Paramedics in Germany
Paramedics in Germany are part of the Emergency medical services in Germany. The position is called Rettungsassistent or Rettungssanitäter in German. The Rettungsassistent is one of several professions in emergency-type prehospital care.
The development of ambulance services in Germany started in the late 19th century. Typically volunteer aid organizations, some private companies in larger cities and so called rescue corps provided ambulance services mostly with very little training or medical background. After World War II, prehospital care in Germany was in its infancy; the idea to professionalize emergency health care was picked up by several university medical centers in the late 1950s and 60s (Cologne, Frankfurt, Heidelberg and Munich). The idea to bring the doctor to the patient, rather than the patient to the doctor was already born before World War II. The result was the evolution of a type of ambulance physician called a Notarzt who dealt primarily with providing emergency medical care in the out-of-hospital setting. The service delivery model that this approach describes is commonly referred to as the Franco-German model.
After World War II in most predominately rural areas the German Red Cross provided an ambulance service. In West Germany the Fire Departments provided 24/7 service as a professional service in some cities and urban centres or towns. With the increase in individual motorized traffic at the beginning of the 1950s, road accidents also increased, leading to greater numbers of both injuries and fatalities. This encouraged the formation of several emergency services, one of the first being the Johanniter-Unfall-Hilfe e.V., a subsidiary of the German Order of St.John. These services not only transported patients, but had limited means of treating them on-scene, as well as being able to arrive at the scene of accidents more quickly.
In the 1950s and 1960s, the EMS role was primarily done on a voluntary basis by individuals with only minimal training in emergency health care. The first emergency medical technicians were trained jointly by some fire departments and universities. In the 1970s, however, it became clear, that are more professional approach is needed. A law to establish the occupation of Rettungssanitäter has been discussed, with a 3-year training curriculum (Gesetzentwurf der Bundesregierung über die Definition und das Anforderungsprofil des Berufes ´Rettungssanitäter´ (BT-Drucksache 7/822)). The government however saw difficulties in financing the training of this new profession. Unfortunatelly than in 1977 the original idea was introduced as a 3,5 month training curriculum common to all Länder (federal states) of Germany. This led to a more professionalized approach, but clearly below the level of the intended original law. By the 1980s it became clear that many situations were occurring in which the knowledge level of the Rettungssanitater was inadequate, and the developing role of the ambulance physician (Notarzt) needed additional assistance in treating patients in the field. It was deemed necessary to find a new profession with even more knowledge and skills. This was when, in 1989, the profession of the Rettungsassistent was created. In contrast to the Rettungssanitäter, the Rettungsassistent is a state-certified profession. Over the past 25 years EMS in Germany has evolved into a formal, well organized structure, with standards for staff training, vehicles, and service delivery.
Individuals who want to become a paramedic in Germany are required to undergo two years of training at a vocational college, most of which are privately owned, but are controlled by the state. In many federal states, with the exception of Thüringen and Sachsen, which cover some or all of the tuition fees, the students have to pay for their own training. Tuition fees range from € 2.500 to € 4.500, depending on the college, state and organisation. Typically, firefighters, policemen and members of the armed forces who undergo training do not pay tuition; their employer covers the fees.
The paramedic training consists of two major parts, vocational college and EMS internship. These are almost evenly divided into two one-year terms. In the first year, the student learns the theoretical basics of this profession, including invasive procedures. Incorporated are several weeks of in-hospital internships, typically in emergency departments, operating rooms and trauma units. The theoretical training is divided into several major parts:
- basic anatomy
- body functions
- internal medicine
- disease patterns of the above
- traumatological injuries
- law, rights and duties
Furthermore, the student is taught skills in treating patients. These include:
- basic diagnostic skills (blood pressure, heartrate, glucose level, oxygen saturation)
- advanced diagnostic skills (using and interpreting ECG, auscultation, neurological examination)
- intravenous, subcutaneous and intramuscular application of medication
- treatment of internal diseases like myocardial infarction, pulmonary edema, hypertension
- treatment of traumatic injuries like fractures, amputations, cuts and bruises
- endotracheal intubation and ventilation
The first year ends with a board examination which covers all the knowledge a paramedic must have. In the second year, students have to do a minimum 1600-hour internship in the EMS to further their skills. Usually, they start as a third person on a transport ambulance in order to observe and learn from the trained professionals. Sometimes, paramedic students who also have the qualification of Rettungssanitäter are used as a second on a two-person team. However, at all times the student will be under supervision by a Lehrrettungsassistent. After completing their year of internship, there is a closing meeting after which, should the student be deemed fit, he or she is awarded the vocational title of Rettungsassistent. The certificate is issued by the Ministry of Health.
