“Death is an extremely grave non-emergency; its only treatment is mourning”. That is how doctor Miguel Martinez Almoyna introduces his concept of emergency. The retired 92-year-old anaesthesiologist played an active role in creating France’s SMUR, and later SAMU, emergency medical systems. Still quite active overseas (in Brazil and Mexico), where he has exported the French pre-hospital model, he explains his approach to régulation médicaleTelecommunications-based medical triage by a physician, known as a regulating doctor (médecin régulateur).
For more about medical triage: Lachenal, G (Dir). (2014). La médecine du tri. Histoire, éthique, anthropologie. Presses Universitaires de France., whose purpose is to guide patients to the medical services their condition requires while offering a range of responses corresponding to different degrees of severity and urgencyMinistère de la santé et de la prévention. (2016). SAMU – SMUR. Accessed on 23.11.2022..

In what historical context did the concept of a medical emergency emerge?

Miguel Martinez Almoyna:  The first SMUR unit was created in response to the post-World War II polio epidemic, in May 1956, at the instigation of the director of Assistance Publique-Hôpitaux de Paris (AP-HP). Its development was entrusted to doctor Maurice Cara, then an assistant anaesthesiologist and research fellow at the CNRS. Back then, the issue was transferring patients who needed mechanical ventilation from conventional departments to specialised intensive care unitsTo learn more: Natali, J. (2011). Éloge de Maurice Cara (1917-2009) à l’Académie Nationale de Médecine. Accessed on 23.11.2022.. That gave birth to the concept of regulation – exclusively medical, at first – between a requesting doctor, a médecin régulateur-transporteur, and a receiving doctor.

With the rise of hospital and pre-hospital emergency medicine in the 1960s and ‘70sTo learn more: Wanecq, C-A. (2018). Sauver, protéger et soigner : une histoire des secours d’urgence en France (années 1920 – années 1980) [Doctoral thesis]. Paris: Science Po., the SMURs became involved in handling traffic accidents, at which point emergency call centres had to adapt to calls from non-medical witnesses (police and first responders, and then, starting in 1979, the general public)The challenge here is to move from an in-person clinical semiology to a remote linguistic semiology.. That was one of the aims behind the creation, in 1990, of the Permanenciers auxiliaires de régulation médicale (PARM), now Assistants de régulation médicale (ARM), modelled on Europ Assistance’s 24/7 non-physician call center operators. As Paris SAMU doctor and lecturer at the time, I coordinated their training with the Université Paris-Descartes’s continuing medical education department, which consisted mainly of lecturer-researchers from the humanities.

The latter soon realised the limits of the training, and asked me: “How are you supposed to make a choice if you don’t have any concepts?” Indeed, while traditional medical specialties had their own terminology and classification systems, young emergency medicine had none. So from the long list of theoretical tools that needed to be defined and taught, the top priority became creating a central concept of regulation: what is an emergency? With no answers other than preconceived notions from medicine, François GondriWe were unfortunately unable to obtain his contact information. , an ergonomist from the Université Paris-Descartes, came to observe how the Paris SAMU worked.

What were his conclusions?

A four-variable equation for quantitatively assessing an emergency was gradually developed. The first variable is the seriousness of the situation – that is, is it dangerous enough to be life-threatening or leave permanent sequelae? The second variable is an estimate of how much care is needed, how technically advanced that care must be, and what medical specialties will be required. The third variable is derived from the first two: how quickly the sequelae will become irreversible and how much time can elapse before treatment. For example, a recent cardiac arrest is an emergency based on all three of these criteria, and a SMUR should be dispatched immediately; in contrast, some cancers, while potentially fatal and requiring highly advanced treatment, do not require urgent care, given how slowly the disease progresses.

