goals 14 3.2 Research questions 14

4 Theoretical Considerations 15 4.1 Theory 15 4.2 Conceptual Model 16

5 Research Methods 18 5.1 Literature Review 18 5.2 Policy Analysis 20 5.3 Interviews 20

6 Results 22 6.1 Pre-hospital trauma care systems 22

6.1.1 Belgium 22 6.1.2 France 25 6.1.3 Germany 28 6.1.4 Luxembourg 30

6.2 Cross-Border Trauma Care 36 6.2.1 Current State 36 6.2.2 Obstacles 38 6.2.3 Need and Future Possibilities 40

7 Discussion 42 7.1 Strengths and Limitations 45

8 Conclusion and Recommendations 47 References 49 Appendices 55

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List of figures

Page

Figure 1: Trimodal Distribution (Carter, 2013) 9

Figure 2: The Research Region (Luxembourg Gouvernment, 2016) 12

Figure 3: Resource Dependence Institutional Cooperation Model (de Rijk et al., 2007) 15

Figure 4: The Trauma Care Chain model (Sommer, 2014) 16

List of tables

Table 1: Search Strategy for the literature review 19

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List of acronyms ABCDE Airway, Breathing, Circulation, Disability, Exposure

ALS Advanced Life Support

AMU Aide Médicale Urgente

ARS Agence Régionale de Santé [Regional Health Agency]

ARSB Austrian Road Safety Board

ASS Administration des Services de Secours0

ASSU Ambulance de Secours et de Soins d’Urgence

ATLS® Advanced Trauma Life Support

BLS Basic Life Support

BTCCE Boundless Trauma Care Central Europe

CGDIS Corps Grand-Ducal d’Incendie et de Secours

CMH Centre Médical Héliporté

EC European Commission

EMS Emergency Medical System

EU European Union

EMRIC Euregio Maas-Rhine in Case of Crisis

ERSC European Road Safety Observatory

GDP Gross Domestic Product

LAR Luxembourg Air Rescue

MB Moniteur Belge

MUG Mobile Urgente Groep

NEF Notarzteinsatzfahrzeug

PARM Permanencier Auxiliare de Régulation Médicale

PHTCS Pre-hospital Trauma Care Systems

PIT Paramedic Intervention Team

PHTLS® Pre-Hospital Trauma Life Support

RDB Rettungsdienstberreiche

RDIC Resource Dependence Institutional Cooperation Model

RLP Rhineland-Palatinate

RTA Road Traffic Accidents

RZV Rettungszweckverband

SAMU Service d’Aide Médicale Urgente

SL Saarland

SMUR Service Mobile d’Urgence et de Réanimation

VSAF Véhicule de Secours et d’Assistance aux Victimes

WHO World Health Organization

YPLL Years of Potential Life Lost

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Abstract

Background: Trauma is an important and often underestimated cause for disabilies and death

in the world. In Luxembourg, trauma is the leading cause of death in young people.

Improvements in trauma care systems and cross-border collaboration are estimated to be

contributing factors in reducing the mortality related to trauma. The Boundless Trauma Care

Central Europe Project analyses national trauma systems in Europe and existing cross-border

collaborations in the different border regions. The main aim is the standardization of working

methods and the creation of a European trauma network to stimulate the creation of new cross-

border trauma collaborations.

Objective: In the scope of the BTCCE project, this study aims to analyse pre-hospital trauma

care in Luxembourg and its Greater Region (Belgium, France, Germany). Moreover, the

current state, obstacles, need and future possibilities in the field of cross-border trauma care in

the study region are explored. As previous studies have been conducted only partly on

Luxembourg, this study puts its focus on Luxembourg.

Methods: A mixed-method approach has been used to conduct this study. The research tools

include a narrative literature review, a policy analysis and semi-structured expert interviews.

Results and Conclusion: A number of system differences, notably on the level of education of

dispatch center and ambulance staff have been identified. In combination with staff resource

problems in the Luxembourgish system and other obstacles, systematic cross-border trauma

care collaboration on the ground is non-existent in the study region. The existence of legal

documents stimulating cross-border collaboration in emergency care does not seem to have a

positive effect on the latter. A current reform of the Luxembourish system could be a door

opener to more cross-border initatives in the future.

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1. Introduction

“Every six seconds someone in the world dies as a result of an injury”

World Health Organization (WHO), 2014

Life threatening medical emergencies are a very wide field in medicine, covering a number of

different severe and unforeseen events caused by either illness or injury (Stevenson, 2015).

This study will solely put its focus on medical emergencies caused by injuries.

The ancient Greek word trauma is the origin of the term commonly used today; it refers to a

wound or injury (Lock, Last, & Dunea, 2006). Hence, a trauma can be defined as an injury of

the human body through an extrinsic source (Deutsche Traumastiftung, 2016). This definition

clearly differentiates injuries from other medical emergencies like cardiac events, in which the

trigger is of intrinsic nature. Furthermore, psychological traumata are also defined with the

same terms, but will not be the focus of this study. Physiological traumata can be classified

“into blunt trauma and penetrating trauma. Blunt trauma most commonly results from

automotive crashes or falls; penetrating trauma is caused by gun shot wounds, stabbing, or

shotgun blasts. From a prevention point of view, it may be more rational to classify trauma

into unintentional (automotive crashes and falls) or intentional (deliberately inflicted, such as

gunshot wounds, stabbing)” (Lock et al., 2006, para. 6).

On a global level, the WHO (2009) estimates injury as an important public health problem,

killing 5.8 million people globally each year, and causing many long-lasting disabilities.

Unintentional injuries are the cause of death for over 250 000 European Union (EU) citizens

annually, and over 3 million permanently disabled patients (Austrian Road Safety Board

(ARSB), 2009). According to Eurostat (2009), 21.8 % of all fatal injuries in the European

region can be attributed to road traffic accidents. Moreover, 19.3 % in this category are caused

by fatal falls (Eurostat, 2009). Even though the number of road traffic accidents (RTA) has

dropped over the last decades, the number of disabilities attributed to RTA is assumed to rise

due to an increased number of non-fatal injuries (ARSB, 2009). It is indeed the latter that are

often forgotten when estimating the burden of trauma.

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The indicator of Years of Potential Life Lost (YPLL) allows to measure the socio-economic

loss caused by the potential years a person would have lived, if not having died prematurely

(Gardner & Sanborn, 1990). The YPLL accounted to RTA is higher than the YPLL caused by

cardio-vascular diseases or cancer (European Road Safety Observatory(ERSC), 2009). The

costs of fatal, severe and minor traumata accounts for approximately 2% of the EU member

states’ GDP, which amounts to EUR 189 billion (ERSC, 2009). To tackle this burden of

disease, a multitude of measures are proposed, including improvements in trauma care (WHO,

2009). According to the ERSC (2009), improvements in trauma care systems can lead to a 15-

20% reduction in mortality rates.

With this in mind, the Boundless Trauma Care Central Europe (BTCCE) project aims to

analyse the different European trauma systems in order to improve the quality of care for

trauma patients, especially in border regions. In the scope of this project, this study will analyse

the current pre-hospital trauma care system in Luxembourg. Furthermore, it will assess whether

there are already cross-border trauma care cooperations and screen for their need and for

obstacles for to the latter. The combination of the number of deaths and disabled patients due

to trauma and its major financial impact on the EU and Member States’ economy, make the

BTCCE project and this study an important contribution to EU citizen’s health and safety, and

thus to economic growth of the EU. Multiple studies on the same topic have been conducted

in the BTCCE project, each in different regions. Hence, the background information on trauma

care (systems) might be comparable, as it is factual information. However, each study aims to

bring in different views on the topic.

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2. Background

The following section provides further background information on pre-hospital trauma care,

trauma care standards, regionalization, the region of interest and the BTCCE project.

2.1. Pre-hospital trauma care

Pre-hospital trauma care systems (PHTCS) are usually embedded in existing emergency

medical services. If provided in a quick and effective manner, PHTCS can reduce harm caused

by serious injuries (WHO, 2005). The ERSC (2009) differentiates between minor and major

trauma; minor injuries are usually treatable by a general practitioner on the patient’s request,

while major injuries have to go through a chain of help to be treated according to the patient’s

immediate needs and injuries. Major traumata are often characterized by multiple injuries,

known under the name “polytrauma”. This “chain of survival” starts at the moment of the

incident, followed by the first care provided at the accident location, the transport, the

admission to an adequate hospital and ending with rehabilitation (Soreide & Grande, 2001).

This study will only focus on the first part of this chain, from the moment of the accident to

the admission to the emergency room; intra-hospital and rehabilitation care are therefore

excluded.

The WHO (2005) differentiates between two forms of PHTCS: basic pre-hospital care and

advanced pre-hospital systems. Advanced pre-hospital systems often have a complex structure

and involve a significant number of healthcare professionals, whilst basic systems make use of

basic first aid interventions, often provided by bystanders. The latter are, if applied timely,

considered almost as effective as more complex systems (WHO, 2005; ERSC, 2009). The basis

of every system is formed by volunteers, first responders and lay bystanders with knowledge

in basic life support (BLS), while healthcare professionals involved in advanced systems

include highly trained paramedics, nurses and physicians. (ERSC, 2009).

The tri-modal distribution is a widely recognized concept in the field of trauma care. Developed

in 1982, this concept suggests that death after injury occurs in three peaks. As can be seen in

figure 1, the first and most important peak includes victims that die immediately or in a time

frame of 60 minutes after the incident; this peak accounts for 50% of all fatalities. The second

peak (30%) occurs after 1 to 4 hours, while the last peak (20%) covers late casualties in a time

frame of more than 4 hours up to one week (Demetriades, et al., 2005).

