Emergency medicine in Southern Brazil

I N T E R N A T I O N A L R E P O R T

Ross D. Tannebaum, MD*

Jeffrey L. Arnold, MD‡

Armando De Negri Filho, MD§

Viviane S. SpadoniII

From the Section of Emergency Medi-cine, Provena St. Joseph MedicalCenter, Joliet, IL, and the Departmentof Emergency Medicine, University ofIllinois College of Medicine, Chicago,IL*; the Department of EmergencyMedicine, Cedars-Sinai MedicalCenter, Los Angeles, CA‡; GeneralSecretary of the Brazilian Network ofEmergency Cooperation, PlanningDepartment, Hospital Municipal dePronto Socorro,§ and UniversidadeFederal do Rio Grande do Sul,II PortoAlegre, Brazil.

Received for publicationAugust 6, 1999. Revisions receivedMarch 24, 2000, June 21, 2000, andSeptember 21, 2000. Accepted forpublication October 4, 2000.

Presented at the 8th InternationalConference in Emergency Medicine,Boston, MA, May 2000.

Address for reprints: RossTannebaum, MD, Section ofEmergency Medicine, Provena St.Joseph Medical Center, 333 NorthMadison Street, Joliet, IL 60435; fax815-741-7660; [email protected].

Copyright © 2001 by the AmericanCollege of Emergency Physicians.

0196-0644/2001/$35.00 + 047/1/112252doi:10.1067/mem.2001.112252

Emergency medicine is developing rapidly in southern Brazil,where elements of both the Franco-German and the Anglo-American models of emergency care are in place, creating auniquely Brazilian approach to emergency care. Although emer-gency medical services (EMS) in Brazil have been directlyinfluenced by the French mobile EMS (SAMU) system, withphysicians dispatched by ambulances to the scenes of medicalemergencies, the first American-style emergency medicineresidency training program in Brazil was recently established atthe Hospital de Pronto Socorro (HPS) in Porto Alegre. Emergencytrauma care appears to be particularly developed in southernBrazil, where advanced trauma life support is widely taught andSAMU delivers sophisticated trauma care en route to traumacenters designated by the state.

[Tannebaum RD, Arnold JL, de Negri Filho A, Spadoni VS.Emergency medicine in southern Brazil. Ann Emerg Med.February 2001;37:223-228.]

I N T R O D U C T I O N

The Federal Republic of Brazil covers 3.3 million squaremiles, encompassing almost 50% of the entire continentof South America.1 Brazil is also one of the world’s mostpopulous countries, with 165 million people in 1998.2

Although the Brazilian government incorporates 26 statesand the Federal District of Brasilia,1 the country itself canbe divided into 5 distinct geographic and cultural regions:(1) the south, with the city Porto Alegre; (2) the southeast,with São Paulo and Rio de Janeiro; (3) the northeast, withSalvador and Recife; (4) the central, with Brasília; and (5)the north, which includes the Amazon region.

Brazil is a nation of great economic contrast. With re-cent annual economic growth of 3% lifting the averageper capita gross domestic product (GDP) to $6,300, theBrazilian economy now ranks among the top 10 economiesin the world ($1.04 trillion GDP in 1997).1 Nevertheless,

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vast areas of Brazil still reflect third world conditions, in-cluding much of the north and northeast and the periph-eries of major cities, where people live in slums or favelasthat rank among the poorest places on earth.

This report focuses on the emergency care system inPorto Alegre, as representative of the wealthier southernregion of Brazil. Porto Alegre, with 1.5 million inhabitants,is the capital city of the southernmost state of Rio Grandedo Sul. Most inhabitants of this region descend fromItalians and Germans who immigrated there during the19th century. Porto Alegre prospers from the largest mid-dle class in Brazil. Although favelas exist (30% of the pop-ulation lives below the poverty line), they are less com-mon in Porto Alegre than in São Paulo or Rio de Janeiro.

