PROBLEMATIC ASPECTS AND CHALLENGES AHEAD OF THE MEDICAL PROFESSIONALS WORKING IN EMERGENCY MEDICAL CARE IN BULGARIA

PURPOSE: The article aims to determine the most common problematic aspects and challenges ahead of the medical professionals working in emergency medical care in the Republic of Bulgaria. For that reason, scientific developments, reports and publications of researchers and experts have been studied and analyzed. MATERIALS AND METHODS: A survey was conducted via an interview and direct anonymous questionnaire throughout the first quarter of 2019 amongst 325 respondents. RESULTS: The medical professionals providing emergency medical care face numerous challenges that require instant and adequate measures. Options for overcoming the difficulties that medical professionals face daily are sought at all levels of the hierarchy. A lot of work is done in the direction of a real interaction between all the subjects. CONCLUSIONS: The issues of the EMC require complex, radical measures.


INTRODUCTION
Identifying, describing and solving the problematic aspects and challenges ahead of the medical professionals working in emergency medical care in the Republic of Bulgaria and the implementation of relevant reforms will lead to building a comprehensive, scientifically sound organization of medical activities, establishing the most rational and highly effective emergency medical care, adequate to world and European standards, meeting the specific needs of the population of the Republic of Bulgaria All this as a set of facts gave us reason to focus on the organizational aspects (the lack of manpower, low salaries, bad working conditions, insufficient number of ambulances, stress, mental and physical load, the problem about violence and safety of the medical professionals working in the Republic of Bulgaria are some of the major issues of the system) of the work of the medical professionals working in the emergency medical care in the Repub-lic of Bulgaria, which is the subject of this scientific work.
The Emergency Medical Care is a core element of the Healthcare in the Republic of Bulgaria.Providing the citizens with emergency medical care is primary care and an obligation of the state.It is provided by medical professionals in the Centers for Emergency Medical Care (CEMC) and the Branches for Emergency.
Medical Care (BEMC) and the Emergency Departments are part of Medical Centers that provide 24-hour access to medical care.
According to the Bulgarian legislation and, in particular, Ordinance ¹ 1, medical professionals can perform qualified and competent medical care in all conditions individually or in a team under the guidance of a doctor.They perform preventive activities related to socially significant diseases.
The medical professional works in the emergency medical care units as an assistant to the doctor, in the emergency team or an independent team.Assistant to the personal physician (GP), the doctor in the specialized teams and the anesthesiologist.In the establishments for hematology and transfusiology, social care, social homes, dispensaries, sports halls, school health centers, medical insurance of summer camps, green schools, excursions, and tourist vacations and as a medical specialist in the health services of the enterprises.[1].
The medical professionals providing emergency medical care face numerous challenges that require instant and adequate measures.A lot of them are not ready to face the reality.Society does not respect the Healthcare institutions, not some social groups and does not demonstrate respect towards the medical professionals.
The medical professionals providing emergency medical care face numerous challenges that require instant and adequate measures.Options for overcoming the difficulties that medical professionals face daily are sought at all levels of the hierarchy.A lot of work is done in the direction of real interaction between all the subjects (medical professionals, society, training and state institutions, management, etc.) [2,3].
The presented article aims to: -to determine the most common problematic aspects and challenges for medical assistants working in emer-gency medical care in the Republic of Bulgaria and -provide basic guidelines and an adequate response to these challenges.

MATERIALS AND METHODS
To achieve the purpose set, scientific developments, reports and publications of researchers and experts have been studied and analyzed.A survey was conducted via an interview and direct anonymous questionnaire throughout the first quarter of 2019 amongst 325 medical specialists working at CEMC.The survey studied the structure, the organization, the work motivation of the medical professionals and the problems of the EMC.The primary information was collected through anonymous surveys with 325 medical specialists working in emergency medical care.
The research was conducted with medical specialists working from different regions of the country with different structures and organizations of work.This will allow us to analyze the work and problems of medical professionals providing emergency care in general.
Permission to conduct the study was requested from the director of the respective Center for Emergency Medical Care.
The limitations of the study are due to the subjective evaluations of the participants and can be defined as relatively imprecise and unsystematic.Another limitation that has an impact is the differences in the working conditions, equipment and provision of medical personnel in the different emergency centers and the affiliates also have an impact.