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Fig.1: Trimodal Distribution

Even though this concept is widely taught and accepted in the trauma field, several studies

suggest it being an outdated concept (Demetriades, et al., 2005; Negoi, et al., 2015). Today’s

data rather indicates a single, initial peak, followed by a continuous decline in fatalities

(Demetriades, et al., 2005; Negoi, et al., 2015; Pang, Civil, Ng, Adams, & Koelmeyer, 2008).

In line with this, the concept of the “golden hour” suggests that in the time frame of 60 minutes

after injury, advanced medical measures are most effective in order to reduce mortality and

morbidity (Harmsen, et al., 2015). This is confirmed by Aldrian, Koenig, Weninger, Vécsei, &

Nau (2007), who suggest that early airway management and good preclinical trauma care

reduce complications in the in hospital phase. For neurotraumata and haemodynamically

unstable patients with a penetrating trauma, a quick transport to a hospital has been found to

be especially beneficial. However, for all other patients proper advanced medical treatment on

scene is recommended over rushing the patient to a medical facility (Harmsen, et al., 2015).

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2.2. Trauma Care Standards

“The first step for the improvement of the pre-clinical care of injured patients is to self-critically realize, that mistakes happen in every pre-clinical care of polytraumas.”

- Wölfl, et al., 2008

According to Pang et al. (2007), trauma care has significantly improved in the last two decades.

The survival of the patient is influenced on different factors, including the mechanism of injury,

age and the body area(s) affected by the trauma (Demetriades, et al., 2005). Hence, a

systematic, fast and effective approach to the assessment and treatment of trauma patients is

thought to be beneficial for the patient’s outcome (Kool & Blickman, 2007).

With this in mind, a multitude of different standardized methods have been developed.

Advanced Trauma Life Support (ATLS ®) is a concept developed for a standardized, priority-

oriented management of trauma patients in the emergency trauma room. ATLS ® is called ‘the

common language of trauma’ and one of the main approaches is ‘treat first, what kills first’

(Münzberg, et al., 2010). Another concept that is specifically aimed at PHTCS is Pre-Hospital

Trauma Life Support (PHTLS ®). In contrary to ATLS®, PHTLS® addresses all staff involved

in the treatment of the patient in the pre-hospital phase (American College of Surgeons, 2014;

Wölfl, et al., 2008). This program builds up on ATLS ®, leading to a connection between

hospital and pre-hospital personnel, by ‘speaking the same language’ and working with the

same concepts. PHTLS ® also uses the idea of priority-oriented working, which results in the

assessment method ‘ABCDE’: A stands for ‘Airway management and cervical spine

stabilization’, B for ‘Breathing or ventilation’, C for ‘Circulation (haemorrhage and perfusion)’

, D for ‘Disability (neurological)’ and E for ‘Exposure/Environment’ (Wölfl, et al., 2008).

Other important courses in the field of trauma care are the International Trauma Life Support

(ITLS) and the European Trauma Course (ETC). According to Williamson, Ramesh, &

Grabinsky (2011) most courses in trauma care teach in essence the same way of working.

However, pre-hospital trauma care in Europe still varies from country to country, despite

having comparable types of trauma. This can be partly explained by the fact that (healthcare)

systems have evolved in parallel over time and that different types of personnel (and their

training) are being used in the emergency systems (Lockey, 2001).

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Scientific evidence shows that courses teaching a systematic approach, like PHTLS ®, have a

positive effect on the quality of care delivered to trauma casualties (Mohammad, Branicki, &

Abu-Zidan, 2014). Nevertheless, differences in personnel education persist (Mohammad,

Branicki, & Abu-Zidan, 2014) and only weak evidence is available for an actual decrease in

mortality through PHTLS ® (Johansson, et al., 2012).

2.3. Regionalization

In the European Union, 37.5% of the population lives in border regions (European

Commission, 2015). Due to their distance to the heart of the country, these areas are often

economically less developed (Brand, Hollederer, Wolf, & Brand, 2008). In order to improve

the quality of life and the development of those regions, cross-border cooperation can be

advantageous (Brand et al., 2008).

In trauma care, time is an important factor (Harmsen, et al., 2015). However, in border regions,

the closest or most suitable health care provider is sometimes to be found in the neighbouring

country (Jabakhanji, et al., 2015). According to the European Commission (EC) (2015, page

2), “borders often represent barriers to harmonious development”. To stimulate the use of

scarce resources in trauma care in the most effective way, the idea of regionalization in PHTCS

is gaining more and more attention. It has been shown that mortality can be effectively reduced

by regionalizing trauma care (Aldrian et al., 2007; Liberman, Mulder, Lavoie, & Sampalis,

2004). Moreover, the EC (2013) recommends to extend such regional cooperation, which is

predominantly organized within one country, to a cross-border setting, in order to reduce the

burden of trauma linked to RTA.

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2.4. Luxembourg

“Every 34 hours someone dies of a trauma in Luxembourg.”

- Direction de la Santé, 2014

Fig.2: The research region

This study will focus on the Grand-Duchy of Luxembourg and its neighbouring countries.

Luxembourg is a landlocked country in the heart of Europe and with its surface of 2586 km2,

it is one of the smaller member states of the EU. The two main geographical regions within

Luxembourg are the hilly ‘Ösling’ in the North (highest elevation: 560 meters), which is

part of the Ardennes massif, and the ‘Gutland’ (Goodland) in the south. Luxembourg shares

a border with the Belgian Wallonia region, of which the ‘Province of Luxembourg’ (B) and

the ‘Province of Liege’ (B) are directly located at the border. This region is characterized by a

lot of agricultural, wooded and hilly areas. In the south, the French region ‘Grand-Est’ borders

with the more densely populated and industrial part of the Grand-Duchy. On the east side, three

rivers form the border between Luxembourg and the German federal states Rhineland-

Palatinate and Saarland. All together, these regions constitute the ‘Greater Region’. Moreover,

Luxembourg has three official languages: French, German and Luxembourgish. The latter is

the national language (Service Information et Presse, 2015).

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Traumata are considered as a serious problem in Luxembourg. In a governmental trauma

report, it is stated that in addition to direct healthcare costs and long-term coverage of care

costs for handicapped patients, trauma and its consequences have a significant impact on the

economic growth of Luxembourg (Direction de la Santé, 2014). In line with this, the annual

costs for hospitalizations linked to trauma are estimated at EUR 50 million. Moreover, in the

general population, trauma is the fourth cause of death, while in the age group of “15-24”,

trauma is by far the leading cause of death. With 79% of fatalities caused by an injury in this

age group, Luxembourg tops the European average of 62% (Direction de la Santé, 2014).

2.5. Current State of BTCCE

“There should be no borders hindering acute care measures of the trauma care chain within the borders of the European Union.”

-BTCCE (Meier T. , 2014)

The BTCCE project originates from the project “Euregio Maas-Rhine in case of crisis”

(EMRIC), which has achieved significant improvements in daily cross-border emergency care

in the Euregio Maas-Rhine (Ramakers, 2015). Within EMRIC, the idea developed to expand

this regional project of ‘trauma care without borders’ to the western German border, and

potentially to the whole of Europe. Consequently, knowledge has to be gained on the different

national systems and existing cooperations to learn from each other and foster cooperation. In

the current phase, the project is also being expanded to the Scandinavian countries (Ramakers,

2015).

The main goals of the BTCCE project are the definition of common standards, the

standardization and enhancement of emergency communication channels between EU

countries and the creation of a certification method for trauma supplies and suppliers, and last

but not least to promote cross-border cooperation (BTCCE, 2015). Furthermore, the project

aims to investigate in regions with non-existing cooperation if there is a need or possibility for

cross-border cooperation.

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3. Research goals and questions

The following section elaborates on the goals of this research questions, synthesized into four

research questions, representing the foundation of this study.

3.1. Research Goals

The main goal of this research was to analyse the Luxembourgish pre-hospital trauma care

system, in order to evaluate if there is a need and possibility for cross border cooperation with

the neighbouring countries. Firstly, an analysis was conducted on the different trauma systems

in the region of interest to make a comparison possible. As the main aim was to gather data

about Luxembourg for the BTCCE project, and because the other countries had already been

covered by former studies, the description of the Luxembourgish trauma system has been more

extensive. Secondly, the legal basis for the different systems was explained and further

evaluated for cross-border aspects. Thirdly, the current state of cross-border operations,

obstacles and the need for collaboration was assessed. The cross-border cooperation section in

this study focussed on the Grand-Duchy of Luxembourg (Luxembourg-

Germany/France/Belgium) and not on cooperations concluded between other countries (e.g.

France-Germany, Belgium-France), as those have already been partly covered in former

studies. Moreover, the study time and word limitation did not allow to evaluate further

cooperations and cover all four systems equally. This study also excludes existing cooperations

and agreements in the field of disaster response and all non-medical services (Firefighters,

police) involved in the pre-hospital trauma care chain (BTCCE, 2015).

3.2. Research Questions

Based on these objectives, the following research questions have been developed:

1. How is the trauma care chain organized in the Grand Duchy of Luxembourg, France,

Belgium and the German federal states of Rhineland-Palatinate and Saarland?

2. Which policies exist on regional and national level concerning trauma care and cross-

border trauma care in the Greater Region?

3. Which cross-border cooperation agreements exist in the Greater Region? If existent,

how are these agreements applied in practice?

4. Which future cooperation is of interest for the region and how could this potentially be

realized?

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4. Theoretical Considerations

In the following section the theoretical base and conceptual model for this research will be

explained.

4.1. Theory

The theory to be used for the analysis and evaluation of this study will be the Resource

Dependence Institutional Cooperation Model (RDIC), developed by de Rijk, van Raak and van

der Made (2007). This theoretical model has been established using four sociological theories:

The network theory, organizational behavior theory, resource dependence theory and the new

institutional theory (de Rijk, van Raak, & van der Madem, 2007).

