Emergency medical services in Germany

Emergency Medical Service (Rettungsdienst) "Rescue Service" in Germany is a service of public pre-hospital emergency healthcare, including (but not limited to) ambulance service, provided by individual German cities and counties. It is primarily financed by the German health insurance companies.

Organisation

Responsibility

In Germany the individual German states are legally responsible for the provision of emergency services, but typically delegate these responsibilities to the individual community level. Municipalities, including both smaller communities ("Gemeinden") and cities ("Städte") are given responsibility by the State for equipping and operating fire departments ("Feuerwehr"). German law mandates the provision of fire and rescue services, including EMS, staffing and equipping according to levels which correspond to local population. In cities, this is usually provided directly by the Fire Prevention Bureau (sometimes called "Amt 37"); one of the higher-ranking departments in a municipality.

Unlike fire protection, the task of providing EMS, while legally mandated, is not necessarily performed directly by the municipality. In some cases, the municipality will provide the service directly, usually through the fire department. EMS may, however, be contracted out by the municipality to a number of other potential service providers, including both community non-profit organizations and privately owned companies. Thus, EMS in Germany may be provided by any of the following, or in some cases, a combination of modes:

• The Fire Department
• The "Johanniter-Unfall-Hilfe e. V." (The German organisation of the St. John Ambulance)
• The "Malteser Hilfsdienst" (The German organisation of the Order of Malta Ambulance Corps)
• The German Red Cross (Deutsches Rotes Kreuz)
• The DLRG (Deutsche Lebens Rettungs Gesellschaft [German lifesaving foundation])
• The ASB (Arbeiter-Samariter-Bund [Labor-Samaritan-Alliance, part of the European "Samaritan International (SAINT)"]
• Privately owned companies

Leadership

In Germany, EMS is a component of one of the key tasks (public safety) which every municipal government is required by law to perform. As a result, there are strict regulations regarding qualifications, job performance, EMS system performance including response time, and the types of vehicles and equipment required. Compliance with those regulations is usually evaluated with respect to effectiveness and meeting public need by the local cities/communities, assisted by specialised physicians.

Typically, community or service area ("Rettungsdienstbereich") employs a Medical Director, (Ärztlicher Leiter Rettungsdienst), with a role that is similar to EMS Medical Directors elsewhere. The Medical Director is responsible for the creation and issue of regulations, protocols, and standards of care on behalf of the community. Compliance with such regulations and medical protocols is mandatory for both EMS provider organisations, and for their personnel. The Medical Director usually performs these tasks with considerable latitude. Regulations and protocols may be developed and issued at the discretion of the Medical Director, who is required to govern their actions according to the general guidelines and financial guidance provided by his county or municipality. The position Medical Director is that of a Consultant, and in some German states is required by law.

Roles

As in many other places, in Germany, the EMS system performs two major functions:

• Emergency Services - Responding to all calls concerning immediate danger to the life and/or health of a person. This is the core component of the service, which is called Notfallrettung or Rettungsdienst in German. This service addresses acute onset illness and injury conditions, such as myocardial infarction, or accidents with severe injuries, to name just two.

• Non-Emergency Services - Arranging and performing the transport of non-emergency patients (i.e. transfer to, from, and between hospitals). This service is called Krankentransport in German, and provides service to non-ambulatory patients with low-acuity or chronic conditions, or to those who are recovering from acute care situations, and who lack the ability to use other means of transport (i.e. by taxi, own car or public transport).

In addition to regular emergency and non-emergency services, there are Mobile Intensive Care Units MICU stationed in most of the major cities. These units correspond to the Critical Care Transport function found in other places. They are brought into action whenever a patient with a serious and complex medical condition, requiring advanced levels of support during transit needs to be transferred between hospitals. This service usually applies to intensive-care unit patients, hence the German name Intensivtransport.

While not formally affiliated with the EMS system, the General Practitioner(GP) frequently interacts with that system. In Germany, it is still commonplace for physicians to make house calls for those patients who are not able to visit a medical practice. Additionally, most cities and counties run a service called Ärztlicher Hausbesuchsdienst(Physician Home Call Service), which provides a GP to make housecalls for all people in the specific area. The physician will not only respond to patients from their own practice, but will also visit and treat patients all over the area. The GP service is delivered and maintained by an organisation known as the Kassenärztliche Vereinigung (Union of Health Fund Approved Physicians) and is usually only used for minor illnesses (i.e. fever, common cold), where a hospital stay is not necessary but the intervention of a Physician may be advisable. The availability of this service provides a better treatment option to those patients who, in other EMS systems, might generate low-acuity ambulance calls or emergency department visits. Occasionally, the visiting GP will contact the EMS dispatcher and order a Krankentransport, should it be determined following medical assessment, that the patient could be cared for in a safer and better manner in a hospital.

