Germany

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General

Capital – Berlin

Land Size – 348,672 sq km

Population – 82,282,988

Language(s) – German


Prehospital Care


Overview

  • Modern and highly efficient system
    • Provides sophisticated prehospital treatment
  • Fully-equipped medical team, with MD if required, “will reach virtually anywhere in the country in 15min”
  • Challenges:
    • Evidence of improved outcomes by early specific treatment requires highly-qualified professional emergency physicians
    • Recruitment problems due to unfavorable working conditions
    • Number of hospitals being reduced to cut health care costs
      • Number of MD-staffed ambulances also being cut
      • Resultant questioning of value of MD-based system
        • Leads to consideration of Paramedic-only system


History

  • Johann Friedrich von Esmarch launched initiative for first aid education in laypersons
  • Ernst von Bergmann established prehospital EMS in Berlin at end of 19th Century
    • Stretchers affixed to hand wheelbarrow for transportation of sick/injured
  • 1908 – First International Congress for Prehospital Emergency Medicine
    • Ambulance services supervised by physicians
    • Attend Pt’s on-scene
  • Martin Kirscner (surgeon), 1938: “The injured should not come to the physician, thephysician should go to the injured”
  • 1957 – Viktor Hoffmann MD decided that only immediate life-threatening Pt’s should be treated on-scene
  • 1966 – Friedrich Wilhelm Ahnefeld formulated “Chain of Survival” concept
  • 1989 – national certified training scheme for ambulance personnel confirming occupation as a profession


EMS System Model

  • Franco-German
  • Ratio of 3:1 or 4:1 non-physician-staffed ambulances to physician-staffed vehicles
  • Response Time goals
    • Differences exist, though in general EMS has to be guaranteed to arrive at scene in 10-15mins of dispatch


Lead Agency

  • EMS prehospital legislation remains at state level – (16 states)
    • Ground EMS agencies – responsibility of local communities and cities
    • HEMS – responsibility of the states


Funding

  • Health insurance is mandatory
  • German law provides right for any person to receive medical attention at any hour of day, and by emergency physician if necessary
    • “EMS represent 1% of total health care expenditure with 0.06% for the HEMS” (Roessler, 45)


Levels of Care & Education/Training

  • Non-Physician Personnel
    • 3 Qualifications
      • Rettungshelfer (RH):
        • 160h class; 80h practical
        • Focus on resuscitation and emergency medicine
        • Mostly found as unpaid volunteers at public events/non-emergency transport
      • Rettungssanitäter (RS):
        • 160h class; 160h clinical; 160h practical training
        • Most common level of training until 1989
      • Rettungsassistent (RA):
        • Replaced RS as formal qualification required
        • 2 yrs training
          • 1st yr: 1200h theoretical/practical
          • 2nd yr: 1600h apprenticeship in ambulance service
    • Most German states require that each ambulance has at least one experienced RS and on RA, preferably two RA
    • None are authorized formally to:
      • Administer Meds
      • Establish IV access
      • Defibrillate
      • Perform Tracheal Intubation
    • “Emergency Competence” – Common practice/procedure to perform these skills if MD is not immediately available on-scene and procedure is necessary to treat life-threatening condition, includes:
      • Defibrillation
      • Peripheral IV access
      • ET Intubation w/o relaxants/anesthesia
      • Crystalloid fluid infusion:
        • Isotonic NaCl, Lactated Ringers
      • Drug administration:
        • Glucose
        • Epinephrine
        • Diazepam
        • Inhaled b2-adrenergics
        • Nitrate Spray
  • Emergency Physicians
    • Intensive additional training in EMS
    • Most work part-time, with roots in anesthesia, surgery/orthopedics or internal medicine
    • On-scene, MD can provide all necessary interventions
      • ALS
      • Thrombolysis
      • Antiarrhythmics
      • Strong analgesics
      • Anesthesia and intubation
      • Ventilation
      • Reduction of dislocations/fractures
      • Chest drainage
    • Minor cases dealt with on-scene, preventing unnecessary hospital admissions
    • All regions required to have lead MD on-call to coordinate EMS response in MCI’s


Medical Direction

  • Medical Directors (as of recently)
    • Supervison
    • Resources Planning
    • Quality Management and Audit
    • Continuing Education of EMS personnel
    • Represents EMS on external bodies
    • Coordinates activities of EMS with other institutions


Specialty Services

  • HEMS – responsibility of the states.
    • Nonprofit organizations commissioned to deliver service (German Red Cross, etc.)
    • Supplements ground service “between sunrise and sunset”
    • 53 helicopter stations each with range of 50km (Roessler, 45)


Dispatch

  • Dispatchers are qualified paramedics with additional dispatch training.
  • 80% of control centers coordinate EMS, non-ambulance transport and fire brigade. (Police have own dispatch)
  • Triage to send ambulance only or MD-staffed vehicle as well.
    • Determined by Pt’s condition or the situation
  • Two Systems for MDs dispatched to scene
    • Stationary – MD-staffed ambulance
    • Rendezvous – MD arrives in rapid response car with all equipment but no transport capability
      • More flexible; 87% of systems


National Emergency Telephone #

  • 112


Emergency Medicine & Emergency Care

  • 3 Categories
    • Regular Care
      • Internal Medicine
      • General Surgery
      • Obstetrics
    • Extended Care
      • Regular Care
      • Some specialized departments
      • Cardiology
      • Gastroenterology
      • Neurology
      • Vascular Surgery
      • Orthopedics/Trauma Surgery
    • Maximum Care
      • Comprehensive range of specialties on-site


Disaster


References


Links

DIEMS Home Page