Figure 3: Resource Dependence Institutional Cooperation Model (de Rijk et al., 2007)

As can be seen in figure 3, the theoretical model consists of three levels, namely, cooperation

(Level 1) depending on the willingness to cooperate and the ability to cooperate (Level 2). The

latter get influenced by factors (Level 3) including perceptions, goals, dependence, resources

and legislation. This theory will allow to analyse the gathered data in a systematic manner and

facilitate the comparison of the Luxembourgish trauma system to the neighbouring

organizations. Furthermore, the identification of problems will be simplified, making a

structured presentation of recommendations possible.

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4.2. Conceptual Model

The trauma care chain is a chronological description of the process a trauma patient undergoes

after the causal event has happened. According to Wilhelm (2011), the chain starts at the place

of the incident and ends in rehabilitation. Based on this tool used by actors involved in trauma

care, Sommer (2014) developed a new conceptual model for a bachelor thesis in the same

BTCCE project.

Figure 4: The Trauma Care Chain model (Sommer, 2014)

In figure 4, the trauma care chain is depicted as cubes. The trauma (for example an accident)

causes a primary damage, which in the ideal case leads to an emergency call to a dispatch

center. Emergency Medical Services (EMS) get alerted to provide pre-hospital medical care at

the place of the incident. Thereupon, the patient is brought to the emergency room where first

diagnostics get performed. After this assessment, the patient gets hospitalized on either an

Intensive Care Unit (ICU) or general ward, depending on the degree of the trauma. The final

step in the process is rehabilitation. The well-functioning of this trauma care chain depends

on laws, regulations and (cross-border) agreements. If all parts work well together, secondary

damage can be prevented and lead to a better outcome for the patient.

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The use of this conceptual model will allow a very structured and practical approach to the

results section of this research, as it is based on the actual process used in trauma care provision.

This will guarantee a realistic representation of all components involved in the system and

cooperation. Moreover, a comparison between different studies/countries in the BTCCE

project will be made possible by using the same model.

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5. Research Methods

In pursuance of answering the research questions of this study, a mixed method approach

including different research tools has been used. First, a narrative literature review has been

conducted to investigate the current state of knowledge of the scientific community on the

broader topic of trauma and cross-border emergency care. The review of literature has also

been used to identify already existing collaborations in the region of interest. In addition, an

in-depth analysis of the existing (scientific) papers in the BTCCE project has been performed

to use and complete the already raised data by former contributors.

Second, a policy analysis of EU and the respective countries’ legislations has been used to

gather data on the legal situation concerning (cross-border) trauma care in the research area of

this study. Finally, the information raised with these two methodological tools has been

complemented by qualitative semi-structured interviews with stakeholders. The combination

of these three methods allowed for the creation of a realistic representation of the current state

of cross-border trauma care in the Grand Duchy of Luxembourg.

5.1. Literature review

The use of a variety of databases for this narrative literature review is important to ensure that

the highest number of studies published in the relevant field can be identified. Consequently,

data has been collected from the scientific databases PubMed, Science Direct, Springer Link

and the Maastricht University Library. Furthermore, the databases of the WHO, European

Commission and Eurostat have been used to complement the literature review with relevant

reports and scientific publications. Below, the exact search strategy including databases, search

terms, combinations of the latter, inclusion and exclusion criteria are displayed in table 1.

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Table 1: Search Strategy for the literature review

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5.2. Policy Analysis

As the research goals of this study also include the legal situation concerning (cross-border)

trauma care in the region of interest, a policy analysis has been conducted to assess relevant

documentations. The different types of policies analysed in this study are EU directives and

regulations, national laws and bilateral agreements/decisions between countries.

The data was collected using the search tools on the websites of EUR-LEX and the EU

Commission for EU policy. Moreover, national policies, agreements and regulations on (cross-

border) trauma care provision in the Grand Duchy of Luxembourg have been retrieved from

the competent government bodies. The databases publicly accessible include the legislative

search tool “Legilux” and the search engines of the Ministry of Health, Ministry of Interior and

the Luxembourg Institute of Health. Additional policies have been identified during the

analysis of the material found in the literature review.

5.3. Interviews

Additionally, the data collected during the narrative literature review and policy analysis have

been complemented with qualitative semi-structured interviews. This interview technique is

very useful as it “ensures that the researcher will obtain all information required, while at the

same time it gives the participant freedom to respond and illustrate concepts” (Morse & Field,

2002, p. 94). This technique mainly uses open-end questions and encourages the interviewees

to freely talk about the investigated fields of trauma care systems, provision and cooperation.

The interview questions have been based on existing questionnaires previously used in the

BTCCE project; a comparison of study results in the project has consequently been facilitated.

The original questionnaire was first used for a study on ‘Impediments to trans-border rescue

efforts’ by the German Federal Highway Research Institute (Pohl-Meuthen, Schäfer, &

Schlechtriemen, 2006).

A non-probability approach was used to recruit interviewees. Purposive sampling implies that

the researcher selects the interviewees based on their suitability to the requirements of the

conducted study (Kent, 2007). Considering this study’s goal to achieve knowledge in a very

specific and highly specialized field, this sampling method allowed to select experienced

stakeholders within the field of this study. Potential participants were contacted via e-mail.

Only one institution required to get authorization at their public relations department. Before

giving consent to participate in the study, the stakeholders have been informed about the

context and goal of this study.

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Interview partners for this study were:

- Mr. Alain Becker, head of the ‘Direction des Services de Secours’ at the Ministry of

Interior in Luxembourg

- Mr. Michel Feider, international relations official at the ‘Direction des Services de

Secours’ at the Ministry of Interior in Luxembourg

- Mr. Paul Schroeder, director of the Administration des Services de Secours, the

operational government institution of rescue services in Luxembourg

- Mr Laurent Schaltz, Adjudant-Chef, Service Incendie et Ambulance de la Ville de

Luxembourg (Luxembourg City Fire/Rescue Brigade)

- Mr. Tom Manderscheid, medical doctor specialized in anesthesiology at the Urgent

Medical Aid Service (SAMU) at the Centre Hospitalier du Nord (CHdN) hospital in

Ettelbrück, Luxembourg. Head of the SAMU North.

- Mr. Georges Weyer, nurse anesthetist at the SAMU at the CHdN hospital in Ettelbrück,

Luxembourg. Responsible nurse anesthetist for the SAMU North.

- Mr. Steve Greisch, chairman at Luxembourg Life Support, Continuing Medical

Education instructor at the Centre Hospitalier Emile Mayrisch (CHEM) hospital in

Esch-Sur-Alzette, Luxembourg.

- Mr. Didier Dandrifosse, Head of Medical Department, Luxembourg Air Rescue

The interviews were conducted in a face to face setting at the participants’ work setting in

Luxembourgish and French. Prior to the meeting, the interview questions have been shared

with the stakeholders to allow them to prepare for the meeting and have relevant data available.

Each interview took on average 30-45 minutes and got recorded using a microphone and saving

device after prior authorization of the interviewees. The questionnaire is split up in 2 chapters,

the first part focusing on the specific organization of trauma care in Luxembourg, the second

part exploring the cross-border aspect in the region of interest. The questions gave the

stakeholders a lot of space to freely talk about the topic. A list of keywords and/or sub questions

insured that all relevant aspects would be covered during the meetings. The audio files have

been transcribed and translated on the same day. The interview questions and transcripts of

each interview can be found in the appendix. Moreover, the interviewees had the opportunity

to approve the quotes used in this study in order to ensure the authenticity of the translations

from the interview transcripts, known as a member check.

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6. Results

Cross-border cooperation requires existing national trauma care systems. Hence, this results

section will first explore the four national systems, then analyse the current status of cross-

border operations and conclude with a review of need, future possibilities and obstacles for

cooperations in the region of interest.

6.1. Pre-hospital trauma care systems

In this first section, the four national trauma care systems will be explained from a governance,

organizational, operational and legal point of view.

6.1.1. Belgium

Structure of governance in trauma care

The Belgian Emergency medical system (EMS) is primarily regulated on national level.

However, the responsibilities are spread over three levels: The federal level is responsible to

set a legal frame for the EMS system and also sets national standards for staff, material and

education. The ‘SPF Santé’ [Ministry of Public Health] is the competent government authority

on national level. The second level are the so-called ‘zones de secours’ [Security zones], which

are responsible for the organisation and functioning for set regions. The third level is the

operational level of intervention centres. In Wallonia, 85 ‘services d’indcendie’ [rescue

services] stations are spread over the region; most of those centres are principally run with

volunteers. The use of professionals Wallonia is not common (Union des Villes et Communes

de Wallonie , 2014). In addition, the Belgian EMS system is mainly in public hands. A private

ambulance sector exists, but is mainly used for secondary patient transports. (Pohl-Meuthen et

al., 2006)

23

The Organisation of Dispatch centres

The Belgian dispatch centres are reachable by the number 112. All calls concerning civil

protection, fire services and medical emergencies are treated in the so-called “centre 112/100”

(Ait-Zaid, 2015). Per province, one dispatch centre is responsible for the treatment of

emergency calls.

In the province of Luxembourg(B), Arlon is the responsible centre for the biggest part of this

research region, while a minor stretch at the very north border with the Grand-Duchy is covered

via the Liege dispatch (Union des Villes et Communes de Wallonie , 2014). The operators in

the dispatch centres have no medical background, but get trained in urgent medical aid (540

hours) and the conduction of emergency calls over a time frame of several months (Ait-Zaid,

2015; Belgian Federal Government, 2016). Furthermore, the operators work according to

protocols which guide them in the decision to deploy the rescue resources required for the

different types of medical emergencies (Ait-Zaid, 2015; Nijs & Broos, 2003). Moreover, all

dispatch centres have ‘infirmiers-régulateurs’ [nurse-regulator], who do not take calls

themselves but rather supervise operations (Ait-Zaid, 2015).