M E D I C A L E N V I R O N M E N T

The major cause of death in Brazil today is cardiovasculardisease, followed by cancer, respiratory disease, andtrauma.3 In general, patients in urban areas of southernBrazil have diseases of lifestyle similar to those in devel-oped countries. Trauma, from motor vehicle crashes andinterpersonal violence, is a major problem in southernBrazil and the leading cause of death from age 15 to 60years.3 Much penetrating trauma stems from the drugtrade in the poorly policed and impoverished favelas.Substance abuse is an increasing concern in the favelas,where crack cocaine abuse is growing and alcohol abuse,petroleum solvent sniffing, and other drug abuse areprevalent.

Several tropical diseases are endemic in different regionsof Brazil. Even physicians in urban Brazil must be familiarwith tropical medicine, because they occasionally seepatients from rural areas presenting with cardiac or coloniccomplications of Chagas disease, portal hypertensionfrom schistosomiasis, malaria contracted in the Amazon,dengue fever, and occasional snake or scorpion envenom-ations.3

H E A L T H C A R E E C O N O M I C S

Both the public and the private sectors finance health carein Brazil. The federal government funds universal medicalcare through the Sistema Único de Saúde (SUS) program,which was passed into constitutional law in 1988.3,4 SUSfunds public hospitals in Brazil and contracts for medicalcare at individual private hospitals. Because Brazilians arenot required to qualify or register for SUS, any person inBrazil can receive free medical care at any hospital with an

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SUS contract. Although the federal constitution guaran-tees universal health care to all Brazilians through SUS,the actual delivery of this care is limited by insufficientgovernment funding. Brazilian health care is also fundedby private medical insurance, which both complements,and in some cases, competes with SUS.4-6 Certain nationalcorporations and government entities also provide em-ployees with medical insurance, which is only valid atspecified hospitals.

H E A L T H C A R E S Y S T E M

The health care system in Brazil is also divided intopublic and private sectors, operating in parallel. Accord-ingly, Brazil has both public and private medical schools,hospitals, and out-of-hospital care services.4,6 Even pri-vate hospitals with SUS contracts often divide their emer-gency departments into separate areas for patients withprivate medical insurance and patients with SUS, creatingan often jarring disparity between modern, well-equippedsides for the insured and often overcrowded, third world–appearing sides for patients with SUS.

Brazilian hospitals tend to specialize in specific areas ofmedicine, such as trauma or cardiology. For example,trauma hospitals provide care for patients with virtuallyany type of trauma, including orthopedic or hand injuries,but will refuse to admit patients with medical disease.Hospitals specializing in internal medical care, such asthe Hospital de Clínica in Porto Alegre, will transfer apatient with even a simple shoulder fracture. Hospitalsspecializing in cardiology, such as the Instituto de Cardi-ologia in Porto Alegre, may even have cardiac EDs, butonly for patients with cardiac emergencies. Major centersoffer the same state-of-the-art medical technology avail-able in more developed countries.

Physicians are more widely specialized in Brazil, with63 officially recognized medical specialties comparedwith 24 specialty boards in the United States.7,8 Emer-gency medicine per se is not yet an officially recognizedmedical specialty in Brazil. The recent trend of reducingthe number of medical specialties in Brazil poses a majorobstacle to the future recognition of emergency medicineas an independent medical specialty.

Although the health care system in different regions ofBrazil is based on similar law and organizational frame-work, facilities in the less-populated northern and Amazonregions are usually less well-equipped and physicianstend to be less well-trained. As in the United States, thereis a maldistribution of physicians with an overabundance


also recognizes the public SAMU service as having theauthority to set additional standards and to coordinate allpublic and private services. There are no standards gov-erning qualifications of EMS physicians, except that theymust hold a valid state license to practice medicine.