Those three quantifiable medical criteria satisfy the four main ethical principles of emergency medicine set out by the European Resuscitation Council in its 7 December 1990 Lisbon DeclarationThe only citation we could find from the Lisbon Declaration came from: Condé N. (2013). Création du SAMU-SMUR en République de Guinée [Master’s thesis]. La Défense : ESSEC. Accessed on 23.11.2022.; those principles were themselves derived from the bioethical principles set out in the Belmont ReportOffice for Human Research Protections. (1979). The Belmont Report. Ethical principles and guidelines for the protection of human subjects in research. Accessed on 23.11.2022.– namely, to respect and promote the autonomy of the person (autonomy), to improve quality of life (beneficence), to reduce all forms of iatrogenesis (non-malfeasance), and to promote equality and justice (justice). For the urgency equation’s creators, however, it would have been intellectually dishonest and medically biased to stop there. Indeed, as the code of medical ethics reminds us, doctors serve both the individual and public healthOrdre national des médecins. (2021). Code de déontologie médicale. Accessed on 23.11.2022., so a fourth factor – more a value than a normFor a succinct contextualisation of the equation as part of a philosophical discussion on the ethics of triage: Valette, P. (2013). Éthique de l’urgence, urgence de l’éthique. Presses universitaires de France.– had to be added to make this approach to emergencies complete: that is, social value.

What is social value?

Social value is an extremely powerful factor, whether conscious or not, capable of transforming a non-urgent situation into a situation of maximum urgency. It is defined as the pressure caused by the psychosocial impact of the situation that the regulating doctor is dealing with. It depends, among other things, on the number and nature of the people involved, the location, the circumstances, the media presence, and the doctor’s interest in the situation. Regarding that last point, a few examples: a doctor with a strong personal affinity for sociomedical issues who will handle a call for a homeless person differently than a less-interested colleague; or a former cardiologist who is now a médecin régulateur who will be more careful with calls involving heart disease; or a researcher working on emergency medicine in schools who may pay greater attention to calls from educational institutions, etc.

But social valence is not exclusive to either regulating doctors or to the medical corps more generally. It reflects the society as a whole. For example, in western societies, all other things being equal, a serious accident involving an infant will have more of an impact than one involving a dependent elderly person. More generally, it can be seen in the individual choices we make in everyday interactions. Leaving aside racial and facial discrimination, which are exaggerated forms of it, social value is easily illustrated with the following statement: “You react differently when it’s your child than when it is not your child.”  Here’s another example: in North American emergency call centres (911), the proximity of a public figure would be an additional argument for sending emergency vehicles, independent of the seriousness of the situation. That can be explained by the fear that a media personality might create pressure by questioning the failure to send help, or by the possibility that an elected official who witnessed the scene might support emergency services when they are later under discussion at the political level.

What role should this notion play?

We can classify emergencies using the following equation: seriousness x care needed x social value, while considering the time factor. This formula works for both traditional emergencies and extraordinary health situations. There is, however, no precise definition of social value in medical regulation. Sociology and group psychology studies are thus essential to preventing potential excesses, and doctors should be a part of such studies to offer their experience.

Whatever our opinion on the subject, disregarding social value in decision-making represents a cognitive bias. Seeing social value as contrary to social justice amounts to an erroneous view of equality and the ethics of triage. I believe there is an urgent need to affirm its existence and better define it, for two reasons: so that it can be taught, and so that it can be incorporated into new technologies. Indeed, given the historical context of its creation, the equation should be taught not just at CFARM training centres, but also in schools, for health democracy’s sake; it is a schoolteacher’s job to learn what an emergency is. Moreover, with the use of artificial intelligence in emergency medical services appearing inevitable, we need to rethink emergencies. We need more research on telephone conversations with non-medical third partiesOne example of research along these lines: Robert, L. (2022). Détermination interactionnelle de l’urgence et processus d’innovation en régulation médicale téléphonique au SAMU [Doctoral thesis]. Montpellier: Université Paul Valéry.. That could help us determine, based on certain words or word combinations, the degree of urgency and thus the seriousness, the level of care needed, how long the person can go without care before suffering irreversible damage, and the social value, and thus the appropriate help to send.

Interviewed by Jean-Sébastien Marx, Olivier Guillard, and Elba Rahmouni.