Ambulances

According to Nijs & Broos (2003), ambulances are staffed with a driver and an assistant; the

two ‘secouristes-ambulanciers’ [ambulance staff] are educated on a basic level with 160 hours

of initial training (Ait-Zaid, 2015; Sommer, 2014). Furthermore, the ambulance personnel has

to take 24 hours of extra training per year to refresh their knowledge and their theoretical and

practical skills are assessed on a 5-year basis. (Nijs & Broos, 2003). The legal response time

for ambulances is set at 5-10 minutes (Pohl-Meuthen, et al., 2006). Ambulances are either

operated by fire stations, private operators, hospitals or the Red Cross (Belgian Federal

Government, 2016).

In addition to this service, Belgium makes use of an emergency doctor vehicle called ‘Service

Mobile d’Urgence et de Réanimation’ (SMUR) [Mobile Urgency and Reanimation Service]

or ‘Mobiele Urgentie Groep’(MUG) [Mobile Urgency Group]. These vehicles are based at

hospitals, and are equipped with a doctor specialized in emergency medicine and a nurse

specialized in intensive and emergency care (Belgian Federal Government, 2016).

24

The response time of the SMUR is set at 15-20 minutes; ambulances and SMUR usually

operate in a rendezvous system, with the SMUR providing medical personnel and advanced

equipment, and the ambulance being used for the transport of the patient (Ait-Zaid, 2015; Pohl-

Meuthen et al., 2006). The use of standards for the treatment of trauma patients is not common

(Sommer, 2014).

For both ambulances and SMUR, the legal requirement is to transport the patient to the nearest

hospital based on transportation time; trauma-related patient needs are not listed as exceptions

to that rule (Nijs & Broos, 2003). As reported by Pohl-Meuthen et al. (2006), the SMUR have

a high number of missions due to the low level of education of the ambulance staff.

Consequently, a new intermediary service has been introduced in Belgium: The ‘Paramedic

Intervention Team’ (PIT). The ambulances with these teams are stationed at hospitals and are

equipped with a ‘secouriste-ambulancier’ and a nurse specialized in intensive and emergency

care. According to Aid-Zaid (2015), the team of the PIT works according to medical protocols

and is joined by a SMUR if their competences are exceeded. The underlying idea is to reduce

the interventions of the SMUR, to make sure they are available for life-threatening emergencies

(Belgian Federal Government, 2016).

Helicopters

Two helicopters are stationed at locations where response times tend to be high and are

equipped and staffed like the SMUR (Belgian Federal Government, 2016). The closest

helicopter to the Luxembourgish border is located in Bra-sur-Lienne in 26 km linear distance

to the closest border point (CMH Bra-Sur-Lienne, 2016).

Legal Situation

The legal basis of the Belgian EMS is formed by the law of the 8th of July 1964 on medical

urgent aid1, which has since been updated multiple times through policy changes. The most

important and recent changes are embedded in the law of 22nd of February 19982 and the law

of the 15th of May 20073.

1Loi du 8 juillet 1964 relative à l’aide médicale urgente (Moniteur Belge (M.B.) 25.07.1964)

2Arrêté royal fixant les normes auxquelles doit répondre une fonction « service mobile d’urgence » (SMUR) pour être agréée (M.B. du 02/09/1998)

3Loi du 15 mai 2007 relative à la securite civile (M.B. 31.07.2007)

25

The 1964 law regulates the functioning of the urgent medical aid, control of operators, the

education of staff (only secouristes-ambulanciers) and the financing of the system. In

contemplation of the 1964 law, the “arrêté” (act) of 1998 covers the team composition,

education and equipment of the SMUR/MUG. Both laws don’t mention cross-border (trauma)

care.

In contrast, the law of 2007 is more specific about the area of intervention of the different EMS

professionals. This law is a huge reform of the EMS in Belgium, and it took more than seven

years to come completely into effect in full (Union des Villes et Communes de Wallonie ,

2014). Based on this law, the country was split up into ‘zones de secours’, but it is emphasised

that the borders of provinces shall not form an obstacle to interventions, which shall rather

follow the principle of delivering the quickest and most suitable help to the patient (Moniteur

Belge, 2007, Art. 7). In addition, the government gives those responsible for the functioning

of a zone, the authority to conclude cross-border cooperation agreements of cooperation with

any public authority of a neighbouring country, in order to assure a more efficient functioning

of civil security missions in this zone (Moniteur Belge, 2007, Art. 22). Hence, the responsibility

for cross-border cooperation, also in trauma care, lays within the local ‘zones de sécurité’.

6.1.2. France


In France, the EMS is regulated on the national level, guaranteeing a uniform service all over

the country (Pohl-Meuthen et al., 2006). The organization and enforcement of the different

laws and regulations is the responsibility of France’s sub regions, the ‘départements’ [province]

(Masmejean, Faye, Alnot, & Mignon, 2003). The responsible governmental authority on the

regional level are the recently created ‘Agences Regionales de Santé (ARS) [Regional Health

Agency], supervising multiple ‘départements’ (ARS, 2016). Moreover, the governmental and

legal representative of the French government on the ‘département’ level is the ‘Préfet’ who

also has influence on the EMS, notably in extraordinary cases like disasters (Ministère de

l'Intérieur, 2015).

26


The French dispatch centres, known as ‘centres 15’ are reachable under the Europe-wide

emergency call number 112 and the number 15, the latter being rather known by French citizens

(Masmejean et al., 2003). According to Pohl-Meuthen et al. (2006), in some sub-regions the

112 number leads to the firefighters’ dispatch centre, but the the two call centres are well

connected. The ‘centres 15’ are also known under the name ‘Service d’aide médicale

urgente’(SAMU) [Urgent Medical Aid Service], and function as sole medical emergency call

centres located at hospitals for a defined area, usually a sub-region or region (Ait-Zaid, 2015).

When calling the “15”, one first reaches a caller, a ‘permanencier auxiliaire de regulation

médicale’ (PARM) [medical regulation assistant], who collects general information on the

emergency, location and personal information. Then, the call is transferred to a physician

(‘médecin-régulateur’), who decides on the appropriate rescue resources to be sent out to the

patient (Ait-Zaid, 2015; Masmejean et al., 2003). Furthermore, the physician gives instructions

to the patient or person calling to take first BLS measures while the rescue team makes its way

to the scene (SAMU de France, 2015).

Ambulances

The dispatch centre can deploy different types of ambulances to the patient, according to their

needs:

First, the BLS ambulances ‘Ambulance de secours et de soins d’urgence’ (ASSU) [Ambulance

for rescue and urgent care] are either operated by private companies, charitable organizations,

such as the Red Cross, or the firefighters (Masmejean et al., 2003). The firefighters’

ambulances ‘Véhicule de secours et d’assistance aux victimes’ (VSAF) [Vehicle for Rescue

and Assistance to Victimes] usually consist of three ‘pompiers-ambulanciers’[Firefighter-

Ambulance Staff] and in some cases one of the three team member is a nurse-firefighter (Ait-

Zaid, 2015). The ASSU ambulances are equipped with two ‘ambulanciers’ [Ambulance Staff].

As reported by Pohl-Meuthen et al. (2006), the ambulance teams have to follow 160 hours of

theoretical courses, followed by practical internships.

Second, the SAMU can deploy an emergency doctor vehicle, called SMUR. These hospital-

based crews consist of a physician specialized in emergency medicine, a nurse (anaesthetist)

and an ‘ambulancier’. In most cases, these mobile intensive units are cars, which do not have

the capacity to transport patients (Ait-Zaid, 2015; Pohl-Meuthen et al., 2006).

27

Hence, the SMUR is most often joined by an ambulance. Moreover, the SMUR team stays in

close contact with their colleagues at the dispatch centre for updates, preparation and

coordination of the intrahospital care (Masmejean et al., 2003). The choice of the hospital is

coordinated with the medical dispatch and depends on distance and the injury type of the patient

(Masmejean et al., 2003).

Helicopters

Air rescue is highly developed in France with 42 SMUR-helicopters located all over France

and consisting of the same teams and equipment as the SMUR vehicles (SAMU de France,

2015). The closest French SMUR-helicopter is located in 87 km linear distance to the

Luxembourgish border in Nancy (Ait-Zaid, 2015).

Legal Situation

Today’s legal basis for the French EMS system is formed by the law of the 23rd of May 2006

on urgent medical aid4. This law sets out the conditions to operate a SAMU and/or SMUR, the

organization and the staffing of the latter. Moreover, it is stated that patients who need special

surgical or medical treatment in order to survive shall be directed by the SAMU to the most

appropriate hospital (Légifrance , 2006, Art 6123-32-1). Additionally, cross-border care is

explicitly mentioned in this law. It is stipulated to foster networks between the different actors

in the field, in order to create an equal access to the system for all patients (Légifrance, 2006,

Art R. 6123-26). These networks shall be sub-regional, regional or interregional; international

cooperation with neighbouring countries may also be organized (Légifrance, 2006, Art R.

6123-28). The ARS is the competent authority to sign agreements for cross-border

collaboration (Légifrance, 2006, Art R. 6123-29).

4Décret nᵒ 2006-576 du 22 mai 2006 relatif à la médecine d’urgence et modifiant le code de la santé publique (Journal Officiel de la République Francaise (JORF) 119, 23 mai 2006)

28

6.1.3. Germany

In Germany, every federal state has their own structure and legislation for the provision of

EMS (Busse & Blümel, 2014). Out of the 16 states, Rhineland-Palatinate and Saarland’s EMS

systems will be discussed hereinafter.


