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dear students our next workshop ambulance will be given by yesterday and tinkering brewers first they will explain what ambisa rescue team is and how they work then they will be talking about the team behind the urgent ambulance and the non-urgent transport and the required qualifications finally they will simulate a case where they will explain how the abcde protocols seems like and then it's very important to interact with the paramedics and be sure they will be asking you guys some questions yes sir the floor is yours you are there good afternoon everybody my name is jesse i am uh ambulance paramedic in uh irt ambu say in vanium antwerp i've been a paramedic for the past six years and i'm gonna take you on a little belgian ambulance tour so first i will explain what our company looks like so irta is the largest private ambulance company in belgium we have over 350 employees over 400 volunteers and over 150 vehicles our standards are quality safety and comfort of course because we are working with a lot of patients and we perform urgent non-urgent international events and custom-made and doctor-on-call services within our company we have 13 emergency bases with 16 emergency ambulances they're mostly based in the antwerp region but we have ambulances overhaul belgium four non-emergency bases with over 73 vehicles 18 doctor-on-call bases and one headquarter in venice we we transport over 200 000 non-urgent patients every year 1 800 international repatriations every year and then multiple tailor-made services for example the medical services on brussels airport and other nice things so the emergency ambulance system in belgium is coordinated by a dispatch central uh 112 that's our emergency number so we provide ambulances for the central but we don't dispatch them it's a completely out of our leak and we don't do that they are have basic equipment with them for example an aed bandage materials and uh and stuff like that the basic first aid they can perform they can be assisted by a much vehicle the much is the mobile urgency group it's a emergency paramedic and an emergency doctor who have been trained on pre-hospital situations and they can assist the the ambulance crew when needed we usually perform our tasks with two paramedics they had a basic training and then if needed the mich will come but we have a small exception here in antwerp and that's the pit it's a paramedical intervention team and they consist of one paramedic and one emergency nurse who can perform smaller tasks such as pain medication assistance with hypoglycemia and stuff like that the the reason behind this is because we have very few vehicles in antwerp so the doctor could stay in the hospital or on the really urgent calls and the nurse can perform smaller tasks when needed the characteristics of our emergency ambulances you can see the typical battenburg striping since two years there is a new law that states that every emergency ambulance in belgium has to have the battenburg striping and the yellow fluorescent collar there is a fixed price per transport so every patient who has been transported or who has been seen by our ambulance crew will pay 60 euros that's the complete cost and then our company receives some money from the government as well to perform our tasks we are equipped with the basic so an ad oxygen and stuff like that we can perform basic uh tasks uh non-invasive so with a serious injury we we call them we as paramedics cannot give any medication so with patients who are in too much pain or need anything for example nausea then we have to call a mush or a pit to assist us but usually when we do around 10 transports a day we have two to three times that we need a much orbit to assist us so the mobile emergency group it's an emergency doctor and an emergency nurse they work in a hospital on an emergency department and when they get a call they come and save us like pain medication resuscitation intubation is all for milk vehicles it's invasive procedures and we cannot do them as paramedics in belgium um they can be automatically dispatched by the emergency dispatching central if needed if the caller states that it's a cpr is being performed then they will send the vehicle automatically otherwise if we are on scene and we say oh there is too much pain for the patient we need some assistance and we can call back up from the much as well the qualifications for the ambulance crew in belgium so there is a course provided by a provincial um education center there is only one education center per province in belgium um it's um class hours theory and practice combined and then there are four days of internship on an emergency department as well as much and ambulance if you have a positive positive evaluation you will receive your uh your diploma and a blue batch that you can perform ambulance transports in belgium and then it consists of basic training of abcde procedure resuscitation a lot of training and simulation so we can do our complete best the non-urgent transport in belgium is a little bit different than the the rest so it's coordinated by our own dispatch central we have 73 ambulances in flanders and wallonia who perform these transports and it's usually from hospital to hospital from house to hospital or from a nursing home to a hospital people who can't walk or are not mobile and need medical attention they can be transported by our ambulances to consultations etc they can also perform emergency transports outside of the emergency dispatching central for example uh premature born babies uh or out of the whole provence