SAMU is the major provider of out-of-hospital traumacare in Porto Alegre. It also currently provides about half ofthe nontrauma EMS care in the city. SAMU is free to all citi-zens and is supported by SUS, mostly through municipalfunds. SAMU was established in 1995 after an agreementbetween Brazil and France to exchange technical informa-tion. A major characteristic of the SAMU system is the eval-uation or screening of emergency calls (medical regulation)by a physician at the communication or dispatch center.Medical regulation may result in medical advice to thecaller, basic life support (BLS) ambulance dispatch, or ALSambulance dispatch. Importantly, not every call to SAMUresults in an ambulance dispatch. The management tool ofmedical regulation was sanctioned by the Federal Councilof Medicine in 1998 and was more recently made official bythe Ministry of Health. One physician works with the teamof communication operators to screen cases. Two otherphysicians are available to be sent to the scene of medicalemergencies. SAMU ambulances are dispatched from 5bases throughout Porto Alegre.

The public accesses SAMU by calling 192. The currentSAMU director is attempting to popularize this numberfor all medical emergency calls. At the dispatch center, 5to 6 communication operators act as medical regulationassistants, answering about 2,000 calls per day, with mostcallers simply requesting information. SAMU dispatchesapproximately 1,800 ambulance runs per month.

Similar to US advanced cardiac life support (ACLS)ambulances, SAMU ambulances are well equipped withoxygen, airway equipment, intravenous equipment, car-diac monitors/defibrillators, standard ACLS medications,and even respirators. Because 45% of SAMU dispatchesare presently for trauma, most patients are brought to 1 ofPorto Alegre’s 2 trauma centers.

The fire department and military police each have theirown ambulance system and public access numbers. Bothsystems are currently being absorbed into SAMU, and mostcalls are now routed to the dispatch center in Porto Alegre.

In regions where the highway system is privatized, anEMS system exists with BLS ambulances placed 30 kmapart on private roads. This system also provides ALSambulances staffed by relatively well-compensated physi-cians ($25 to $30 per hour). The guiding philosophy ofthis service is to transport patients as rapidly as possible to

of physicians in the metropolitan areas, and a shortage ofphysicians, especially specialists, in the poorer ruralareas.3,4,6

M E D I C A L S C H O O L A N D R E S I D E N C Y T R A I N I N G

Students enter medical school in Brazil immediately aftergraduation from high school and after passing a competi-tive qualifying state examination. Medical school lasts 6years. Emergency medicine is included in the curricula atthe 4 medical schools in Porto Alegre.

Brazil offers residency training in most medical spe-cialties. Training in either internal medicine or generalsurgery generally takes 2 years. Training in medical sub-specialty areas consists of an additional 1 to 3 years after 1to 2 years of internal medicine residency, whereas train-ing in surgical subspecialties begins after 1 to 2 years ingeneral surgery. On completing postgraduate training,many Brazilian subspecialists take a qualifying examina-tion, although it is not necessary to pass this examinationto practice a subspecialty. Recently, residency training inemergency medicine was established at the Hospital dePronto Socorro (HPS) in Porto Alegre.

E M E R G E N C Y M E D I C A L S E R V I C E S

The emergency medical services (EMS) system in PortoAlegre is similar to EMS in other metropolitan areas ofBrazil. It is relatively well developed and involves a num-ber of often overlapping services. In the country’s north,ambulances are less well equipped and the organizationalstructure is looser. In the Amazon region east of Manaus,EMS may be nonexistent.

The various services that comprise EMS in Porto Alegrecan be grouped into 3 categories: (1) the public servicerepresented by the Servico de Atendímento Médico deUrgencia (SAMU) and the fire department, (2) privatizedhighway services, and (3) fully privatized (nonhighway)ambulance services. There has been a recent trend to reg-ulate and coordinate all of these diverse EMS services byBrazilian federal and state governments. In the 1990s, theFederal Council of Medicine and the Ministry of Healthestablished out-of-hospital care standards for EMS sys-tems. The Franco-German model of emergency medicinehas influenced all of these systems, with physicians fre-quently riding in ambulances. Paramedics do not exist inBrazil because Brazilian law precludes nonphysiciansfrom performing intubation, defibrillation, and otheradvanced life support (ALS) procedures. Brazilian law



previously selected hospitals, including the 2 trauma cen-ters in Porto Alegre.9,10 This service is paid from moneygenerated by tolls. As with the SUS-supported SAMU ser-vice, patients are not charged directly for these services.