The training can be shortened under specific circumstances. Students who hold the title of Rettungssanitäter are allowed in most states to shorten their theoretical training and, if they have already worked in EMS for some time, they only need to do a shortened internship, depending on the state in which they do the training. In Sachsen-Anhalt, the internship usually consists of only 480 hours.
Certification and training required in Germany
Besides the Rettungsassistent, there are three other professions in German EMS. The least-trained would be the Rettungshelfer(BLS) with only basic skills, followed by the Rettungssanitäter(between ILS and ALS), which used to be the most advanced pre-hospital care role. Short course is being phased out. Ranking above the Rettungsassistent (ACLS) is the Notarzt, a physician with special training in emergency medicine. In Germany, emergency medicine does not exist as a recognised medical specialty on its own but as a sub-specialty (Zusatzweiterbildung) with a board certification (Notfallmedizin). As a result, the Notarzt is most often an anaesthetist (although occasionally an internist or surgeon) performing this work in addition to their regular practice > All professions are normally deployed according to their skills There is some pressure in Germany to eliminate the qualifications of Rettungshelfer or Rettungssanitäter in the non-voluntary areas of the German EMS. This is driven by the assumption that even today these two do not possess the skills for today's modern and complex emergency medicine. Every state has different requirements to staff an ambulance or emergency physicians vehicle (Notarzt-Einsatz-Fahrzeug, NEF).To phase out short courses
|Roles in German emergency medicine|
|Job title||English counterpart||Training||Normal roles|
|School||Hospital internship||Ambulance Internship||Ambulance (KTW-Krankentransportwagen)||Emergency Ambulance(RTW - Rettungstransportwagen)||Emergency Physicians Vehicle(NEF-Notarzteinsatzfahrzeug)|
|Rettungshelfer(EMT-B)||EMT-BLS||160 hours||none||80 hours||driver||driver (occasionally)||driver (occasionally)|
|Rettungssanitäter(Paramedic-German: RS)||Paramedic between(ILS and ALS)||160 hours||160 hours||160 hours + 40 hours for exam||Paramedic crew chief||Paramedic(ILS/ALS)||driver|
|Rettungsassistent(Paramedic-ACLS-German:RA)||Paramedic EMT-P ACLS||12 months||10 weeks||1 year||ACLS crew chief for back up||crew chief||driver|
|Notarzt||Emergency physician||6 years||2 years||60 runs||-||-||crew chief|
Some German states and/or some organizations (employers) require yearly training (mostly around ~30 hours) for serving in professional EMS.
Other possible professional roles are EMS leader on scene, emergency dispatcher, shift or group leader, supervisor/trainer and EMS chief or positions outside the classic EMS field such as consulter or salesman for EMS equipment.
Skills maintenance and continuing education requirements
After completing training, paramedics do not need to be recertified after a specific time like in other countries. This means that, at least theoretically, someone having been certified as a Rettungsassistent/Rettungssanitäter in 1991 might very well be on the educational level of that time. While recertification is not legally required, most municipalities order their EMS staff to do a certain amount of additional inservice training every year. Such training is typically in the range of 30–40 hours. However recertification exists for courses like ALS, PALS, BTLS which are increasingly required by employers within the EMS system.