Standards

Emergency telephone numbers

The nationwide emergency number for the fire brigade and emergency medical services in Germany is 112. This number can be called toll-free from any phone (fixed-line, mobile or phone booth). The German police is available toll-free at 110 (or alternatively via the 112 operator). Dispatchers speak German and English (and the languages of neighboring countries in border areas); in some bigger cities (i.e. Berlin, Hamburg, Cologne or Munich), they might also understand Turkish and other language(s).

Although it is not official, some mobile phones accept the American "911" as an emergency number in Germany, but it will not work from fixed-line phones or phone booths.

Personnel

There are three qualifications in German EMS: the physician, the Rettungsassistent and the emergency physician (Notarzt). While the emergency physician does not need to be a board certified specialist (e.g. surgeon, anaestetist etc.) a formal qualification in emergency medicine is required by law (see below).

Emergency physician (Notarzt)

The emergency physician, in German Notarzt, must be a Physician with a post-graduate Arzt im Rettungsdienst certification. Having a formal medical speciality field (i.e. surgery) is not required, however a minimum term of residency and additional training following medical school is required in order to obtain certification. While the position is technically open to any physician who completes the certification process, due to the inderdisciplinary nature of medical emergencies, most of the physicians employed as Notarzt are anaesthetists. Once on scene, the Notarzt performs all tasks associated with physicians in the field, acts as the Crew Chief, and provides medical direction to all subordinate EMS staff.

German Ambulance Paramedical Assistant (Rettungsassistent) skills and training

The Rettungsassistent in most parts of Germany is only allowed to practice ALS under the direct supervision of a Doctor. Literally, the term means "rescue assistant", meaning that those in this role assist the Notarzt during pre-hospital treatment. The closest profession in other countries is that of EMT.

The title Rettungsassistent is regulated and protected by German law.

The first phase of training includes classroom and hospital clinical. It takes 1200 hours, this is about one year full-time. However, part-time education and side entries exist. A state licensed examination after this first stage permits the candidate to begin a 1600 hours preceptorship in the pre-hospital setting under the survey of a paramedic instructor (Lehr-Rettungsassistent).

The scope of training is defined as being able to perform life saving action to emergency patients on scene until a physician takes over, establish transportability of such patients, monitor and support vital body functions during transportation to a hospital and transport ill, injured or other needy persons - even if non-emergency patients - with appropriate care. Restrictions in treatment are the scope of training and practise, some laws restricting decent methods to physicians (i.e. medication with specific narcotic drugs) and the fact that they aren't allowed to give a concluding therapy, which is restricted to physicians and licensed practitioners. A physician should be called to scene if he can perform other life saving tasks the patient needs, usually regulated by a physicians indication catalogue ("Notarzt-Indikationskatalog") depending of the service and state.

Other qualifications

In Germany, there are two other lower level qualifications enabling a person to work in EMS. These are the Rettungshelfer, comparable to an EMT-B and the Rettungssanitäter, comparable to an EMT-I in the United States. Depending on the state in which they work, those in the Rettungshelfer role are usually the drivers of non-emergency patient transports, with a Rettungssanitäter acting as crew chief for the vehicle. In most German states, for emergency ambulance service, those in the Rettungssanitäter role are often the drivers of emergency ambulances and act as an assistant to the Rettungsassistent.

Additional qualifications

Some additional qualifications closely connected to EMS include:

• Leitender Notarzt ("Senior EMS Physician Field Responder") - a Notarzt with medical leadership responsibilities connected to mass casualty incidents.
• Organisatorischer Leiter Rettungsdienst - A Rettungsassistent whose role is to organize tactical EMS aspects during mass casualty incidents (i.e. communication, staging, transportation and such).
• Lehrrettungsassistent or Praxisanleiter Rettungsdienst ("Paramedic Instructor") - A Rettungsassistent responsible for the education and training.
• HEMS Crew Member - A Rettungsassistent who works as medical aircrew, responsible for assisting the pilot and the physician on a rescue helicopter.
• Leitstellendisponent - Someone who works in a dispatch center, most EMS dispatchers are obligated to obtain the level of Rettungsassistent, depending on local regulations. An additional dispatcher training course completes the skill set for dealing with emergency number calls and coordination of emergency and non-emergency responses.

Training

In the German system, not only paramedics, but also physicians have recognized roles and skill levels. The following table will give a brief overview about the major qualifications for both physicians and technicians, and their place within the German EMS structure.