province of antwerp will be transported to the university hospital in this university hospital um the ambulance from the emergency the emergency ambulance from the university hospital can't do all these transports because then there would be a too long of time that the area isn't covered so we provide vehicles who are specially equipped for these kind of transports also transports accompanied by doctor or emergency nurse if needed for example in the brussels region we have a permanent vehicle with a nurse and doctor who performs transports if needed it can be seated supine or in a wheelchair and our vehicles are also provided to perform all the transports if needed so the characteristics there is also a buttenburg striping it's a new law since two years and we're in the phase of changing now so the battenburg striping will be only one block instead of two blocks and it will be a white background instead of the yellow fluorescent color the transports can be demanded through the mutuality by the patient himself or by the hospital then they will call us and we will give them an ambulance they're also equipped with the basics for example an ad oxygen if needed but the training is situated differently than the emergency ambulance so the training isn't as wide as an emergency ambulance the for example on the photo you can see the neonatal transport care unit at a special vehicle who is completely equipped with all the necessary things to transport premature born babies also the international repatriations can be urgent transports because sometimes when people for example in france uh have uh have been resuscitated and they are now intubated then we will go and uh get them with our ambulance crew and doctrine paramedic um the qualifications of the non-urgent ambulance have been changed uh last week so there is a new law since uh 2019 which has been uh which has gone into effect of uh starting off last week so it's a class of 120 hours so it's only 12 hours less than the emergency ambulance also theoretical and practical courses and they have an internship of five days on the non-urgent ambulance in the internship they will have to perform a number of patients for example they will have to do one dialysis transport they will have to do one oncological transport if they do not reach their quota they will have to do extra days after a positive evaluation they are graduated and they will get a visa to be able to perform non-urgent transport and they had a basic training for example vital signs checking resuscitation if needed oxygen therapy etc then we are going to check our abcde protocol so we have been changing to the abcde protocol uh four years ago before that we used another protocol but the abcde is widely spread over the whole world and it has been uh evidence-based medicine that we changed to do to this so um it's a step-by-step plan so you cannot uh oversee anything uh if you complete the plan then you should have seen everything and you should be ready to transport the patient to the hospital and the most important thing of the abcde protocol is treat first what kills first so if you have a patient who has had an accident and his leg is broken but his heart isn't beating then he will perform cpr until his heart beats again and then you can check for uh for his leg so treat first what kills first that's the most important uh rule of ambulance in belgium so the basics just remember the abcs it's a nice one especially in antwerp on a friday night airway breeding and can you walk to the ambulance uh a lot of intoxicated people that's uh yeah widely spread in antwerp so that's why we use this one so the a stands for airway but before the a we do something really important it's checking our own safety and the safety of the patient for example if we step in somewhere and it's been a drug user he's unconscious but there are needles everywhere then we will check if we can take the patient out instead of working in a danger and dangerous environment also people who are aggressive or if the the roads aren't safe then we will call in backup from the fire department or the police we won't bring ourselves into any danger after that we will do a quick abc round the quick abc round is a chat to check if we need to perform cpr or not so when we approach our patient we will start talking we will ask what happened and if the patient starts talking then we can go on to the next abcde protocol because then we know that the airway is clear she has a breathing and there is circulation if the patient does not talk then we will check if there is breathing if there is no breathing then we will perform cpr and the abcde protocol leaves us then we will call him back up from the mush and we will perform cpr until or deceased or ready to transport so the first rule of the abc is the airway it's create a free airway we can do it by uh putting in a goodell tube that's a performance that an ambulance crew can perform we can do uh intubation that's for the keeper a laryngeal mask is not for the ambulance crew it can be performed by the doctor or an emergency nurse who has the right qualifications can insert a laryngeal mask as well or by position we can create a free airway for example intoxicated persons we will put them on their side so they can keep reading and have a clear airway if the airway is clear we're going to check the breathing how is the patient breathing it's not only the the oxygen saturation is important but also how does he present to us is a is the is the breathing agonal or paradoxical or anything are there any trouble breathing because the patient can breathe and maybe