Added skills training available
Paramedics can acquire further qualifications, enabling them to apply for different or higher paid jobs within EMS. One of them is the HEMS crew member training, after which the Rettungsassistent is certified to work on a rescue helicopter. This role includes assisting both the pilot (i.e. navigating, spotting landing sites) during flight, and assisting the emergency physician with medical care. Another qualification is that of Lehrrettungsassistent, a Rettungsassistent qualified to teach and supervise paramedic students during their training. Those seeking this role receive special training in which they learn education theory and the use of teaching strategies. (PPEd & PGCE)
For senior paramedics with a lot of expertise there is the qualification of Organisatorischer Leiter Rettungsdienst (OrgL). This qualification is closely related to mass casualties. A Rettungsassistent assuming this position will be responsible for the triage, treatment and transport functions, as well as coordinating and directing the activities of others during those events. Although this is a 2-week course, most municipalities demand additional leadership training in disaster units (i.e. leader of a medical platoon) before the certification in this role will be granted.
In the newest development, the Rettungsassistent can also train to become an Emergency Room Specialist (Kranken-und Gesundheitspfleger / Schwester)(http://www.printernet.info/nurs_scien923489-ETERZ/LW08aSchTLM.pdf)
Furthermore university degrees like Bachelor and Master Programs in Rescue Engineering or Health Care Management offer opportunities for German paramedics to take leadership roles in emergency health care systems and the general health care field. An example is the Bachelor of Arts Emergency Practitioner programme offered at the akkon Hochschule für Humanwissenschaften in Berlin.
Restrictions on practice
After training has been completed, the Rettungsassistent(ACLS)or Rettungssanitäter(between ILS and ALS will work as team leader on emergency- and patient-transport-ambulances. He or she may also act as driver of an NEF, a special vehicle used for transporting an emergency physician (Notarzt) to the scene, and for assisting the Notarzt during treatment. The job includes all aspects of the training that has been received. Basically, in absence of a physician, the paramedic is responsible for diagnostics and treating the patient. Unlike many examples of the Anglo-American model, the Rettungsassistent/Rettungssanitäter does not have 'de facto' permission to perform any application of medication or invasive techniques. Invasive skills are often seen as being reserved for physicians. Under supervision of a physician, however, the Rettungsassistent or Rettungssanitäter is allowed to perform every technique that has been learned in school and training. If the Rettungsassistent is not available the Rettungssanitäter ia allowed to perform every technique that has been learned. Should the need arise to perform such skills without supervision, there exists a rule called Notkompetenz (Emergency powers), which theoretically allows this. This includes, but is not limited to:
- Application of specific medication
- endotracheal intubation without the assistance of neuromuscular relaxant medication (e.g., succinylcholine, rocuronium, etc.).
It should be noted that this rule does not qualify as a law, but merely a guideline by the Ärztekammer (Federal Board of Physicians) and is always subject to local procedures and guidelines. In theory at least, a Rettungsassistent/Rettungssanitäter will violate several federal laws when performing treatment alone. However, when treatment is necessary to avert death or severe disability of a patient, the state of emergency laws will usually take precedence.
- Dick WF (2003). "Anglo-American vs. Franco-German emergency medical services system". Prehosp Disaster Med 18 (1): 29–35; discussion 35–7. PMID 14694898.
- Moecke H (January 1998). "Emergency medicine in Germany". Ann Emerg Med 31 (1): 111–5. doi:10.1016/S0196-0644(98)70292-6. PMID 9437353.
- §8 RettAssG - Federal Paramedic Act
- "Rescue Services in Europe". Retrieved 2008-11-24.
- "Paramedic courses (Notfallmedizin.de website)(in German)". Retrieved 2008-11-24.
- "Preclinical Poly-Trauma Management (in German)". Retrieved 2008-11-24.
- Cooke MW, Bridge P, Wilson S. (2001). "Variation in emergency ambulance dispatch in Western Europe". The Scandinavian Journal of Trauma and Emergency Medicine 9 (2): 57–66.
- German Physicians law - Heilpraktikergesetz
- German Federal Board of Physicians: Directives regarding emergency powers for Paramedics - treatment
- German Federal Board of Physicians: Directives regarding emergency powers for Paramedics - medication
- German Penal Code §34