RESULTS
A great part -44.7% of the medical professionals are still forced to engage in other activities to earn more finances.They work at 2 or more workplaces in conditions of constant stress and violence.Our study shows that 86.4% of the interviewed have faced violence at work, as only 13.2% have not experienced violence.Violence in all its varieties inevitably affects the physical and mental health of the medical professionals and their level of motivation for work and often leads to the development of burnout syndrome, which has a negative impact on the health of the medical professionals.
The violence towards medical professionals goes on.It occurs reciprocally to the violence in our society, where it escalates daily.Very often, during their work, the medical specialists are subjected to violence and aggression by the patients, who are most often uninsured and of ethnic origin.
Violence is the answer of society to the many unsolved issues of Healthcare.The Centers for Emergency Medical Care are the last place where people that are uninsured or have already tried to go to another place (GP cabinet -personal physician, hospital, specialist, etc.) go.All this reflects on the medical professionals who are available 24/7 and are the violence's greatest victims because of the system's disadvantages.
In many towns and villages (mainly the smaller ones), the EMC plays the role of 24-hour medical service because of the lack of GPs there, making providing medical care practically impossible.In the smaller towns and villages, the GP comes once or twice a week because they provide medical care to a few.During the rest of the week, all the patients rely on the EMC as there is no other 24/7 care.All the uninsured, geriatric or cancer patients in need of palliative care count on the EMC.All patients are urgent, and calls cannot be refused.The EMC executes uncharacteristic activities, playing the role of a buffer between outpatient and hospital care.The question of what is happening with staff training is still on the agenda.Medical professionals work is responsible -they work on locations with a doctor, accept the 112 phone calls (emergency telephone number in Bulgaria), assess and coordinate the urgency.They work on the imposed triage.Sometimes, it is necessary for them to go on addresses alone, although according to the current EMC standards, they do not have the competence needed.According to the Ordinance No.3 of 6.10.2017 for approval of the medical standard "Emergency Medicine", medical professionals cannot perform this type of activity on their own.More than 50% of the medical professionals experience average or low levels of satisfaction with their working conditions (poor sanitary and hygienic conditions and social needs) and professional equipment (insufficient resuscitation vehicles, adequate medical facilities, and consumables).The analysis of the data is visualized in Figure 1, Figure 2 and Figure 3. soon.In the meantime, just 8% of the working medical specialists are not older than 35 [8].Usually, in the emergency departments, doctors who are narrow specialists or trainees are on duty.The reasons for the fluidity are the great workload of the emergency portals, the low salaries, and the constant conflicts during the hospitalizations with the medics from the hospital or the EMC teams.On the one hand, a doctor in the emergency portals is pressured by their colleagues from both hospital care and outpatient care, but on the other hand -from the patient waiting for free and faultless emergency care [9].
Outpatient emergency medical care suffers from a lack of manpower -there are only 80% full-time medical professionals.The existing teams manage to do their job but at the cost of overtime and overload.A lot of the medical professionals are in pre-retirement or retirement age, as some of them work on a second employment contract.These compensatory mechanisms make the providing emergency medical care possible.However, they keep running out [10].

CONCLUSION
The conducted research allows us to draw the following conclusion: The issues of medical professionals require complex, radical measures.
-At least a 50% salary increase because 39.6% of the emergency medical specialists determine their financial situation unsatisfactorily, which barely covers their expenses; 44.7% are forced to engage in other activities in order to receive additional income; -Improvement of the working conditions and limiting the factors leading to the development of burnout syndrome; -New, adequate medical facilities and consumables; -Major replacement of resuscitation vehicles.In our survey, there was a question: "In the process of your work, do you have a shortage of medical equipment and supplies (medicines, etc.)?".Most of the respondents -43% indicated that the ambulances and the equipment in them are obsolete and do not meet their actual needs.The equipment often does not work and is not adequate for the implementation of the activity, which is a prerequisite for the emergence of risks in providing medical care to emergency patients; -More rights for the medical professionals -a change in the EMC standards so their competence would be enough to enable them to work independently and take responsibility for their work.Their education, skills, and knowledge must be evaluated.This way, the lack of medical professionals: -clearly written rules and standards which give the opportunity for rules to be obeyed and make it possible to trace who observes them and responsibility to be sought accordingly.At the moment, the standards and the regulatory often change piece by piece, and this way, public relations can't be covered, and chaos and unnecessary tension is created; -changes in national legislation;

DISCUSSION
The lack of manpower, low salaries, bad working conditions, insufficient number of ambulances, stress, mental and physical load, the problem of violence and safety of the medical professionals working in the Republic of Bulgaria are some of the major issues of the system.
A relatively high number of acts of aggression towards medics have been registered, most of which are verbal, but there are also instances of physical assault on medics during work.On a global scale, violence against medical professionals is a fact, and verbal violence is leading, and it is most often committed by the patient's relatives and the patient themself.[4] To limit violence against medical specialists, the Ministry of Health seeks assistance from the Prosecutor's Office.Installation of video surveillance "panic buttons" in order to prevent violence and search for legal responsibility of aggressive patients and their relatives.[5] Medical specialists are one of the professionals most at risk of developing burnout syndrome.
The professional activity of health care workers is one of the busiest and responsible activities because it is closely related to the responsibility for the health and life of a person, emotionally demanding, causing psychophysical tension and stress.[6] According to the data analysis, 6380 medical professionals worked in the CEMC on 01.01.2014.1457 of them were doctors, 2652 medical professionals and other medical professionals (nurses, obstetricians, etc.) and 2271 Ambulance drivers [7].
The number of professionals working full-time in the CEMC on 30.06.2019 was 7113.Regarding the total number of staff in the separate centers, there are significant differences that cannot be proven by objective indicators such as population or area of the serviced territory in a district.For example, districts with similar indicators that determine the needs of structures of the EMC have differently formed structure and number of staff based on historical or lobbying principles.The differences in the determined staff number are directly connected with the lack of accurate mechanisms for determining the type, number, and distribution of the EMC teams in the separate CEMC.The age structure of the staff shows negative tendencies.Every fourth medical professional is between 55-65 years old.These medical professionals are going to leave the system -equipment with panic buttons in the ambulances and video surveillance for greater security of the teams against the manifestations of violence; -introduction of telemedicine for more accurate primary diagnosis of medical professionals from emergency medical care, determining and triggering the best answer to the call; -the professional organizations to perceive the fate of the class as a cause and, together with the trade unions, to strengthen the institutional interests of all medical professionals; -media support to increase the rating of medical professionals and to reduce the tension and the necessary media support.Media propaganda is needed to explain to the population what emergency medical care is and when we should resort to it.