Several private ambulance services operate in PortoAlegre. Patients pay a monthly insurance premium forprivate ambulance service (approximately $10 to $15).Uninsured patients may also access private ambulances,but must pay at a higher rate of $100 to $150 per trans-port. The physicians who provide care in these ambu-lances are usually moonlighting residents or other physi-cians with no training in emergency care.

Many emergency physicians believe that an inappropri-ate number of seriously ill medical patients are brought toEDs by taxi or private vehicle. Some reasons suggested forthis are that the public is generally unaware that SAMU canbe accessed for conditions other than trauma, and that pri-vate ambulances are expensive for uninsured patients.

Because emergency medicine does not yet exist as aspecialty in Brazil, an emergency physician may be anyphysician with a license to practice medicine. In the largeurban academic medical centers, teams of internists, gen-eral surgeons, and occasionally orthopedists see adultemergency patients. These teams may also include resi-dents and medical students. Residents and young physi-cians building their private practices frequently moon-light in smaller EDs. Pediatricians see children in the EDsof pediatric hospitals.

Emergency physicians are not well compensated inBrazil. In Porto Alegre, physicians working in EDs earnapproximately $10 to $20 per hour.

EDs at both public and private hospitals serve the peo-ple of Porto Alegre. The largest public ED in Porto Alegreis at the Hospital Nossa Senhora Concecão complex, pro-viding care to a reported 360,000 patients per year. Com-prised of 4 hospitals and 1,100 beds, this complex is thelargest in Porto Alegre and includes the 300-bed HospitalCristo Redentor, which specializes in trauma. Conse-quently, the ED is flooded with indigent patients, manywho arrive by bus from throughout the state seeking carefor chronic medical problems. During the day, 6 internists,2 surgeons, 1 gynecologist, 4 dentists, and 6 medical resi-dents staff this ED. During the night, even fewer physi-cians and residents are on duty.

The ED at the public Hospital de Clínica de PortoAlegre sees about 70,000 patients per year and is staffedby internists, surgeons, pediatricians, and residents ininternal medicine, surgery, and pediatrics. This hospitalis the main teaching facility for the Universidade Federaldo Rio Grande do Sul medical school.


The ED for the private Hospital da Santa Casa complexactually consists of 2 separately staffed departments lo-cated on opposite sides of the main hospital. The privateside is staffed by 2 internists during the daytime and theindigent side is staffed by 1 internist. These departmentssee a combined 77,000 patients per year. The hospitalcomplex is composed of 5 separate hospitals, includinghospitals specializing in cardiology, neurology, and pul-monary medicine and serves as the main teaching facilityfor another medical school.

The ED at the private Pontificia Universidade Catolica(PUC) Hospital São Lucas consists of 6 separately staffedemergency care units, 3 for adults and 3 for children. Foradults, there are separate public and private general EDsand a combined critical care ED for critically ill patientsregardless of insurance. These 3 units provide emergencycare to an estimated 120,000 adult patients per year.During the day, 2 internists staff the privately insuredadult unit and 1 internist, 1 resident, and 1 student staffthe indigent unit. Two internists, 1 resident, and 1 stu-dent also staff the adult critical care unit. The 3 pediatricemergency units are also separated into areas for the pri-vately insured, indigent, and critically ill and follow thesame pattern of staffing. Although the PUC hospital isconsidered private, it has contracted with SUS to provide70% of its inpatient beds to SUS patients. Approximately70% of its emergency patients are also funded by SUS.This modern hospital also serves as the main teachinghospital for the PUC medical school.

These ED volumes may be inflated because the totalnumber of ED visits tends to include the total number ofhospital admissions or outpatient clinic visits. In addi-tion, SUS patients often seek care in the public hospitalEDs for all of their medical needs, including primary carefor chronic medical problems. The volumes reported byprivate hospitals may be skewed because hospital admis-sions are often routed from private physician officesthrough the ED.

