EMS Around the World: The Hungarian National Ambulance Service
Roots of the Modern Ambulance Service in Hungary
The National Ambulance Service (NAS) is the largest health and ambulance organization in Hungary, which has been doing rescue and patient transport for seventy years. It was founded by the Hungarian government in 1948. The roots of ambulance history date back to the last third of the 19th century in Hungary.
The predecessors of NAS were the Budapest Volunteer Ambulance Association (1887), and the Counties and Cities Ambulance Association (1926). The last was operated by a nation-wide ambulance station network. After WWII, NAS was founded in 1948 by nationalizing its predecessor in titles, becoming a countrywide-competent state-run organization. Its professionalism was guaranteed by its 131-year history of the development of rescuing. One of the most telling examples is that in the year of the nationalization, the Counties and Cities Ambulance Association provided the total infrastructure and the personnel for the new organization (96%), while the Budapest Volunteer Ambulance Association ensured the medical professional background in 1948.
Since developing its centralized structure, the NAS has more than tripled the number of ambulance stations while its manpower has grown more than twenty-fold and the number of cars has increased seven-fold.
In order to ensure a more efficient operation, the National Ambulance Service established the county ambulance organization form in county seats around the mid-1960s, which were also parts of NAS. It was headed by the director-general and his professional administrative departments with their directors deciding on technical and organizational matters. Counties had competence in other local cases. In 2005, this structure changed when the NAS formed the regional ambulance organizations (RAO), which have taken over the role of the early county ambulance-systems.
These seven regional ambulance organizations are parts of the NAS today. Each RAO has a local director with chief paramedic and economic-technical department. All RAOs are supervised by the director-general and his colleagues (economic-technical director, medical director, HR director, judiciary director) with their departments (there are more than thirty) from the Budapest headquarters. Some departments make sure that they directly take part in the everyday operational work, such as in the Operation Major Department, Dispatch and Coordinate Department of the Head Physician, and the Operating and Organization Department. NAS is a standardized organization with unified vehicle fleets, equipment, drugs, uniforms, and education and medical treatment guidelines. Its local stations are commanded by ambulance doctors or paramedics, and sometimes by EMTs in the smallest stations.
The Ambulance Station Network
In the founding year of 1948, the NAS’s network system had 76 stations. Today, it has 254 ambulance stations, which are independent from hospitals and other health organizations. The aim is that any scene in Hungary be reached within 15 minutes after alerting. We distinguish three categories of ambulance stations. Type C stations are the biggest; they are led by ambulance doctors or paramedics and they have at least eight or more ambulance vehicles. Type B stations have four to seven vehicles and are commanded by paramedics or EMTs. Type A stations are equipped with two to three ambulances and are also led by paramedics or EMTs.
Nationwide, ambulance units travel nearly 40 million kilometers (over 24.8 million miles) per year. There are 7,500 ambulance employees who have been responding to more than one million calls per year. The NAS has an annual average budget of nearly $146 million (40 billion HUF).
Coordination of Ambulance Resources and the Dispatch System
The dispatch and coordination of ambulance resources are integral parts of the emergency medical services work. Abiding by unified professional principles, the NAS manages the entire vehicle fleet from its 19 rescue dispatching call centers, which utilize telecommunications apparatus with nationwide coverage. Each of the 19 counties has one coordination-dispatch center. The Budapest-based Central Coordination-Dispatch Center (CCDC), created in 1951, is the largest. If necessary, the CCDC is permitted to command the other centers.
In recent years, the European Union and the Hungarian Government supported the development of its dispatch and coordination system with considerable financial resources. The total budget of the ambulance call and coordination project was $14.5 million (more than four billion HUF). Meanwhile, the NAS’s ambulance call number (104) has changed (except the Central RAO, Budapest with Pest County) to 112, the common European emergency telephone number. In spite of this, the ambulance coordination and dispatch have remained part of the NAS. Nationwide, the NAS accepts 3,000 first aid calls on an average day, 1,000 of which are received by the Budapest-based CCDC. The NAS fulfills more than one million first aid calls per year. These centers are managed by ambulance doctors or paramedics who send the appropriate ambulance units from regional stations to the scene.
The NAS has defined its role in education and scientific life. From the mid-1950s to the mid-seventies, the NAS has launched training courses to train paramedics, semi-physicians, and EMTs.
According to the 1975 Health Ministerial provision, the training has been continued within the framework of higher education. In recent years, young people who are interested have the opportunity to participate in graduate courses for paramedic education at universities. The courses are offered in the following university centers: Budapest (capital city), Pécs with its part of Szombathely department, and the Nyíregyháza campus of the Debrecen University. The paramedic education requires four years of studies at the university.