The EMS of Rhineland-Palatinate (RLP) and Saarland (SL) have many common features, but

differentiate slightly in the governance of the systems. In Saarland, the Ministry of Interior is

responsible for the legislative framework and supervision of the system. The operational charge

is in the hands of the ‘Landkreise’ [subregions], which are joined together in one

‘Rettungszweckverband’ (RZV) ) [Rescue Administration Union].The RZV determines the

locations and providers of ambulance stations and dispatch centres (Ministerium der Justiz SL,

2004). Similar to this, the Ministry of Interior of Rhineland-Palatinate is the responsible

governmental institution for the local EMS. In contrast to the smaller Saarland, Rhineland-

Palatinate is split up into several ‘Rettungsdienstbereiche’ (RDB) [Rescue Services Region],

which get managed by a ‘Kreisverwaltung’ [district administration]. Moreover, the Ministry of

Interior publishes a state plan which determines locations of ambulance stations and provide

an additional operational framework for the RDB (Ministerium der Justiz RLP, 1991).


In both federal states, dispatch centres are either shared with the firefighters or exclusively for

medical emergencies and cover a pre-defined area. Both the medical and integrated dispatch

centres are available under the number 112. Moreover, the staff handling medical emergency

calls have to be ‘Rettungsassistent’ [rescue paramedic] (Ministerium des Inneren RLP, 2014;

Ministerium der Justiz SL, 2004). In Rhineland-Palatinate, one dispatch centre is available per

RDB (Ministerium der Justiz RLP, 1991). Besides, the dispatchers in Rhineland-Palatinate

work according to protocols called ‘Notarztindikationskatalog’ [Emergency doctor indicators

catalogue] (Ministerium des Inneren RLP, 2014).

29

Ambulances

Rhineland-Palatine and Saarland operate a comparable fleet of ambulances with regards to their

equipment and personnel. Primarily, every ambulance has to be staffed with at least two

professionals. For life threatening emergencies called ‘Notfallrettung’ [emergency rescue],one

of the professionals has to be trained as a ‘Rettungsassistent’ [rescue paramedic] and for

transports of other less severe cases the ambulance has to be staffed with at least one

‘Rettungssanitäter’ [First aid worker] (Ministerium der Justiz SL, 2004). Due to a recent

reform, the ‘Rettungssanitäter’ are now being called ‘Notfallsanitäter’ [emergency paramedic]

and follow advanced education programmes (Sommer, 2014). Their training takes 3 years,

which consists of 1920 hours of theoretical courses and 2680 practical hours on the field (Die

Johanniter(a), 2014). In contrast to this, the ‘Rettungssanitäter’ receive 160 hours of theoretical

training and 320 hours of practical internships. (Die Johanniter(b), 2016).

Furthermore, both Rhineland-Palatinate and Saarland operate emergency doctor vehicles,

called ‘Notarzteinsatzfahrzeug’ (NEF) [Emergency Doctor Vehicle], which are staffed with a

physician specialized in emergency care and a ‘Notfallsanitäter’. The NEF is in most cases

used only for the transportation of the medical team and their equipment to the scene, where

they meet the ambulance team in the rendez-vous system (Ministerium der Justiz SL, 2004).

Besides, the response time in Saarland is set at 12 minutes (Ministerium der Justiz SL, 2004),

while in Rhineland-Palatinate 15 minutes are required (Ministerium des Inneren RLP, 2014).

According to Sommer (2014), the introduction of international trauma standarts varies per

region and even sub-region within each federal state, as the education of paramedics is

organized by their respective medical manager. This leads to differences in the use of working

standarts in the field of trauma within the two federal states.

Helicopters

Helicopters are equipped with the same teams like the NEF vehicles (Ministerium der Justiz

SL, 2004). The closest helicopters are located in Wittlich (RLP) in 32 km linear distance to the

north of Luxembourg and in Saarbücken (SL) in 52 km linear distance from the south-west

Luxembourgish border.

30

Legal Situation

The EMS in Saarland is legally based on the rescue services law5, which outlines the

functioning of its EMS in detail. Furthermore, it states that the regulation of cross-border

cooperation is a task of the federal state, under consultation with the RZV. Besides, foreign

ambulances in cross-border missions are described as equal to German ambulances

(Ministerium der Justiz SL, 2004, §6a).

In Rhineland-Palatinate, the law of the 22th of April 1991 on rescue services6 determines the

functioning of the local EMS. Same as in the Saarland law, foreign ambulances are recognized

in this federal state (Ministerium der Justiz RLP, 1991, §21(4)). Moreover, it is regulated that

bordering dispatch centers have to support each other in case of scarce resources, without

directly refering to cross-border collaboration (Ministerium der Justiz RLP, 1991 §7(7)). In

conclusion, the responsibility on cross-border agreements in the German research area lies

within the respective Ministry of Interior.

6.1.4. Luxembourg

In the following part, the Luxembourgish EMS system will be explained. Due to a major reform

of the system, both the existent and planned system will be elaborated hereinafter. Moreover,

this part will be complemented by data collected through interviews with the different actors

in the field. As interviews for the present study were only conducted in Luxembourg, less data

was available for the other countries. Moreover, the neighbouring countries had already been

extensively covered in previous studies, explaining the need for more information on

Luxembourg.

5Saarländisches Rettungsdienstgesetz (SRettG) 13th January, 2004 6Landesgesetz über den Rettungsdiesnt sowie den Notfall- und Krankentransport (Rettungsdienstgesetz – RettDG -) in der Fassung vom 22. April 1991

31


The ‘Administration des Services de Secours’ (ASS) [Rescue Services Administration], which

is placed under the authority of the Ministry of Interior, is the competent government body

responsible for the functioning of the Luxembourgish EMS (ASS, 2014a). While the ASS is in

charge of the operational aspects, the ‘Direction des Services de Secours’ [Department of

Rescue Services] at the Minsitry of Interior manages legislations and regulations to guarantee

the efficient functionning of the ASS and its associated services (Ministère de l'Intérieur,

2014a).

The new law project proposes the creation of a new and centralized institution, called “Corps

grand-ducal d’incendie et de secours”(CGDIS), which will regroup firefighters, rescue and

emergency medical services (Ministère de l'intérieur, 2015b). The proposed law on the

organisation of civil security and the creation the CGDIS is currently being reviewed by

parlamentarian commissions and other interst groups. This project will be hereinafter refered

to as the reform.


Due to its small size, Luxembourg has only one ‘112’ dispatch centre where all calls related to

medical emergencies and fire rescue are treated (Schroeder, personal communication, April 14,

2016). According to Schroeder (personal communication, April 14th, 2016), the current

dispatchers are not required to have a medical or EMS background and do not get any training

in that field. However, a part of the employees also work as volunteers in the rescue system,

which will be explained in more detail later. The training operators receive, does solely involve

the handling of the technical equipment of the dispatch centre (Schroeder, personal

communication, April 14th, 2016).

Furthermore, a completely new dispatch software and system is currently being installed; the

new system is fundamentally a decision tree which guides the dispatcher (and caller) in a

standardized manner through a number of questions. At the end of the inquiry, the program

will decide upon the appropriate rescue resources for the described emergency (ASS, 2016b).

In contrast, the current system uses a catalogue of keywords, that if mentioned by the caller,

lead to the dispatching of an emergency doctor vehicle (ASS, 2016b).

32

The dispatcher will then alert the physician on duty for out-of-hospital emergencies in his/her

sector, who will then decide on how (helicopter or car) to carry out the mission. Despite the

introduction of the new software, which has the ability to correctly decide on the appropriate

rescue resource, the physician on duty still holds the decisional power (Greisch, personal

communication, April 15th, 2016). Additionally, it is planned to staff the dispatch centre in the

future with professional firefighters with basic education in the field of EMS as a minimum

requirement (Schroeder, personal communication, April 14th, 2016).

Ambulances

The main actor in the field of ambulances is the governmentally organized ‘Protection Civile’

[Civil Protection], which is mainly functioning on volunteer work (Becker, personal

communication, April 14th, 2016). Ambulances are stationned at 25 rescue centres all over

the country, including the professional firefighters in Luxembourg City (Schroeder, personal

communication, April 14th, 2016). According to the ASS (2014c), BLS ambulances are

staffed with three “secouristes-ambulanciers” [Ambulance Staff]. The current training of the

volunteer ‘ambulanciers’ is described by the government itself as obsolete (Ministère de

l'intérieur, 2015b). In line with this, Manderscheid (personal communication, April 11th, 2016)

states that the current ambulance staff is poorly educated and essentialy provides not more than

first aid. Moreover, parts of the staff seem to lack practical skills, despite having the theoretical

knowldege (Weyer, personal communication, April 13th, 2016).

Another problematic factor is that the volunteers first have to drive to the rescue stations before

getting the ambulance on the road, leading to intervals of up to 10 minutes before an ambulance

even leaves the rescue station (Manderscheid, personal communication, Aprill 11th, 2016).

Furthermore, a steady decrease in volunteers is being noted, while the country’s population has

grown by 30% in the last 30 years and the number of interventions of all rescue services has

also augmented by 29% (Ministère de l'intérieur, 2015b). Thus, the current reform is an

essential step to improve the present system (Becker, personal communication, April 14th,

2016). According to the director of the ASS, a partly professionalization of the ambulance

services has already begun before the reform, with currently 81 professional ambulanciers that

are already in service in a number of rescue stations (Schroeder, personal communication, April

14th, 2016). This step was urgently necessary, to guarantee a good and safe functioning of the

system (Ministère de l'intérieur, 2015b).

33

As stated by Becker (personal communication, April 14th, 2016) the professionalization will

be further developed, but the importance of the volunteers in the EMS is not questioned in this

reform. The new training program will be comparable to, but not a copy of the German

“Rettungssanitäter”. (Becker, personal communication, April 14th, 2016).

In contrast to the ‘Protection Civile’, the ambulance service of the Luxembourg City

Firefighters is only employing professionals, who are all certified as a German

“Rettungssassistent” through a collaboration program with German professional firefighters.