have a good saturation but also be clinically not okay then we will check that as well we can treat as an ambulance crew by oxygen or by aerosol it's a medication and the ambulance crews in belgium cannot give any medication the only exception for aerosol is if the ambulance is already on scene and the mush is on the way we can give them an irasol if the much doctor approves that we can give the irosome if there are any deviations in the much or in the complete abcde protocol then we will call in backup from the mooc to assist us with anything if the breeding is checked we will go check the circulation um not only the heart frequency and the blood pressure but also the rhythm is are there any heart problems in the past is there any retrosternal pain things like that we cannot treat uh the patient if needed the most interaction will be with the bush they can give any medication to uh to help the the heart problem uh the only thing we can do is uh things like uh position positionary changes and stuff like that so if the circulation is checked and it's fine we go to the d from disability with this ability we are mostly going to check the neurological improvement or disimprovement of the patient for example the glaucoma scale is frequently used in pre-hospital situations also pearl check if the pupils are equal and reactive and responsive to light and then we use the wapa it's a belgian [Music] word it's uh it stands for a patient who is alert is verbally responsive is only responsive to pain or unresponsive so if the patient is awake and kicking then we will score him an a if the patient is completely unconscious then it will be a you but mostly most frequently used is still the glasgow coma scale because it's uh you can check the improvement of the patient we will perform a fast test if necessary the face arm speech time protocol it's to check if there is any uh signs of an intracranial bleeding or i don't know how to say in english a stroke we will check the glycemia to see if there is a hypo hyper glycemia if there are any deviations in this then we will also call the calling the much to give us assistance with for example sugar or or extra assistance for example people who has who have a glasgow coma scale of three usually we should call in the mush depending on the situation is if there is a glasgow coma scale of three after a big car crash then we will also uh call in help from the from the mooc but the person who has been intoxicated by alcohol we will not call in a milk because there they won't do anything as well they cannot perform any extra things than we can if the disability is checked we go on to exposure we go investigate the temperature of the patients especially in corona timing it's uh an important thing we will ask for as ample it's a complete check of the patient's history and current situation so the s stands for situation what happened why did you call the ambulance the a stands for allergies does the patient have any allergies to medication or etc because if the if the mood arrives and they will give any medication it's important to know the m stands for medication does the patient already take any medication at home and why does he take them the p stands for past history does he have any problems with his heart with his lungs what's uh is there a reason why the ambulance comes now and if it's is it uh possible that it's in the past history as well did the patient eat the that's the l from last meal it's important if there are given any sedatives etc to perform to prevent puking and then the e stands for uh event what's the event that happened that leads to these symptoms for example a car crash can be an event but also uh an intracranial bleeding can be an event as well which gives certain symptoms we go ask for the pain scale as well this can be a vascular so visually with the faces on the the line or an energy score with a cipher from 0 to 10. we perform a head to toe a complete check we're going to check the patient completely for example if there has been a car crash and a patient says his leg hurts we will check him from head to toe if there are any other injuries if this is done and we don't need any extra information we can also intervene here to do extra things if necessary then we will prepare him for the transport we can do this in several ways the patient can get in the ambulance himself we can put him on our stretcher we can immobilize the the complete spine if necessary that's all in uh prepare for transport it's when everything else is done and we're sure that the patient can go to the hospital then we will start the the preparations the muschatz if he came he will always call to the emergency department of the the hospital of destination so they are aware that we are coming and they can prepare for example every um serious injury from example car crashes or active resuscitations where people are still being resuscitated in the ambulance we'll go to the university hospital in antwerp and they have a complete uh trauma crew who will be ready on arrival that's the uh short presentation of the how the ambulance in in belgium works so now we're gonna show you how the ambulance in uh in belgium looks like from the inside what equipment we have with us and then afterwards we're gonna do a little simulation so we can show you how we work and then we can interact with you as well to give us any ideas okay and first of all we're gonna take five minutes of break and then we will proceed hello not my speed so welcome back everybody we're gonna show you our uh emergency ambulance from belgium right now so most important in our ambulance