Porto Alegre also has many private clinics advertisingthemselves as emergency hospitals, but which are actu-ally the equivalents of US walk-in centers. These free-standing clinics are not usually affiliated with hospitals,making diagnostic evaluations and arrangements forinpatient care problematic.

EDs in southern Brazil stock the same drugs and equip-ment available in more developed countries, althoughthere is often a 3- to 5-year delay before new drugs becomeavailable. Other standard ACLS medications are typicallyin supply. Defibrillators, intubation equipment, and ven-tilators are standard equipment in southern Brazilian


began training on January 1, 1996. Recently, the programhas been expanded to 4 residents per year. Residents maybegin after completion of medical school. As of 1999,there were 8 salaried faculty for the program. Attendingfaculty of the program have all completed residency train-ing in internal medicine, and most have completed fel-lowships in either critical care medicine or cardiology.Attending physicians in the program generally have out-side private practice, salaried hospital, or other practicecommitments.

The residency program curriculum was developed bythe program director and faculty. This curriculum is basedon that of North American emergency medicine training.Clinical training consists of 6 months of resuscitationroom (trauma and medical), 4 months of ED and minoremergency clinic, 1 month of combined otorhinolaryn-gology and ophthalmology, 1 month orthopedics room, 3months of trauma ICU, 1 month of coronary care unit(CCU), 1 month medical ICU, and 2 months of EMS. Inaddition, there are outside rotations: 1 month pediatricemergency room, 1 month obstetrics/gynecology emer-gency room at the Hospital Nossa Senhora Conceicão,and 1 month cardiac emergency room at the Insituto deCardiologia. Residents are responsible for keeping arecord of required procedures. There are approximately 5hours per week dedicated to conference learning.Attendance for residents is mandatory. This includesdidactic lecture, journal club, and case review confer-ences. Residents are responsible for their own textbooks.Commonly used textbooks include American emergencymedicine textbooks, and various medical and surgicaltextbooks from both Brazil and the United States. There iscurrently no in-training or completion examination takenby the residents. Official recognition of the HPS emer-gency medicine residency training program awaits officialrecognition of emergency medicine as a specialty by theFederal Council of Medicine of Brazil.

F U T U R E O F E M E R G E N C Y M E D I C I N E

In establishing the HPS emergency medicine residencytraining program, physicians in southern Brazil havetaken an essential step in the development of emergencymedicine as a specialty. The creation of a core of special-ists in emergency medicine in a country has always en-abled improvements in other emergency medicine sys-tems (patient care, academic, and management) andremains the sine qua non for future development. Whetherthese newly trained emergency physicians should staffSAMU, hospital-based EDs, or both are questions of eco-

EDs. Although emergency physicians perform thrombol-ysis with streptokinase, conscious sedation and rapidsequence intubation are rarely performed (usually onlyby anesthesiologists). Angiography and computedtomography (CT; often on older-generation imagingequipment) are available in most hospitals. Ultrasonog-raphy is sporadically available in Brazilian EDs.

Overcrowding is a common problem in Brazilian EDs.In some EDs in Porto Alegre and São Paulo, patients rou-tinely wait 1 to 3 days for admission to an inpatient bed.During this time, complete evaluations are performedand entire hospital courses take place. Patients with myo-cardial infarctions are ruled out, patients with gastro-intestinal bleeding undergo endoscopy, and after surgery,some patients are returned to the ED for postoperativecare. Patients with ventilators may remain in the ED fordays.

Brazil also lacks laws regulating interfacility transfers.Because hospitals often specialize in various areas ofmedicine, patients presenting to one hospital may bereferred to another. Indigent patients who present to pri-vate hospitals without a SUS contract are usually turnedaway without stabilization.