Moreover, a standardized working approach according to the ABCDE scheme is systematically

used for trauma patients (Schaltz, personal communication, April 22nd, 2016). According to a

recent amendment to the new reform, the Luxembourg City Firefighters will be integreated in

the new centralized institution CGDIS (Ministère de l'Intérieur, 2016c).

Based at three hospitals, the SAMU is the Luxembourgish advanced mobile medical support

team, not to be confused with the French SAMU. The SAMU uses a car equipped with

intensive care material and a team consisting of a physican and nurse both specialized in

anesthesia (Schroeder, personal communication, April 14th, 2016). Thus, an intervention of

the SAMU always implies the deployment of a BLS ambulance. At two sites (Ettelbrück,

Luxembourg City), the physician also has the choice to opt for transportation by helicopter

(Manderscheid, personal communication, April 11th, 2016). While the SAMU teams are highly

specialized and skilled, not all team members necessarly are educated in pre-hospital care; it

depends per hospital and doctor wether courses like PHTLS® are followed or not (Greisch,

personal communication, April 15th, 2016).

Concerning joint trainings between different rescue teams, Weyer (personal commuication,

April 13th, 2016) adds that there is no line and no collaboration for advanced education between

ambulance and SAMU staff. In accordance with this, Schroeder (personal communication,

April 14th, 2016) says that every professional (group) currently follows their own advanced

education programs. Nevertheless, there were multiple attemps to implement PHTLS® in all

medical rescue services in the country, but due to the resistance of the ‘Protection Civile’, the

attempts have been unsuccessful (Manderscheid, personal communication, April 11th, 2016).

According to Greisch (personal communication, April 15th, 2016) PHTLS® has been bought

on own initiative by a number of ‘Protection Civile’ rescue stations.

34

Besides, a First Responder pilot project, introduced by the ASS, has been in place in 47

volunteer fire stations for 2-3 years. The fire fighters get trained as first responders and get

deployed by the dispatch center according to a list of keywords7 (Schroeder, personal

communication, April 14th, 2016). Moreover, response times are high both for the SAMU and

ambulances, because of long distances which need to be travelled (Manderscheid, personal

communication, April 11th, 2016). Pursuant to this statement, the government proposes in the

reform to reorganize the rescue stations in a way to insure that all the population can be reached

in 15 minutes (Ministère de l'intérieur, 2015b).

Helicopters

According to Dandrifosse (personal communication May 6th, 2016), the Luxembourg Air

Rescue (LAR) organization is integrated in the Luxembourgish EMS, based on a

convention/contract with the Ministry of Interior. The LAR provides and operates in total two

helicopters stationed in the north and in the centre of Luxembourg at the hospital on duty. The

main role of the helicopter is to transport the SAMU team, after the decision of the physician

on duty to use the helicopter, to the patient. The helicopters are equipped with a pilot and a

flight nurse of the LAR and get joined by the hospital-based SAMU team for interventions.

Consequently, if the SAMU team is on a ground-based mission, no simultaneous missions can

be flown as there is no physician available for the helicopter (Dandrifosse, personal

communication, May 6th, 2016).

The helicopters are an important component of the SAMU system, as they can reduce the

otherwise long response times by ground significantly. However, at night, helicopters are not

flying, which leads to very long response times for large parts of Luxembourg. According to

Dandrifosse (personal communication, May 6th, 2016), the LAR helicopters and pilots are

equipped and certified to fly at night, but there is currently no demand from the government

authorities for night flights. In the field of education, the LAR medical team has to take

amongst others PHTLS® courses and due to the different national backgrounds of the staff, a

common standardized working approach is used (Dandrifosse, personal communication, May

6th, 2016).

7Words or situations described by the person calling 112, like for example ‘car crash’

35

Legal Situation

The current legal basis for the Luxembourgish EMS is formed by two laws: First, the law of

the 27th of February 1986 on urgent medical aid8 lays down the functioning of the SAMU

system (Legilux, 1986). No reference to cross-border care has been found in this law.

Second, the law of the the 12th of June 2004 on the establishment of the ASS9 regulates the

structure and functioning of the different departments of this institution. Concerning cross-

border (trauma) care, it is only stated that cross-border and interregional relations underlie the

administrative division of the ASS (Legilux, 2004, Art 11). If the new reform will be passed

by parliament, both laws will be replaced by one single policy, the law on the organisation of

civil security and the creation the CGDIS10. In the project, cross-border care is mentionned

several times : the responsible operational authority for crossborder, interegional, europan and

international collaborations would be the CGDIS (Ministère de l'Intérieur, 2016c). Moreover,

the volunteer firefighters (“pompiers”) could participate in missions on national territory as

well as in foreign countries (Ministère de l'Intérieur, 2016c, Art 28). However it is not specified

if this also applies to the new professional staff and ambulances in particular.

8Loi du 27 février 1986 concernant l’aide médicale urgente (Mémorial A - N° 16 - 7 mars 1986) 9Loi du 12 juin 2004 portant création d’une Administration des services de secours (Mémorial A - N°96 – 25 juin 2004)

10Projet de loi portant organisation de la sécurité civile et création d’un corps grand-ducal d’incendie et de secours (Dépôt : le 18.8.2015)

36

6.2. Cross-Border Trauma Care

The following section describes the level of cross-border trauma care in the study region by

examining the current state, obstacles, need and future possibilities as discussed in the

interviews with local experts. The collaboration is described from a Luxembourgish point of

view.

6.2.1. Current State

All interviewees stated that in general, there is no systematic daily collaboration in the field of

PHTC between Luxembourg and its neighbouring countries. However, secondary patient

transports to specialized hospitals abroad happen from time to time (Weyer, personal

communication, April 13th, 2016). Hereinafter, the current situation will be further elaborated

on country by country.

Luxembourg-Belgium

Since 2012, a convention between Luxembourg and Belgium on cross-border transports by the

SMUR, SAMU and ambulances exists. The agreement established on BENELUX level

mentions several important points: It is recognized that cross-border cooperation in the field of

urgent medical aid can improve intervention times and that borders or system differences shall

not interfere with the medical care of the patient. However, it is acknowledged that this scenario

is not always the case in this border region, leading to the punctual necessity for cross-border

interventions to compensate for problems in the national systems. Furthermore, the agreement

regulates in detail the operational functioning of cross-border interventions (BENELUX,

2012). According to the person in charge for international affairs at the Luxembourgish

Ministry of Interior, this agreement is only intended to be used in case one country has not

enough rescue resources available in day to day operations. A systematic collaboration was

never planned and does currently not present a political intent (Feider, personal

communication, April 15th, 2016). Moreover, it seems that the convention is mostly not

applied. According to Manderscheid (personal communication, April 11th, 2016), cases of

cross-border interventions are barely known to him.

37

In line with this, Weyer (personal communication, April 13th, 2016) adds that he is aware of

the convention, but does not feel any effect in the field. In agreement with this, the director of

the ASS states that in case of scarcity of rescue resources in Luxembourg or in a neighbouring

country, cross border assistance is not really utilized (Schroeder, personal communication,

April 14th, 2016).

Luxemburg-France

Collaboration with the French neighbours is currently non-existent. According to Dandrifosse

(personal communication, May 6th, 2016), the French exhibit a certain protectionism to the

neighbouring countries. Moreover, there exist cases at the French-Luxembourgish border,

where the French required the Luxembourgish SAMU team to unload the already taken care

of patient, as they deemed being responsible. This has led to longer transportation times for the

patient (Greisch, personal communication, April 15th, 2016). In line with this, Weyer (personal

communication, April 13th, 2016) states that in a train crash at the French-Luxembourgish

border 10 years ago, dispatched Luxembourgish SAMU teams were excluded from the medical

care of traumatized patients, despite having Luxembourgish trauma centers in closer reach.

According to Feider (personal communication, April 15th, 2016), a framework agreement on

cross-border health care cooperation, as well as an administrative arrangement on the

implementation of this framework is about to be finalized between France and Luxembourg.

This arrangement highlights the implementation of specific cooperation conventions and in

particular a convention which will regulate urgent cross-border transports. However, this

agreement will only be applicable for an assistance in case of scarcity of rescue resources; a

systematic collaboration is currently not envisaged (Feider, personal communication, April

15th, 2016).

Luxembourg-Germany

Cross-border operations between Luxembourg and Germany are very well functioning in the

field of air-rescue. The LAR is operating one helicopter (Air Rescue 3) for Rhineland-

Palatinate and Saarland in the scope of a convention, comparable to the contract the LAR has

with the Luxembourgish government. This helicopter is completely incorporated in the German

EMS system and gets alerted by a German dispatch centre (Trier); it flies around 1000 missions

per year. The LAR teams working on Air Rescue 3 are all German-speaking and dispose of all

required qualifications and standards required by Germany.

38

Furthermore, the teams also have the qualifications needed in Luxembourg to be able to also

work on the two helicopters incorporated in the Luxembourgish system (Dandrifosse, personal

communication, May 6th, 2016). As pointed out by Schroeder (personal communication, April

14th, 2016), Air Rescue 3 could be considered a German rescue resource stationed in

Luxembourg.

In addition to the already existing cooperation in the field of air rescue, a convention between

Rheinland-Pfalz, Saarland and Luxembourg is being worked on, but due to the interference of

the German federal government, this project is currently not progressing well (Feider, personal


6.2.2. Obstacles

Resources

A first and most frequently mentioned obstacle is the lack of resources in Luxembourg. Even

though the Luxembourgish EMS system has a good coverage in terms of rescue stations, the

availability of volunteer ambulance staff varies; this leads to a lower availability of ambulances

in certain regions (Feider, personal communication, April 15th, 2016). According to Schroeder

(personal communication, April 14th, 2016), if ambulances would additionally systematically

cover zones of the neighbouring countries, the problem of disponibility of rescue resources in

Luxembourg would be aggravated. In line with this, Weyer (personal communication, April

13th, 2016) and Manderscheid (personal communication, April 11th, 2016) add that one also

has to consider, that in case of cross-border interventions of the Luxembourgish SAMU (or by

a foreign emergency physician in Luxembourg), the own sector would not be covered by an

emergency physician.

