User:Winnie-MD/sandbox/EMSGermany

This article is about the Emergency Medical Services (EMS) in Germany. It is a service of public healthcare that is provided by individual cities and counties and primarily financed gy the GErman health insurance companies.

Responsibility

The responsible body for operating and equipping fire departments are the German communities ("Gemeinden") and cities ("Städte"). By law, they are required to operate a fire-fighting force including EMS in numbers corresponding to the inhabitants of the county or city. In cities, this is usually performed by the Fire Prevention Bureau ("Amt 37"), one of the higher-ranking authorities. Opposite to the task of firefighting in Germany, municipal bodies do have the responsibility for providing Emergency Medical Services but do not necessarily fulfill them by themselves. The task of performing prehospital care can also be performed by non-profit or private-owned organisations. Thus, EMS in Germany is provided by either

• The Fire Department
• The "Johanniter-Unfall-Hilfe e. V." (St. John Ambulance)
• The "Malteser Hilfsdienst" (A subsidiary of the German Order of Malta)
• The German Red Cross
• The "Arbeiter-Samariter-Bund"
• private-owned companies

Tasks

In Germany, the EMS system performs two major functions:

• Responding to all calls concerning immediate danger to the health and/or life of a person. This is the core component, in German called Notfallrettung or Rettungsdienst.

This includes conditions like myocardial infarctation, severe pain or accidents with severe injuries.

• Arranging and performing the transport of non-emergency patients, i.e. transfer to, from, and between hospitals. This is called Krankentransport and is usually performed for non-ambulatory patients who lack the ability to use other means of transport, i.e. by taxi, own car or public transport.

In addition, there are mobile intensive care units stationed in most of the major cities. They are brought into action whenever a patient with a serious condition needs to be transferred between hospitals under special circumstances like being ventilated. This usually applies to ICU patients, hence the name Intensivtransport.

Not belonging to the EMS system, but having a certain interoperability with it are services offered by General Practinioners. Usually every GP is making housecalls for his patients, typically when they are not able to visit a medical practice. Additionaly, most cities and counties run a service called Ärztlicher Hausbesuchsdienst(Physician home call service), which is a GP on call for all people in the specific area. He will not only respond to his own patients, but is visiting and treating patiens all over the area. This service is most of the time run by an organisation known as the Kassenärztliche Vereinigung (Union of health fund approved physicians) and is usually only used for minor sickness (i.e. fever, common cold), where a hospital stay is not necessary but the intervention of a Physician may be advisable. On some occasions, the visiting GP will contact the EMS dispatcher and order a Krankentransport, should he deem it necessary that the patient better belongs in a hospital.

Organisation

German system of prehospital care
Non-Emergency	Public health system
	Profession	English counterpart	Tasks
	Hausarzt	General practitioner	treating patients in medical practice; if patient is not ambulatory, make 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)	Notarzt- einsatzfahrzeug (NEF)
	paramedical
	Rettungshelfer	EMT-B	4 weeks	none	none	driver	driver (occasionally)	-
	Rettungssanitäter	EMT-I	4 weeks	4 weeks	4 weeks	crew chief	driver	driver
	Rettungsassistent	EMT-P	6 months	6 weeks	1 year	crew chief	crew chief	driver
	medical
	Notarzt	Emergency physician	6 years	2 years	60 runs	-	-	crew chief

Leadership

EMS is a key component of the tasks a municipal body has to perform. That is why there are strict regulations concerning job performance, response times and equipment. Those regulations are usually evaluated regarding the needs of the public by the cities/ communities with the help of specialised physicians. Typically, every area of service ("Rettungsdienstbereich") has the position of "Medical Director, EMS" (Ärztlicher Leiter Rettungsdienst), who will issue regulations and protocols which are obligatory for EMS providers and personnel. The Medical Director is usually free in performing his task on his own discretion, as long as he acts by the guidelines and financial possibilities available for his county or municipality. The position Medical Director is that of a Consultant and in some states required by law.

Personnel

There are only two major qualifications in German EMS, one being the Emergency physician and the other being the Rettungsassistent.

Emergency Physician

The Emergency Physician, or "Notarzt", as he or she is called in Germany, must be a Physician with a second qualification "Arzt im Rettungsdienst". It is not necessary to have a special field of medicine (i.e. surgery), but a minimum time of residency and extra training is required after leaving medical school. However, due to the inderdisciplinary nature of medical emergencies, most of the physicians working as Notarzt are anaesthetists. Once on scene, the Notarzt performs all tasks associated with physicians in the field.

Rettungsassistent

The Rettungsassistent is basically in the field what a Anaesthesist Practitioner Nurse is in a hospital. Literally, the term means "rescue assistant", meaning she/he assists the Emergeny Physician in her/his treatment. The closest profession in other countries is a Paramedic. The German Paramedic is the highest level in Europe. However, the Rettungsassistent can perform treatment on his own, bound to specific rules and regulations, depending of the Service and state he serves in. In doing so, he sometimes has to violate federal law (i.e. performing invasive treatments), but is usually protected by State of Emergency law, if applicable. Typically, the first step is done in about one year, followed by the exam. Depending on individual schedules and progress, it might take up to two years. After that, the person will ride either third or second seat on an Ambulance for about nine month until he completes his 1200 hours. After that, he or she is allowed to be called Rettungsassistent.