we have a bed so we can transport the patients in supine position if necessary this bed is especially designed to be able to be put on a special stretcher from the fire department if we have to evacuate people from higher buildings etc they can be put on the bed immediately we have some different stuff for example a special stretcher to pick up patients who are in uh on the ground and they need to be picked up on on our bed we have two seats for our doctor paramedic nurses if necessary so there will only be three people in the back maximum so two medical personnel and the patient himself this is a really uh equipped ambulance normally the normal ambulances in belgium don't have monitoring or respiration with them they only have a small monitoring system because for example we cannot read ecgs we only do a blood pressure saturation and if necessary for leads to check the the hardware rate so they are normally not in the ambulance but this is an emergency international ambulance so that's why they have it we have an external uh aed because if the ad of the monitor fails we have an extra one we have some cabinets with uh for example a manual resuscitator some um collar bands uh and uh puking bags if necessary uh we have a monitoring and with the aed system uh completed in one if necessary a respiration system and an uh suction unit every emergency ambulance in belgium has a suction unit the non-urgent transports have a smaller system which can be manually used but it's not frequently used on non-urgent transports we have a needle container and some small stuff a syringe driver the much always has a few syringe drivers with them and this ambulance for example has one as well but it's not frequently used pre-hospital we have our basic systems like gloves extra stuff we have some blankets with us and then we have a lot of cabinets who uh have the basic equipment for example uh wound packaging uh oxygen therapy wound dressing uh if necessary also since uh the 2016 attacks in paris we have a specially designed terror kit which has tourniquets and israeli bandages etc we have our personal protection equipment since the corona timing we use this a lot masks ffp2 masks and extra gowns if necessary also basic equipment like uh pupil light glycemia setting and uh temperature measurement is in this cabinet then we have an extra cabinet because this is an uh emergency ambulance we have uh basic uh lining equipment to uh to give uh medication if necessary and then some sanitary stuff and extra equipment for the uh the ambulance for example if our suction unit is full we have some extra stuff intubation uh but this is not frequently used because the mush always wants to use their own stuff because they know their own stuff better we also have a specially designed bag which contains all the material we need wound packaging oxygen therapy manual resuscitator if necessary and material to take the blood pressure and the saturation etc is all inside our back so if the patient cannot walk to the ambulance himself we will take the back and measure everything that's needed out here we have oxygen therapy if necessary these are medically purchased so they can only be used in ambulance and pre-hospital settings and not otherwise i will take you back to the the back of the ambulance to show you the other side on this side of the ambulance we have some storing equipment for example our fire extinguisher we hopefully hopefully don't use it it's not to extinguish fires but it's necessary if our own car is on fire we use it we have some extra oxygen for the ambulance itself and then we have a carrying chair for example people who are on the second floor of a building and they need to be evacuated and cannot be uh they cannot walk themselves then we will take them on our carrying chair and put them down the stairs uh spinal immobilization it's uh it has been frequently used in the past but now since a few years there are have been votings to quit with the spinal immobilization and put them on our other stretcher with the head blocks and just tape them there has been a study from the university hospital in antwerp and some some other studies in the united states who have been saying that this is not the right equipment for spinal mobilization we have some extra immobilization for possible fractures and then immobilization for the spine if a person is trapped inside a car then we can evacuate him with these extra immobilization without damaging the the spine extra then i will show you the front of our ambulance this is a basic front so we have a gps the the central dispatches the location of the intervention automatically to the gps so we only have to get in and leave and then we have tablets for the non-urgent transports they get their their transports through to the tablet and then they can leave and they can also update the dispatching central where they are and uh if they're with the patient onward to the patient they also have normally a walkie-talkie we can talk to the dispatching with but this ambulance is not equipped because it usually does the international transport so that we don't use it on the emergency center so that's uh how a belgian ambulance looks like in short we can also if necessary put extra equipment in for example a special mattress if the patient has decubitus etc it can also be modified by the wishes of the client for example our brussels airport rescue team has a special vehicle with special equipment because the ambulance from the airport uses a different equipment and than other ambulances so it's uh we also discuss it always with the the patient and with