EMS in Germany: History And Development by Felix Brinkman, EMS Rettungsassistent
Paramedic Mastery is very pleased to present our readers with our first international article.
Compared to the history of medicine, the history of the emergency medical services (EMS) in Germany is very young and short.
EMS started during the Napoleonic period, where many soldiers were injured and the army command realized, that people were needed to rescue the wounded. Although there were already physicians established in Germany, they were not assigned with the treatment of patients. The army commanders decided to use a “medical transportation division” which only “loaded” the injured people on stretchers or on carts and transported them, without treatment, to the military hospitals on the battlefield. They also waited until the combat was over before they began to help the injured soldiers.
Beside the battlefields there was no emergency medical service for the citizens until the beginning of the 19th century. The big cities of Germany started to run transportation services for sick people. However, it was just a transportation service. that did not treat people until they arrived at the hospitals. These EMS services were provided by the Red Cross, civil volunteers, private companies or the fire departments. Hitler and the Nazis tried to refine this service because of too many different rescue systems in 1943. They wanted to unify this system, but changed it in their National socialistic mindset. They tried to let the National socialized Red Cross provide for the EMS as the only organization. Likewise the downfall of Hitler’s Nazi-Germany this attempt failed and so the Allied Forces determined the way of providing the EMS. In North Rhine-Westphalia, for example, the British Forces made the local authorities to provide for their own EMS system. Not until the 1950s Emergency Medical Services developed properly. The suburban and rural areas were not adequately served. As a consequence of this the concessions for those areas were given to private companies. In the late 1950s the traffic increased and so the frequency of accidents. 1957was the decisive turning point for the civil EMS in Germany: For the first time the ambulances were equipped with a new gear and the treatment of patients was changed by new insights. The advances of development took up between 1989 and 1990: it crucially changed the “transportation services” to the EMS of our days.
The German system of education and training in EMS
Today Germany’s EMS differs from the US-system. In Germany EMS practice is delivered by emergency physicians and three different levels of training. The highest you to be reached without studying medicine, is the “Rettungsassistent”, which is comparable to the Emergency Medical Technician Intermediate. The German educational training at professional schools covers about 780 hours, with theory and practical exercises. Before the examination there is a practical course in a hospital in different facilities like anesthesia, emergency room, critical care units etc. for about 420 hours. After you completed these requirements you are allowed to take the exam. The examination is completed after passing the written, practical and oral exam. If you pass these tests you have not finished yet the apprenticeship. Before you can use the professional title you have to work 1600 hours at an EMS-Station. After a positive final discussion with the medical director of the EMS of the local authorities the level of a recognized occupation in the field of EMS.
Beside the “Rettungsassistent” there are two other training pathways in EMT on two different levels: The “Rettungshelfer” is the shortest training with only 160 hours of educational training at a professional school and 80 hours practice at an EMS Station. The requirements to be a “Rettungssanitäter” are 200 hours of educational training at the professional school, 160 hours clinical practice and 160 hours of practice at an EMS-Station. Both pass final exams set by the state.
Future emergency physicians must have completed a course and obtained a degree in medicine. After that they are obliged to have 2 years practice in intensive care medicine and have visited the class for emergency physicians, with 80 hours of educational training. After completing this educational training for emergency physicians they have to respond to 50 calls as well as verify 10 live saving calls.
Working methods in Germany
The emergency physician responds to every call, where Advanced Life support is needed. The dispatch, sends out an ALS-ambulance and the emergency physician. The ALS-ambulance is called “Rettungswagen” in Germany and is at least manned with one “Rettungsassistent” and one “Rettungssanitäter”. It is often the first vehicle to arrive at the scene. The emergency physician is driven by a “Rettungsassistent” in a vehicle, which you can compare to a supervisor car. In Germany it is called “Notarzteinsatzfahrzeug”.