Moreover, the current rescue services reform in Luxembourg does not allow much space for

attention to cross-border cooperation, as the focus presently is on the restructuring and

reinforcing of the national EMS system. However, the field of cross-border cooperation stays

a priority for the ministry and future developments are expected to go into that direction

(Becker, personal communication, April 14th, 2016). Lastly, Feider (personal communication,

April 15th, 2016) mentions that in case of systematic cooperation, a major re-organization and

reinforcement of certain regions with more professional staff and material

(ambulances/helicopter) would lead to a high financial burden.

39

Qualification and System Differences

Another hindering factor is the difference of qualification and system differences between the

countries. Schroeder (personal communication, April 14th, 2016) points out that the differences

in qualifications differ significantly between the four national ambulance crews. He also raises

the question of equality of care, as a patient would consequently receive different levels of

treatment, depending on which ambulance gets dispatched to the incident. Additionally, the

differences between the French medical dispatch system and the Luxembourgish non-medical

dispatchers creates further problems in terms of transferability (Dandrifosse, personal

communication, May 6th, 2016).

Cultural Differences

Not only differences on education and system level seem to play a role, but also cultural

differences: Greisch (personal communication, April 15th, 2016) states that especially some

French colleagues seem to perceive a certain level of distrust towards foreign colleagues, but

Greisch also assumes that this phenomenon of “not knowing each other” on both sides of the

border would disappear with time in case of collaboration. Moreover, he adds that the French

work philosophy appears more rigid, characterized by their military thinking. In contrast,

collaboration with German colleagues appears easier and more flexible (Greisch, personal


Communication

Furthermore, communication to those working in the field about existing cross-border

conventions seems to be inefficient. Manderscheid (personal communication, April 11th, 2016)

criticizes that EMS staff does not get sufficiently informed about international conventions

(e.g. Lux-Belgian Convention), describing it as miscommunication between those who take

decisions and those who work in the field.

40

Political and Legal Issues

According to Feider (personal communication, April 15th, 2016), a political will for systematic

cooperation in PHTC can currently not be seen, because such cooperation is understood to

potentially have negative effects on the Luxembourgish medical rescue system. However, a lot

of work is being done in terms of non-systematic (assistance according to need) agreements.

Besides, administrative hurdles and differences in responsibilities per country can lead to

lengthy time periods until agreements can be finalized; the administrative burden in

Luxembourg is lower than in the neighbouring countries due to its size (Becker, personal

communication, April 14th, 2016). Moreover, changes in responsibilities (e.g. Germany) lead

to discouragement and delays in the creation of such collaborations (Becker, personal


Another obstacle are legal insecurities in terms of responsibility and medical acts provided to

the patients: Due to different competences of rescue staff in the four countries, it is often

unclear if professionals can provide the same medical acts abroad than in their own country, or

if they have to stick to the local laws. In addition, differences in driver’s licence requirements

and siren standards create legal hurdles (Feider, personal communication, April 15th, 2016).

6.2.3. Need and Future Possibilities

Due to Luxembourg’s topography, Weyer (personal communication, April 13th, 2016) sees an

absolute need for cross-border cooperation as the SAMU in particular has long distances to

travel to regions close to the borders. He adds that this is especially the case at night, as

helicopters are not allowed to fly; for some places foreign SAMU/SMUR teams would reach

the patient significantly faster. In consonance with this, Manderscheid (personal

communication, April 11th, 2016) states that especially in the Northern tip of Luxembourg at

the Belgian and German border, occasional help from or for the neighbours would make sense.

Additionally, in case of parallel incidents, Luxembourg’s EMS can rapidly get into the need

for help from its neighbouring countries due to its limited resources (Schroeder, personal

communication, April 14th, 2016). Moreover, Feider (personal communication, April 15th,

2016) adds that there is no demand for systematic collaboration from Luxembourg, as punctual

interventions in case of lack of resources are needed and most useful for the system.

41

However, Schroeder (personal communication, April 14th, 2016) also identified a need for

help from Luxembourgian forces in the neighbouring regions, as there are relative structurally

weak areas with limited rescue resources. In a few cases, Luxembourgish ambulances would

be closer located to some foreign areas than ambulances from the respective country. In terms

of future possibilities, Manderscheid (personal communication, April 11th, 2016) states that in

case a certain area would require more regular cross-border interventions, the creation of a new

rescue station that would systematically cover this border zone would be more efficient and

guarantee a better coverage than only relying on national systems. Moreover, Dandrifosse

(personal communication, May 6th, 2016) adds that limiting helicopter missions to national

borders is reductive, as helicopters fly fast and far.

42

7. Discussion

The main aim of this study was to analyse PHTCS in Luxembourg and its Greater Region and

the exploration of the current state, obstacles, need and future possibilities in the field of cross-

border trauma care cooperation. The four research questions will be discussed hereinafter and

the transferability of the RDIC-theory on the results of this study will be evaluated.

The first research question explored the four national trauma systems in the study region. In all

countries except Luxembourg, dispatchers are either medical/rescue professionals or at least

got trained in medical basics. However, plans exist in Luxembourg to change the education

and staffing of the dispatchers over long term. The emergency doctor vehicles in the region of

interest feature comparable teams and do most often function in the rendez-vous system.

Therefore, cross-border trauma collaboration with the neighbouring countries on this level

seems most feasible as there are no notable differences in education and competences that these

teams enact. In Luxembourg, two helicopters are available for the national rescue system

during the day. Even though this is a good coverage, the available resources appear not to be

used in an efficient manner: If the SAMU team is on a ground-based mission, the helicopter

cannot be used for further simultaneous missions during that time as no physician is available.

Thus, a helicopter station independent from a hospital and staffed with a SAMU team would

possibly allow to use the available resources more efficiently. Moreover, long response times

for the SAMU teams were mentioned several times during the interviews due to the geography

of the country. As helicopters are equipped to fly at night, response times could be potentially

be reduced drastically if night flights were introduced in Luxembourg. Besides, a cross-border

collaboration with the SAMU teams in the study region would seem to reduce response times

to incidents and consequently improve quality of care for patients.

In the field of ambulances, larger differences between the four national ambulance teams have

been observed in the four countries. While Luxembourg and Belgium to date mostly use

volunteers on ambulances, Germany uses highly trained and skilled paramedics. In France, the

level of education depends on the type of ambulance and the team on duty. The introduction

of the PIT ambulances in Belgium, raises the level of competences for this type of ambulance.

Moreover, the majority of interviewees has described the education of Luxembourgish

volunteers as insufficient and in combination with the reduced number of available volunteer

‘ambulanciers’, the EMS experiences major functional problems.

43

Therefore, the current reform of the Luxembourgish rescue system appears to be a very positive

and necessary development to improve the functioning of the national PHTCS. The reform of

the training program for ambulance staff in connection with the introduction of professional

‘ambulanciers’, who will work together with volunteers, might create a new dynamic and

improve the quality of care for patients. It also seems to unify the different actors in the field

of rescue forces in Luxembourg. By doing so, improved collaboration and quality of care

within the borders, might lead at some point to more cooperation with the neighbours in the

field of pre-hospital trauma care. Furthermore, the use of international standards (e.g. PHTLS)

in the region of interest appears not to be applied in a uniform way. In line with former studies

in the BTCCE project (Meier M. , 2013), the use of international standards seems to depend

on personal initiatives and contacts.

The second research question focussed on existing trauma care and cross-border trauma care

legislation in the study region. In general, a shift in national legal documents towards the

inclusion of cross-border trauma and emergency care is observed. The Belgian emergency care

laws did not include cross-border care until a major reform in 2007. Similar to France, the

Belgian laws now stimulate the creation of collaborations between regions and also with

neighbouring countries with the goal to optimize the care provided to the patients. In contrast

to this, the Luxembourgish and German laws do not directly stimulate cross-border trauma care

collaboration. In all four countries it is clearly states in the laws which authority is responsible

for the establishment and maintenance of collaborations. However, it was mentioned in the

interviews that it can still be a complicated and lengthy process for Luxembourg to negotiate

agreements with the neighbouring countries due to complicated administrative structures. The

results on this research question are in line with the RDIC model, which sets legislation as an

important feature of level three factors, influencing the willingness and ability to cooperate

directly. If the legal basis stimulates cooperation, an important step on the way to more

collaboration is set. Nevertheless, as portrayed in the theory, multiple interconnected factors

on level three play a major role; the influence of those factors is discussed hereinafter.

The third research question’s aim was to analyse the existing cross-border agreements and their

practical application in the study region. A major finding in this field is the 2012 agreement

between Belgium and Luxembourg on cross-border emergency care. Even though this

document regulates every aspect of assistance in case the neighbouring country requires help,

the use of this cross-border help is not common.

44

Seeing as a problem in resources has been identified in Luxembourg, one would assume that

this agreement would be helpful in compensating for temporary lack of resources. The reasons

for the non-implementation of the agreement in practice could not fully be examined in this

study. However, two interviewees working in the field stated that they do not feel well informed

about this agreement. An evaluation of the agreement could potentially investigate problems

and solutions for a more efficient use of the latter. This agreement clearly shows that it is indeed

not only the legislation that plays a role in fostering collaborations, but also the other factors

of the RDIC-theory’s level three: goals, perceptions, dependence and resources. In

Luxembourg, it is especially the factor ‘resources’ that plays a major role. Even though the

legislation factor is well established, the lower availability of volunteers (resource), could have

a negative influence on the legislation factor, and hence on the ability to cooperate. If the

resource problem is solved, the cooperation could probably be improved.