the client if necessary so now we're gonna take a short break of five minutes again and then we're gonna show you how we work as a team to uh help a patient out do you think and we will show you how we work as a team now so first of all we have the abcde protocol but safety first so that's why we take our gowns and also check if the there is no other transport on the roads etc so my colleague the first thing she will do is a manual stabilization of the neck because the patient has been hit by a car we don't really know what problem is yet so this is why we will uh first check this she's awake she's crying so the first abc is okay she has a circulation she has a breathing the airway is clear because she's crying so first thing we will do is check if we need to keep the manual stabilization of the neck miss i'm from the ambulance hi how are you feeling my my arm hurts okay the left or the right arm right okay do you have any pain elsewhere no it's just my arm does your neck hurt no okay do you feel your legs yes okay can you wiggle your toes for me okay it's okay my arm there is no neck or back pain the toes then the arms are both mobile so we don't expect a final injury right now so that's why my colleague can leave the neck as it is and then we're gonna see the abcde protocol so a she has a clear their way she's awake she's conscious so she can clear her airway herself then we're going to check for the breathing so we have a monitoring system right now we can use it to check for saturation and then my colleague is gonna check for a breathing she's gonna put her two arms on the chest of the patient to check if there is a diagonal breathing or normal breathing or anything different miss we're gonna do a little checks a few checks and then we're gonna check your arm oh my god [Music] okay try the breathing slowly okay was that the car oh okay so right now we're seeing she's breathing normally maybe a little hyperventilation but that's okay because if she's been hit by a car it's normal a good saturation and then we can move on so the breathing is okay and we're going to check the circulation we're going to go with our uh heart frequency of the monitoring system but also we feel ah this is the painful arm yes okay so we also check the painful arm to check if there is any perfusion to the to the limbs because if she broke her arm here there is a possible rupture of any uh blood vessels so we also check the the good arm and then the bed arm the bed arm and the good arm so we can feel our pulse it's normal it's regulary and she'll probably have a good blood pressure because i can feel it here but we also check it always blood pressure management always on the good arm and also my head hurts a bit your head hurts a little bit okay we're gonna check in a minute okay do you have any heart problems no no okay perfect in the meantime we can complete the c and we can go on to the d this is the most important in this case she has a good glasgow coma scale we can see but the paint scale etc is uh is important in this case to see if we need assistance from a much or we can do it on ourselves okay so how much pain do you have on a scale from zero to ten six six okay usually we see more than eight or more than seven is a mush and less than seven is uh we can do it on our own but it's also the clinical image of the patient right now she has a possible fractured arm we can do it ourselves we don't need the doctor to come here to check it out okay so the d also we are checking glycemia but we don't do it always because in this case there is no internal affair there is no problem the the problem is clear that the arm is broken or severely damaged and there will be no uh right side problem with the glycemia we also asked did you eat anything yes in the morning i eat breakfast you ate breakfast okay are you a diabetic no diabetes okay if that's she's not a diabetic and she ate well then we will not perform the the glycemia measurement then everything neurologically seems fine right now and then we're gonna go on to the e from exposure so temperature management is really crucial right now in corona timing so we will take our temperature and then we're gonna do a head to toe uh checking okay so my colleague is going to measure the temperature and in the meantime i can do my uh assessment of the patient so ma'am how are you feeling right now only my arm hurts your arm hurts okay so a pain scale of six is still uh uh yes okay perfect do you have any allergies only for uh penicillin okay perfect do you take any medication at home on a regular basis no no okay sometimes uh first time but not on a regular basis okay perfect uh do you have any past history of medical problems no no heart problems wrong problems okay any surgeries on your arm okay perfect you ate the breakfast what did you eat for breakfast um i drank coffee and i ate and yeah and i ate pancakes okay and then the you have been hit by a car now yes and how fast were you cycling yeah lots of bus it was like 10 kilometers and do you have an idea how fast the car was driving yeah it it seems like it was um like yeah 40 kilometers normally you yeah i don't know it was like 40 kilometers it seems very fast okay you always have game consciousness you haven't been on country uh no okay and you know you know what happened with the car accident there is no blurry image just my head hurts a bit but okay you're not nauseous no vomiting i'm gonna check your eyes for a second look up okay we always check the pupils uh to see if there is any neural neurological problem so uh dilated pupils or uh unequal pupils can uh give a sign for neurological