Both advanced trauma life support (ATLS) and ACLSare taught in Brazil. ATLS has been offered since 1993 at12 training centers throughout the country, includingone in Porto Alegre. At this time, more than 4,500 physi-cians have completed ATLS training at more than 300provider courses. Physicians and medical students havealso benefited from the numerous out-of-hospitaltrauma life support courses offered throughout the coun-try. An ACLS provider course was also recently estab-lished in São Paulo.

The state government has designated 2 trauma centersin Porto Alegre. Both provide care comparable to Level Itrauma centers in the United States, with in-house traumasurgeons and operating rooms, CT, and angiographyavailable 24 hours per day.

Located in downtown Porto Alegre, the 130-bed pub-lic HPS specializes in trauma care and serves as the centralbase station for SAMU. In 1998, HPS had 221,000 outpa-tients and 11,000 inpatient admissions. Because approxi-mately 60% of patient visits involve trauma, surgeons andsurgical residents primarily staff the hospital. Accordingly,almost every HPS resident has performed an emergencythoracotomy.

The HPS emergency medicine residency recentlyestablished the first and only emergency medicine resi-dency training program in Brazil. The residency is a 2-year program. The first emergency medicine resident



nomic viability and cultural necessity, not of medical util-ity, at least not until patient outcome data become avail-able. In fashioning a system that mixes characteristics ofthe Franco-German model of emergency care (a regulatedsystem with emergency physicians on ambulances) withthe Anglo-American model (emergency physicians inEDs),11 Brazilian physicians are creating a uniquelyBrazilian approach to emergency medicine that promisesto improve the lives of millions of Brazilians.

Significant obstacles remain to the development ofemergency medicine in Brazil. These include the estab-lishment of a comprehensive specialty organization unit-ing physicians involved in all aspects of emergency care,the development of more emergency medicine residencytraining programs, the creation of a board certificationprocess, and the official recognition of emergency medi-cine as a unique medical specialty. Pioneers of emergencymedicine in Brazil will also be challenged by the seem-ingly disparate systems of care for patients with privateinsurance and patients with SUS. In addition, the provi-sion of emergency care to patients with multiple medicalproblems remains problematic in a system where the hos-pitals themselves tend to specialize at the expense of morecomprehensive offerings. Nevertheless, with significantadvances in out-of-hospital care and trauma care, physi-cians in southern Brazil have already laid the foundationfor the development of emergency medicine into the nextcentury.

R E F E R E N C E S1. World Factbook. Available at: http://www.odci.gov/cia/publications/factbook/br.html.

2. United Nations Population Division. Available at: http://www.popin.org/pop1998/2.htm.

3. Pan American Health Organization. Available at: http://www.paho.org/english/SHA/prflbra.htm.

4. Lewis MA, Medici AC. Private payers of health care in Brazil: characteristics, costs, andcoverage. Health Policy Plan. 1995;10:362-375.

5. Hensley S. Brazilian health care at a crossroads. Mod Healthc. 1999;May 17:34-42.

6. Almeida C, Travassos C, Porto S, et al. Health sector reform in Brazil: a case study ofinequity. Int J Health Serv. 2000;30:129-162.

7. CREMERS. Conselho Regional de Medicina do Rio Grande do Sul. EspecialdadesReconhecidas pelo Conselho Federal de Medicina. Available at: http://www.via-rs.com.br/cremers/espec.htm.

8. Marquis’ Who’s Who: The Official ABMS Directory of Board Certified Medical Specialists.2000. ed 32. New Providence, NJ: Reed Elsevier; 1999;xxi.

9. Okumura M. An emergency rescue service in Brazil. Accid Anal Prev. 1993;25:225-226.

10. Okumura M, Okumura CH. Atendimento pré-hospitalar de acidentados de tráfegorodoviário: experiencia Brasileira. Rev Hosp Clin Fac Med S Paulo. 1994;49:45-49.

11. Dykstra EH. International models for the practice of emergency care [editorial]. Am J EmergMed. 1997;15:208-209.


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Emergency medicine in Southern Brazil