German system of prehospital care
Non-Emergency	Public health system
	Profession	English counterpart	Tasks
	Hausarzt/Allgemeinarzt	General practitioner	Treating patients in medical practice. If patient is not ambulatory, making housecalls. Typically only responding to own patients during practice hours.
	Kassenärztlicher Notdienst	GP "on call"	GP on call after hours, visiting patients not requiring EMS, but responding to calls throughout assigned area.
Emergency	Emergency Medical Service
	Profession	English counterpart	Training			Jobs
			School	Hospital internship	Ambulance Internship	Patient transport Ambulance (KTW)	Emergency Ambulance (RTW)	Rapid Response Vehicle (NEF)
	Technician
	Rettungshelfer	EMT-B	4 weeks	2 weeks	2 weeks	driver	driver (occasionally)	-
	Rettungssanitäter	EMT-I	4 weeks	4 weeks	4 weeks	crew chief	driver	driver
	Rettungsassistent	EMT-P	12 months	10 weeks	1 year	crew chief	crew chief	driver
	Physician
	Notarzt	Emergency physician	6 years	2 years	60 runs	-	-	crew chief

Vehicles

Land Ambulance

The German EMS system's vehicles come in a wide variety of shapes and sizes. All of its vehicles must conform to most aspects of the requirements of European standard CEN 1789 as reflected in the German standard DIN EN 1789 (types A-C) or German standard DIN 75079. The visual identity requirements of the European standard are not yet being followed. The three major types of vehicle are:

1. The Krankentransportwagen (KTW), a van-type ambulance used for non-emergency transport. It conforms to DIN EN 1789-A1/A2: "Patient Transport Ambulance single/multiple patient"
2. The Rettungswagen (RTW), a larger van used for emergencies. It conforms to DIN EN 1789-C "Mobile Intensive Care Unit"
3. The Notarzteinsatzfahrzeug (NEF), a station wagon or small van. Its purpose is to bring the Notarzt (EMS Physician Field Responder) to the scene of the emergency, when required. It conforms to DIN 75079

Additionally, the Mehrzweckfahrzeug (MZF), or multi-purpose vehicle – often referred to as a Notfallkrankenwagen or Kombinationsfahrzeug (KOM) – serves a dual role as patient transport vehicle and as backup for emergency responses and usually conforms to type B of DIN EN 1789.

Other vehicles that are also employed include helicopters for the performance of air ambulance services and, in some coastal areas, boats.

• EMS in Germany
• 
  A modern ambulance used for non-emergency transport (Krankentransportwagen)
• 
  German emergency ambulance (Rettungswagen) from Fire Department Frankfurt
• 
  German Physician Response Vehicle (Notarzteinsatzfahrzeug) from Fire Department Frankfurt
• 
  A Rettungswagen and NEF in action
• 
  Mercedes-Benz T2 in use as a Baby-Notarztwagen

Air Ambulance

Germany has a well-developed air ambulance network, operated in cooperation between Germany's largest automobile club (ADAC), the non-profit "Deutsche Rettungsflugwacht e.V." (DRF) and the German Ministry of the Interior. ADAC currently operates about 35 helicopter ambulances strategically located around Germany, whereas the DRF operates close to 50 aircraft at 28 stations. The helicopter fleet of the Ministry of the Interior operates a small fleet of rescue helicopters, operated by the Bundespolizei. Each of these is staffed by both a Notarzt and a Rettungsassistent. In addition, ADAC operates a fleet of fixed wing air ambulances, including jets, primarily to provide service to their members. An additional 15 helicopters are operated by the Ministry of the Interior, and staffed by German Police pilots. These aircraft are multi-purpose, but will perform emergency responses when required. The intent of this system is to deliver a suitably staffed and equipped medical helicopter to the scene of an emergency within 15 minutes, anywhere in Germany.

• Air Ambulance in Germany
• 
  ADAC rescue helicopter
• 
  ADAC repatriation ambulance aircraft
• 
  DRF rescue helicopter

Equipment

The basic equipment of the above mentioned vehicles are obligatory and are minimal requirements:

• Basic First Aid kit.
• Dressings and Bandages
• Gurney and blankets
• Flexible stretcher, also called a Reeves stretcher.
• Rigid or collapsible transport chair, also called a stair chair in the United States
• Mobile medical ventilator
• Basic diagnostic equipment, like blood-pressure cuffs.
• Portable defibrillator

Depending on the type of the vehicle, there are numerous items which have to be on the ambulance, among them are:

• An ECG monitor
• Rescue equipment
• Immobilization equipment like Cervical collars or spine boards
• Equipment for intravenous therapy

Additionally, several different kinds of drugs are found on an Ambulance, typically a selection of analgesics, anaesthetics, cardiac stimulants, substances for circulatory problems and antidotes. Narcotics are not widely carried on ambulances. Usually only the physician will carry a small amount of Morphine, Fentanyl or Piritramide and closely guard them.