problems so my colleague is going to perform a head-to-toe transp check to see if there is any problem besides from the arm adrenaline in such situations can can give a situation where we as an ambulance crew miss some certain things so she's gonna touch everywhere and she will say it if there if you have any pain then you will uh have to say it always check the belly to see if there is a possible internal bleeding okay we're not gonna check the arm right now because we know that the arm is already uh compromised and then we also check everything completely if this has been checked then we can uh move on to our uh last thing and that's preparation for transport since she has a possible broken wrist because it's the wrist that hurts i think yes okay then we will immobilize the wrist with our vacuum system huh oh so this is a special system we use for wrists we have different sizes of the vacuum systems since the patient is stable we don't need continuous monitoring of the vital signs it's okay can you lay your arm down yeah we'll try okay we're gonna put a little pressure on the arm so we can if there is a fracture separate separated from uh from the the both bone fragments my colleague is going to keep the pressure on the uh on the arm right now and then we're gonna close it when we close the the vacuum spout it will uh be less painful because you can't move your arm anymore okay okay always be sure that you can still see the fingers if there should be any problem and they become bluer things like that then we can check but they should always be visible so this is our vacuum pump we close the vent okay so now you can feel it press a little bit and when i pull the the vacuum i pull the air out my colleague is going to slowly release the hand of the patient and pull our hands out as well so now it's approximately halfway there we're gonna form it around the arm pull the strings again and then we're going to completely suck all the air out is it less painful now yeah okay perfect much better you can move your arm now it's no problem and then you can try to put it on your belly and support it with your good arm okay i'm gonna help you okay then we're gonna put the patient up and see how her reaction is when we put up a patient like this she has been down for approximately 15 minutes at least we also check the blood pressure again if we have a radial pulse which is uh good and we can feel it then we have we know that her blood pressure is high enough to put her up and walk into the ambulance if the patient in this case couldn't be walking anymore because she has a broken leg or things like that then we take our stretcher we transport her to the hospital where she has an x-ray some pain medication and then we'll see if there is any surgery needed but that's the doctor's case okay super we thank you for your attention and we hope you have a nice idea how the ambulance in antwerp and incomplete belgium works now and hopefully we see you again for the next workshop thank you very much for the good help [Music] is all right the students have now the possibility to ask some questions i'm i'm now going to read some questions to uh for yes sir okay so the first question is what are you giving by my a results usually we give a medication like ventolin or duovent by aerosol it's a combination preparation of uh antihero energicum and beta-memeticum to uh to increase the the airflow and the oxygen support in the lungs all right thank you the second question in the netherlands we have special ambulances in which surgeons remove donor organs from a diseased patient how is that arranged in belgium we do not have special ambulances but every hospital who has a possible donor or patient we call them the the harvesting patients and they will call their own surgeon in the hospital and they will perform the the surgery themselves and they will be transported in special vehicles uh some motorcycles and some specially designed cars to uh transport the organs to the necessary hospitals and the necessary patients okay thank you the third question how is the patient with hypoglycemia managed uh hyperglycemia it depends on the patient if the patient is awake and he's known with diabetes and we see a lowered glycemia then we can give him cola and sugar for example we give fast sugars like coca-cola or anything like that usually fanta works better because there is more sugar otherwise we we make them a sandwich with some stuff uh choco for example which works uh on a longer period and then they will check them themselves if this is not possible and the patient is unconscious then we will call a much service or a pit and they will come and give glucose by uh intravenous excess and then when the patient awakes we also give them a sandwich with choco or anything okay that's fine then the fourth question there are people that would give an eye on the pain scale while only having a broken wrist because pain is relative do you acknowledge that or do you always call them when the pain scale is that high it it always depends on the situation in the case we just presented with her broken wrist if she would have answered at 10 i would have probably not acknowledged and not have called the much because giving pain medication and taking a much away from its service for this is quite expensive at first and quite difficult because other patients cannot receive the much when they really need them and not for the pain medication so it always depends on the situation and the patient but in this case i wouldn't have i don't always acknowledge a higher pain scale okay that's fine then the next question