When the emergency physician isn’t there in time the “Rettungsassistent” is allowed to provide some advanced life support techniques, such as:
- Administration of following drugs:
- Epinephrin (for cardiac arrest and anaphylactic shock)
- Dextrose (for hypoglycaemia)
- Midazolam/Valium in the form of MAD or rectioles (seizure)
- Nitroglycerin in the form of spray (for acute coronary syndrome, pulmonary edema)
- ß²-sympathomimetica in the form of spray or nebulization (asthma)
- saline infusions
- pain medication (only in some areas allowed)
- Amiodarone (for ventricular fibrillation and ventricular tachycardia, only in some areas allowed)
- Performance of ALS techniques:
Challenges for the German EMS system
For the German EMS it is a problem, that there is no legal framework for this practice. Often these techniques are performed by “Rettungsassistenten” in a legal grey area. Due to a law from 1939 nobody is allowed to administer drugs except physicians. This is, however, a major problem for the appropriate treatment of patients. All techniques and administration of drugs are recommendations for the “Rettungsassistent” by the German Medical Association, but there is no legislation! The loophole in the law is the “Necessity as Justification”. As a consequence of this the “Rettungsassistent” is allowed to break the law in order to keep somebody alive. The problem in this regulation is, that if something goes wrong the “Rettungsassistent” is liable for recourse for the technique he used or the drug he administered. If the “Rettungsassistent” does not intervene, because he shys away from the consequences of his actions, he could be judged for failure to render assistance in case of emergency. Especially in rural areas, where the emergency physician sometimes needs up to 20 minutes and more before he arrives at the scene, non-physicians get a major problem with this regulation. For he can be made liable for every intervention he conveys or not.
Another problem is, that every city or every county have their own recommendations and approved ALS-techniques. Therefore it is by no means a nationwide recommendation. In City X for example the Rettungsassistent is allowed to administer Amiodaron (Cordarex®) after a third unsuccessful defibrillation. But is not allowed to administer a pain medication before the emergency physician arrives at the scene. While the Rettungsassistent in City Y is not allowed to administer Amiodaron but to administer a pain medication. So even if there were two cities which are only 10 kilometers from from one another, they can have two totally different recommandations and also differences in the treatment of patients by the Rettungsassistent. The Association of German EMTs tries to optimize the labor conditions for “Rettungsassistenten” and arrogates more competencies for them. However, no major changes are expected in the nearer future.
Germany in international comparison
In most parts of Germany the response time to emergency calls is 12 minutes by law. There are two kinds of ambulances in Germany, which can be compared to Basic Life Support and Advanced Life Support Ambulances. The Basic Life Support Ambulances have to transport patients with contagious diseases or diseases that are not life threatening to the hospitals, nursing homes or even to the home of the patient. In some cities the BLS-Ambulances responds to little injuries or diseases that are not life threatening. The Advanced Life Support Units responds to different types of diseases and injuries, which could be life treating. If several criteria are fulfilled, the ALS-ambulance responds without emergency physicians to calls like orthostatic deregulation, fallen person, minor accidents or in other cases. If there is the suspicion of an acute coronary syndrome, cardiac arrest, unconscious patient, major accidents or major incident and so on, the emergency physician is needed and responds together with the ALS-Ambulance to the call. The ALS ambulances respond to every kind of calls, even to hazardous events. There are not specialized units like the HAZ TAC Rescue Medics of the Fire Department of New York.
International algorithms are present in Germany but they have not yet been fully established here in Germany. There are just a few cities or counties that have every emergency physician and “Rettungsassistent” extensively trained in Advanced Medical Life Support or Pre Hospital Trauma Life Support. AMLS and PHTLS are slowly expanding here but it is not the standard. The “Malteser School for Rettungsassistenten” in Aachen is a pioneer in this particular case. They hold the national boards for AMLS and PHTLS of the National Association of Emergency Medical Technicians, they are one of the few schools that teach students, who want to be a “Rettungsassistent” about AMLS and PHTLS. There are emergency physicians that were also taught in AMLS or PHTLS. But it is rare, for it is a new system in Germany and the emergency physicians just have to take the 80 hour emergency physician course once, even if they have been practicing for 20 years already.
There was a trial about the time passing from the moment of the accident until the arrival to the trauma center. The result was, that the average time for this period was 72 minutes. Hamburg has the biggest number of emergency physicians per inhabitant. There are as well many hospitals and an unusual number of maximum care hospitals. The average time in Hamburg for responding to a call is 5 to 8 minutes. From the moment of the accident until the arrival to the trauma center it takes 82 minutes. The recommendation from PHTLS Germany for treatment on the scene is 15 minutes. Sometimes the treatment of the patients takes one hour at the scene even though they were neither trapped nor needed technical rescue.
But there are not just critical aspects in the German EMS system, because emergency physicians allow a maximum care for the patients. It could be optimized, if the education about algorithms for emergency physicians and “Rettungsassistenten” would be unified throughout Germany. The treatment could be optimized.
Incomparable good is the comprehensive network of rescue helicopters with over 50 stations all over Germany – a country which is almost three times bigger than Florida.
There are a lot of opportunities for development in the German Emergency Medical Services and like every sections in medicine it has to develop further to keep pace.
Felix Brinkmann, 20 years, Trainee Rettungsassistent, Düsseldorf, Germany