The graduated paramedics can provide advanced life support (ALS) level care, including: defibrillation, use of an esophageal transthoracic pacemaker, crichothyrotomy, endotracheal intubation, controlled ventilation with respirator, venous puncture (peripheral and central) and venous access with crystalloid and colloid solutions, and CPR for adults, children, and infants. Additionally, they may apply intravenous injections for their patients with legal medications accepted in NAS’s practice. Furthermore, paramedics can perform bleeding control, provide medications with an infuser, treat thrombolysis, and fix damaged limbs and articulations.
The EMT qualification at NAS could previously be obtainable by only the non-formal educations system. Today their education lasts two years (1080-1320 hours) with an additional half-year-long (360-440 hours) specialization. All trained EMTs can provide BLS-level care.
In 1979, the Ministry of Health has recognized the new medical science discipline: oxyology, or emergency medical care. From 1983, the teaching of this discipline has been integrated with medical university graduates’ basic training. The training time for ambulance doctor specification is five years, which is added to the six years of basic physician gradual training. Their competence is based on the paramedics’ practices and treatments due to their physician specifications and trainings.
The Hungarian ambulance system is based on the Franco-German model, in which the ambulance doctors and graduated paramedics are present on scene. It has far-reaching historical roots. For example, in 1954, NAS formed the first special, experimental ambulance unit with ambulance doctors. This special unit was the first in the world at that time, using vein techniques for scene treatment, drugs, defibrillators, pacemakers and other formerly unknown procedures.
The bases of our high-ranked ambulance teamwork are the medical treatment guidelines of the regular postgraduate courses and vocational trainings. In that system, the Medical Professional Department and the Educational Department had a key role. Studies for all ambulance workers (ambulance doctors, paramedics, EMTs, coordinate-dispatch center workers and drivers) are organized by the general and medical directors with departments and colleagues.
Field and Air Ambulances
The development of the NAS’s vehicle fleet is closely correlated with the ambulance station network. In 1948, the Hungarian ambulance system had 134 ambulance cars and there were 19 different types. Nowadays, it has more than 1,000 vehicles, most of which are made by Mercedes-Benz. The NAS fulfills its first aid obligation (rescue and emergency patient transport) with its 784 vehicles twenty-four hours a day.
The most common rescue unit types are: the paramedic (paramedic+EMT+driver) or ambulance doctor (doctor+EMT+driver) and EMT (EMT+driver) teams. The special units are: adult paramedic (paramedic+EMT-driver) or ambulance doctor (doctor+EMT-driver) passenger cars; the pediatric doctor passenger cars (pediatric doctor+EMT-driver); the pediatric ambulance doctor (pediatric doctor+EMT+driver) unit; ambulance motorcycles (doctors or paramedics) and scooters (EMT); and mass accident (EMT+driver) and mobile intensive care (paramedic/doctor+EMT+driver) units. It is greatly advantageous for NAS’s rescue system to use one standardized set of medical and technical equipment to appropriately fit the competencies of doctors, paramedics and EMTs in their levels. The vehicle fleet has its own service background in all RAOs.
The NAS is not only a field ambulance organization—it founded its own Air Transporting Group (ATG) in 1958. In the early years, it used the rescue airplanes for secondary transport, but they were not able to provide first aid on the scene. This experiment changed in 1980 when NAS activated the rescue helicopters, the first type of which was the MI-2 model. The air fleet has been modernized since the early nineties with AS 350 Ecureuil helicopter types, though only EC 135 types are used today. The ATG was re-established by NAS in the last decade and continued its duty as the Hungarian Air Ambulance Nonprofit Ltd. (2006) with seven airbases in Hungary (Balatonfüred, Budaörs, Debrecen, Miskolc, Pécs, Sármellék and Szentes). All helicopter crews have similar composition (ambulance doctor+paramedic+pilot). These special units are alarmed and coordinated by NAS’s centers.
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Gábor, Debrődi. History of the Hungarian ambulance system (1769-2012). Budapest: Hungarian Oxyology Association, 2012.
Tamás, Felkai (1987). Hungarian ambulance history. In László, Cselkó (Ed.), Jubilee album for the centenary of the organized ambulance’s history (pp.7-59). Budapest, National Ambulance Service.
Zoltán, Pap (Ed.): Jubilee album for fiftieth anniversary of the Hungarian National Ambulance Service. Budapest: National Ambulance Service, 1998.