all right in the case of calamity or natural disaster what role does the does the embassy rescue team play how does it help to how does it help to mitigate the loss of life and does it operate any rescue mission it also depends on the situation for example we have uh ambusa is not the only firm who performs emergency transports for example the fire department in belgium does a lot and other private companies do as well so when there is for example a disaster in antwerp we have spartales for example if there is an explosion in sports palace it's a large theater with over 30 000 places then the the first help would be 10 emergency ambulances and they will be from every firm it will not only be ambushed but also the fire department the most nearby ambulances will be handpicked by the emergency central um so if it's an ambush ambulance of course we will respond and extra to those 10 ambulances and five services they will call in help from the red cross the red cross has an um in belgium a system designed for large disasters and first help they will come with all the necessary ambulances in a large case for example if the sport balance with 30 000 people would explode then there will be also 10 ambulances from the nearby provinces for limburg brussels and australia will send some ambulances as well and then ambush will call to the the emergency dispatching central uh we had explosions in zavantim a few years ago and that the the ambulances from brussels would do the first aid and then there would there have been some extra ambulances sent from antwerp from the emergency systems and ambush called and the the emergency central and said oh okay we have five extra ambulances we can make free we will give them to you and you can use them in other cases for example the tsunami in thailand a few i think more 10 or 11 years ago ambucea will provide if necessary medical services for example our ceo our big boss young christian went with the medical team to help out and do a humanitarian mission and if requested we can always uh help out it's usually we have in belgium a bfast team which ambusher rescue team isn't part of but if necessary with really large calamities we can always help all right thank you for your good explanation about that um then the next question when the patient just hurts his or her head how do we manage that what are the things we have to do when the patient is alert and awake and what do we do when the patient is not awake when a patient is not awake and he hurt his head it's always a mush indication uh unconscious patients are actually always a much indication but we have to use our common sense if it's in a nightclub and it's just unconscious because it drank too much then we will not call the mushroom we will do it on our own but an unconscious patient who hit their head is definitely a movie indication because there might be a neurological problem if the patient is awake it depends on the situation we always ask for signs of a commotion for example nausea photophobia vomiting and more specific explosive vomiting and it all it always depends on the situation how hard did she hit her head did she hit her head because she she stumbled on the normal ground or did she fell from a a chair or a table or anything always depending on the situation okay all right then how does the embassy rescue team deal with medical medical legal aspects of an emergency case um an example a road road traffic accident we as a paramedics have an uh uh medical uh in our medical profession it's in in every country i think uh a medical secrecy which we cannot violate for example if we have a car crash and one person appears to be drunk it's not our task to call for the police we have medical secrecy the only case in which we can call the police is when the patient is threatening to hurt himself or is threatening to hurt other people if if the prayer the patient states oh i'm gonna i'm gonna plant a bomb in the university of antwerp then of course we can call the police but in other minor cases it's not our deal for the example of the road traffic accident every accident in which an ambulance is requested because of a patient who is uh injured there will always be police on scene and if one of the patients asks for police we can always request them but we cannot request them because we have hunches off intoxication or anything for example we had a burglar yesterday on our emergency department and we cannot call the m the police because we know he was a burglar we have to treat the medical aspect and that's it if the if there is another person there who says oh he's been burglaring in my house then it's his responsibility to call the cops okay thanks then the last question in my in my country tetanus injection is given to every injured injured person involved in an accident does this happen in belgium too it only happens when the patient isn't sure about his vaccination or if he isn't if he doesn't if he doesn't it doesn't really know like uh yeah maybe i had it but i don't really know for sure of when he's sure that it's been longer than 10 years if he's sure okay i had it last year then we don't give it if he's not sure uh there is a possibility of doubt then we give the the injection all right thank you very much yes sir um if there are any questions then is uh then yeah it's now the moment to ask them are there any questions yeah okay okay then uh this was the workshop ambulance i will yeah special thanks to the two paramedics yesterday and tinka hebrews for the good presentation and um yeah for the simulation so thank you very much and yeah have a nice day thank you you