• EMS Equipment and Work Environment
• 
  Interior view of a KTW: transport chair (left) gurney (middle) paramedic's chair(right). One can also see the O₂ - bottles (cabinet in the rear) and the medical ventilator (right foreground)
• 
  Interior of a type C ambulance
• 
  Interior view of an air ambulance helicopter

Dispatch

A workplace in a German EMS dispatch centre

All emergency calls, regardless of the emergency number on which they originate, are routed to Dispatch Centres; in German Leitstelle. At present, most municipalities operate on an integrated system called Integrierte Leitstelle (joint dispatch), in which all calls involving fire and EMS are answered at the same location, and by the same personnel. There have been attempts to incorporate the police dispatch centers as well, more closely mirroring the U.S.-based 9-1-1 Public Safety Answering Point concept, however, due to the significantly different nature of the calls, it has been concluded that there are more disadvantages than advantages to this incorporation of all dispatch functions.

Once a call via the local emergency number is placed, a dispatcher will answer and ask the caller about the nature of the emergency. Due to dual training in joint dispatch centers, the dispatcher is able to answer calls concerning both the fire department and EMS. While the caller is being interviewed about call specifics, the dispatcher is already working on the computer, which will provide prompt questions, provide advice, and suggest response resources for this emergency. This computer system, while operating in German, is extremely similar to the AMPDS algorithm used by Emergency Medical Dispatchers in the United States.

To illustrate, a call is received in the dispatch center about a possibly unconscious person. The dispatcher will immediately identify the call location, and will then ask further questions, in order to assess precipitating symptoms, specific location, and any special circumstances (no house number, a neighbor is calling, etc.). While this interview is occurring, the dispatcher will enter the command Bewußtlosigkeit (unconsciousness) into the dispatch computer, resulting in an automatic suggestion to dispatch of a Rettungswagen (emergency ambulance) and a Notarzteinsatzfahrzeug (Doctor's Car). Upon entering the address of the patient, the computer will look for the emergency vehicles closest to this address. Now the dispatcher can send the whole package over the air and those two vehicles are alarmed, similar to Computer-assisted dispatch (CAD) in the United States. After sending the alarm, the dispatcher may remain on the line with the caller, providing telephone advice or assistance until the EMS resources arrive on the scene.

File:Alphadual.jpg

Unication Dual Frequency digital pager

"Swissphone PatronPRO" digital pager

Alerting crews

Emergency vehicles are sent on runs by a number of means. The most common system is by pager, issued to every crew. Pagers may operate on either an analog or a digital system. Analog pagers will silently listen on the air for a 5-tone signal being transmitted. Once the individual signal for that pager is detected, the pager will sound an alarm, and will often open the channel for the crew to hear the dispatcher. Further information is being given via radio. The digital pagers will listen on a different channel and once its individual address is transmitted, will prepare to receive a data package. This package normally consists of a short message, providing the address and nature of the emergency as well as additional information. This clears the radio channel of lengthy calls. Theoretically, no additional radio traffic is required when using such a system.

Staging and deploying resources

There are two different strategies used in dispatching EMS vehicles in Germany; the Rendezvous system and the Station system

MICU Rendezvouz system

In this model, the emergency ambulance (RTW) and Doctor's car (NEF) are not necessarily co-located. In most emergencies, only the ambulance is deployed for providing patient care and transport. However, when the situation on scene is of a more severe nature, the ambulance crew can radio in for support by a physician and the NEF will be deployed. There are some medical situations where the NEF will be deployed automatically; those are usually pediatric emergencies, patients who are unconscious, mass-casualty incidents, and situations where the need for analgesics and anesthetics is foreseeable. The advantage of this system is the fact that the physician is available for other emergencies, while the ambulance crew can handle minor cases on their own.

Medico Sanitary Regulation of Emergency Cases

In German Model is different of French Model even if both are Public Health Integrated Emergency Medical Systems. Public direct phonic Medical access to a Physician on line is only possible through the base Hospital phone connexion. Medico Sanitary Regulation of Emergencies is done also through the NEF Physician or base Hospital Emergency Room physicians they "regulate" the case if needed like in MICU secondary transports demands.

Station system

In this system, the physician on duty will actually staff the ambulance, which is now called a Notarztwagen, will be deployed to any serious medical case. The advantage with this approach lies in the ability to perform more difficult tasks without delay, however, on most calls the presence of the physician is not actually required.