Other qualifications

There are two other qualifications enabling a person to work EMS, the Rettungshelfer and the Rettungssanitäter. Those two can be compared to an EMT-B und EMT-I, respectively. Depending to the state they are working in, Rettungshelfer usually are drivers of non-emergency patient transports, whereas Rettungssanitäter act as crew chief. In most German states, a Rettungssanitäter is often the driver of emergency ambulances and assistant to the Rettungsassistent.

Additional qualifications

There are some qualifications closely connected to EMS possible:

• Leitender Notarzt ("Senior Emergency Physician"), a Notarzt carged with responsibilities connected to mass casualties
• Organisatorischer Leiter Rettungsdienst, a Rettungsassistent assisting the former in such scenarios
• Lehrrettungsassistent ("Paramedic Instructor"), a Rettungsassistent who is able to educate and train new personnel
• HEMS Crew Member, a Rettungsassistent who is responsible for assisting pilot and Physician on board of a rescue helicopter

Vehicles and Equipment

Vehicles

interior view of an air ambulance helicopter

A modern Krankenwagen

The German EMS system's vehicles come in a wide variety of shapes and sizes. All of its vehicles must, neverthelss, conform to the requirements of European/German standard DIN EN 1789 (types A-C) or German standard DIN 75079. 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 (emergency doctor) 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 are also employed, e.g. helicopters for the performance of air ambulance services or, in coastal areas, boats.

Equipment

The basic equipment of the above mentioned vehicles are obligatory:

Interior of a type C ambulance

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)

• Basic First Aid kit
• Dressings and Bandages
• a gurney and blankets
• a flexible stretcher
• a rigid or foldable transport chair
• a mobile medical ventilator
• basic diagnostic equipment like blood-pressure cuffs
• a 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
• Resucue equipment
• immobilisation equipment like Cervical collars or spine boards
• equipment for intravenous therapy

and many others. 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 everywhere to be found, usually only the physician will carry a small amount of Morphine, Fentanyl or Piritramide and closely guard them.

Emergency phone number

Germanys EMS is reachable by a number of means, the most forward being the toll-free telephone number 112, wich will connect the caller to the nearest EMS dispatcher. Other telephone numbers include the emergency number for the police 110 , which will forward the call or the information given in the call to an EMS dispatcher. Police and EMS dispatchers are usually separated. In the states of the former GDR, the old emergency number 115 will often still reach an EMS dispatch centre, however this number is not advertized anymore and use is discouraged. In former Western Germany, a lot of EMS calls can only be made by using the 19222 where 112 is not yet available. Where there are lines for 112, 19222 is often used for non-emergency calls like the dispatch of a Krankentransport.

Dispatch

A workplace in a german EMS dispatch centre

Emergency calls are routed to a dispatch centre, in German called Leitstelle. Usually nowadays most municipalities operate on a system called Integrierte Leitstelle (joint dispatch), where all calls involving fire and EMS are answered. There have been attemts of involving the police dispatch centres as well, however, due to the significantly different nature of the calls, there are more disadvantages than advantages. Once a call via the 112 is placed, a dispatcher will answer and ask the caller about the nature of the emergency. Due to dual training in joint dispatch centres, the dispatcher is able to answer calls concerning both, Fire Brigade and EMS. During the time the dispatcher is asking the caller about specifics, he can already work on the computer, wich will provide help and suggestions for this emergency. As an example, should a call come in about a non-conscious person, the dispatcher will ask further, what symptoms preceeded the condition, where the patient is located and if there are any special circumstances (no housenumber, a neighbor is calling, etc.). At the same time, he will enter Bewußtlosigkeit into his computer, which will automatically suggest the dispatch of a Rettungswagen and a Notarzteinsatzfahrzeug. 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. After sending the alarm, the dispatcher might provide for telephone assistance until the EMS arrives on scene.

"Swissphone PatronPRO" digital pager

Alerting EMS

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

Tactics

There are two different tactics in dispatching EMS vehicles in Germany, the Rendezvous system and the station system

Rendezvouz system

A Rettungswagen and NEF in action

Here, RTW and NEF must not necessarily have the same location. In most emergencies, only the ambulance is deployed for providing patient care and transport. However, should the situation on scene be 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 paediatric emergencies, unconsciousness, mass casualties or situations, where the application of analgesics and anaesthetics 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.

Station system

In this system, the physician on duty will be on the ambulance, which is now called a Notarztwagen and will be deployed to any medical case. The advantage here is the ability to perform more difficult tasks rightaway, but in most cases the presence of a physician is superfluous.