In contrast to the 2012 agreement between Luxembourg and Belgium, the collaboration

between Luxembourg’s LAR ‘Air Rescue 3 helicopter’ and Germany functions very well for

over ten years. The company’s international approach makes a collaboration with the

neighbouring countries possible. It is a big accomplishment that the LAR and German

authorities have managed to build up this successful collaboration already a decade ago, and

depict a best practice example for cross-border trauma care. Furthermore, the LAR

collaboration shows a practical example of the functioning of the RDIC-theory: Cooperation

is made possible through the willingness and ability to cooperate, which get influenced by the

perceptions, goals, dependence, resources and legislation. A need, will and ability to cooperate

was present with all actors in this collaboration, leading to a success story with the patient as a

winner.

Another important aspect for this research question was to explore the obstacles for

collaboration in the study region. The current resource problems in Luxembourg indeed seem

to be a major obstacle for cross-border trauma care, creating a situation where disadvantages

outnumber the advantages for collaboration. However, the present reform in Luxembourg

could be a game changer, as not only the resource problem is targeted, but also the obstacle of

education differences obstacle could be reduced through the training program reform and the

introduction of professional ‘ambulanciers’.

45

Moreover, the present study has confirmed a number of obstacles that had been identified in

former studies (Jabakhanji, et al., 2015; Sommer, 2014). This includes politial and legal issues,

communication and system differences. The language barrier described by former studies could

not be confirmed in this region, as Luxembourg is a trilingual country. Thus, the transferability

of study results from one to another (BTCCE) region has to be considered very carefully.

Obstacles and promoters do seem to differ between cross-border regions, as every region has

its own characteristics and problems. A regional problem-solving approach with the goal of

fostering cross-border trauma care is to be preferred over a European solution.

The fourth and final research question aimed to investigate whether additional cooperation in

the future would be of interest for the concerned countries. Apart from the resource concerns

in Luxembourg, it has been stated by the vast majority of interviewees that a collaboration with

neighbouring countries would be beneficial for Luxembourg. Especially because of

Luxembourg’s topography, long response times are often present. A punctual cross-border aid

in a few regions located close to the border, for example the northern tip of Luxembourg, could

therefore reduce the time frame upon the arrival of help. As stated before, Luxembourg’s rescue

system is going through a major reform, which naturally puts the focus on the national system.

As soon as the resource problems have been solved in Luxembourg, more attention should be

placed on fostering and applying cross-border agreements with the neighbouring countries.

This study has confirmed the RDIC-theory in theory and practice, and it qualifies as a very

useful tool to understand the mechanism and problems connected to cross-border trauma care.

Furthermore, the conceptual model (Sommer, 2014) based on the trauma care chain has proven

to be a valuable instrument to understand and structure the workings of trauma care and cross-

border trauma care. To allow comparability, further studies in the scope of the BTCCE project

should make use of the same tools.

7.1. Strengths and Limitations

This study was the first in the BTCCE project that put its focus on Luxembourg. A clear

strength is that the author is a Luxembourg National, with experience and knowledge of the

Luxembourgish system through his education as a nurse anaesthetist. Consequently, contact to

interview partners on all levels was facilitated through personal contacts and the knowledge of

the local language, Luxembourgish. As much as personal contacts can be a strength, it can

also be a limitation, as interviewees are selected by the author himself, which might introduce

a certain level of researcher bias.

46

Nevertheless, the interviewees represent a whole picture of the Luxembourgish system,

including all levels of actors that are important in the field of pre-hospital trauma care in this

country. Another limitation is the study time and word limitation, which is the reason for why

the Luxembourgish system was described in more detail than the three other PHTCS. This can

potentially have led to biased interpretations and conclusions on those systems.

47

8. Conclusion and Recommendations

Pre-hospital trauma care in the study region is in general restricted to operate within the

national borders of the respective countries. Especially on the ground, cross-border

collaboration is non-existent, despite an agreement between Luxembourg and Belgium. More

collaboration agreements are being created with Germany and France, but the motive is always

in the scope of an assistance in case of scarcity of resources. It is to be questioned whether

further agreements will lead to more collaboration, as the experience with the Belgian-

Luxembourgian agreement, as described by the interviewees, did not show any effects in

practice. Consequently, an evaluation of the reasons for this non-application of the already

existing agreement would potentially be helpful to improve the content and implementation of

the new agreements currently in negotiation. Moreover, the collaboration in the field of air-

rescue between Luxembourg’s LAR and Germany could be considered as a role model for

collaborations in the future. The practical experience and knowledge gained over the last ten

years could be used to foster and inform new partnerships in this region.

The current reform in Luxembourg is to be considered a necessary and appropriate step into

the right direction. The partly-professionalization and re-organization of the rescue services

seem to create a unification of all rescue services within the country. Furthermore, this reform

promises to be an improvement for the quality of care for all patients and a door-opener for

new possibilities in the field of trauma care. If the rescue services in Luxembourg manage to

control the resource problem within the country, further cooperation in the field of cross-border

trauma care could be possibly realized in the future.

The following recommendations for policy makers in Luxembourg have been established as a

consequence of the findings of this study. First, the current reform of rescue services in

Luxembourg should be implemented as planned, as it promises to improve education, quality

of care and the unification of all actors in the field of emergency care and rescue. The

consequence of this reform can only be positive for patients. Second, after the reform has been

implemented, the investigation of potential opportunities for collaboration with the

neighbouring countries in the field of trauma care would be a recommendable step to take; the

ultimate goal being the strengthening of the national system and the quality of care for patients.

Third, the introduction of night flights of helicopters in the national rescue system (SAMU-

helicopter) would allow to potentially reduce response times in remote regions of Luxembourg.

48

Moreover, the creation of a helicopter station independent from a hospital (ground-based

SAMU station) could possibly give the opportunity to make a more efficient use of helicopters.

Fourth, the Belgian Luxembourgian agreement should be evaluated to investigate strengths and

weaknesses of this agreement and henceforth improve the implantation of new agreements.

Fifth, for the sake of better collaboration between the different actors in the field of trauma care

in practice, meetings should not only take place on political level, but should also include those

concerned by conventions and agreements: EMS staff.

Finally, the BTCCE project should continue its work in the field of cross-border trauma care

and keep stimulating collaboration in Europe. Unified trauma care standards can be a helpful

tool to harmonize the working method in all countries and bring together the different national

actors in the field of pre-hospital trauma care. However, the implementation of those standards

and the adoption of cross-border agreements should take place on regional level, as every

region seems to have its own characteristics. Included should be a more detailed analysis of

trauma care (cooperation) in France and Belgium, which have not been covered by comparable

studies to date in a detailed manner.

‘In a united Europe, where such borders shouldn’t exist, I would find

it right that the closest rescue resource would come to help.

It is therefore absurd to know that adequate help is close to you, but

they can’t help, because of formalistic reasons, because of a border’

-Alain Becker (Personal Communication, April 14th, 2016)-

49

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Appendices

Appendix I

Interview questionnaire

A.) Starting point:

“Trauma patients shall get the best care, regardless of place and time. Additionally, the patients should be transported to the nearest hospital suitable to their needs, in which case borders should be irrelevant.”

1.) Do you agree with this statement? To what extent?

B.) Pre- hospital Trauma Care in Luxembourg

2.) How is trauma care on the pre-hospital level organized in your country/region?

Keywords: CSU 112, First Responders, Ambulance, SAMU, LAR (Air Rescue) Work according to protocols (Ex: Algorithms, PHTLS, internal/national protocol?

3.) How are the different professionals involved in pre-hospital trauma care educated?

Keywords: - Initial education, professionals involved (nurses, volunteers, “NEW” professional

ambulance staff…), life long learning (ATLS, PHTLS…) - Who is responsible for the education and life long learning of the different professionals

involved (nurses, ambulance…) - Do the different professionals (nurses, doctors, ambulance) get trained with the same

methods/protocols (PHTLS, ATLS, or others)? - Qualification/Profession of dispatcher at CSU 112?

4.) On which legal basis do the different professionals work?

Keywords:

- Laws that give a legal basis for the different professionals (nurses, doctors, volunteers, professional ambulance staff…,)

- Do these laws only apply for the national level or also for cross-border situations?

5.) Is your region member of the German trauma network DGU [TraumaNetzwerk DGU] by the German Society for Trauma Surgery, or is it member of a similar regional, national or international network of trauma care suppliers?”

6.) What impact/changes will the current reform of the civil protection have on the current system (Luxembourg specific)?

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C.) Cross-Border Trauma Care

7.) Are there existing collaborations (contracts and/or operational agreements) about cross border emergency trauma care provision in your region?

7.1. How did these collaborations come into existence?

7.2. Under which legal agreements do these operations get carried out?

7.3. Which levels of the trauma care chain are involved?

7.4. How is the cooperation financed/funded (health insurance)?

7.5 Are there other daily cross-border operations involving trauma patients?

8.) Do you see any differences in cross-border cooperation in air rescue and on the ground level?

10.1. If yes, what are the differences? 10.2. Do other conditions/requirements for cooperation result from this? 10.3. What can be learnt from the already existing cooperation in air rescue?

9.) Is cross-border cooperation of rescue services necessary in your region?

Keywords: Personal point of view, from citizen’s point of view, state level, hospital level

10.) What obstacles exist in your region for cross border cooperation?

Compare to already identified factors in BTCCE

11.) How does an emergency call from the bordering country get forwarded?

12.) Do you have any suggestions for literature, stimuli, recommendations about this topic? Did we overlook something? Any critique?

Questionnaire adapted from: Sommer, A. (2014, July). Analysis of cross-border trauma care cooperation. Displayed along the western border of Germany from Enschede (NL) to Sankt Vith (BE). Maastricht, The Netherlands: Maastricht University

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