# EMS in germany. A time of change.



## Kais (May 23, 2018)

I was wondering what I may contribute to the forums. I've used the search function and found a couple of threads about the ems system in germany. Some of them pretty superficial and none was about the changes that are currently happening. So I decided to give a small insight of what a ems system in germany can look like. There is not THE german ems. It differs a little from county to county (city to city). Regarding the scope of practice for the personnel, it differs alot.

Beside the facts you all might know about the "franco-german" ems model, there are some misconceptions about our system. I made this discovery about the anglo-american system myself.

The german prehospital health care system knows 4 levels of training for non-physicians and 1 for physicians.
They are:

*RH* - Rettungshelfer - ("Rettungs-" rescue and "-helfer" helper) - comp. to *EMR* - about 160h of training:
The RH program differs from state to state. Some require more hours, some require a clinical training. In my state (NRW) a RH recieves no clinical training. They attend 80h of classes and 80h of in the field training. They are considered BLS personnel. They function as the driver of a BLS ambulance or within disaster relief units in case of a MCI. Their scope of practice is limited to advanced first aid, knowning how to us a stretcher and assisting higher levels in patient care.

*RS* - Rettungssanitäter - ("Rettungs-" rescue and "-sanitäter" medic) - comp. to *EMT-B* - 520h of training:
The 16 states in germany agreed that this level will be at least the same amount of time in all states. As training may be a little different, the time spend on classes are considered with 160h, additonal 160h of clinical training and 160h of in the field training. 40h are spend on a week of preparation before exams. RS are the responsibles on a BLS ambulance and drivers on an ALS ambulance. Their scope of practice is BLS level, including assessment of a patient, O/N-PAs, BMV, Oxygen, SGAs, use of an AED, immobilizing and splinting.

The county medical director I work for expanded their scope to TQ, pelvic sling, change of a tracheal-airway, suctioning of an already intubatet patient and FBO removal with a laryngoscope and magill-foreceps AFTER additional training. RS are not considered to perform invasive techniques other than mentioned.

*RA* - Rettungsassistent - ("Rettungs-" rescue and "-assistent" assistant) - comp. to *EMT-I* - 2 years of training:
This level is slowly phased out since 2014. The RA was the former highest non-physician qualification in german ems. The "assistent" part referrs to be the physician-assistant. As a RA you received 1 year of mixed training between classes and clinical training. Most of your clinical traing was within the anesthesiology dept. of a hospital. The second year was in the field training alongside smaller skill-trainings under supervision of a FTO. A RA was (technically still is) the care giver in an ALS ambulance or the driver of a physician response unit. The scope of practice was/is somewhat comparable to what you might call LALS. A medical director could limit or expand the scope of practice. In general, a RA was/is able to: everything the other levels do BLS wise, start IVs, intubate a patient (without reflexes), acq. a 12-lead-EKG, semi-automated defibrillation and push a limited set of drugs including saline/crystalloid fluids, D40, Diazepam, Salbutamol, Epinephrine and Nitro. Once an ALS call is initiated, you were the first to arrive at the scene; a physician response unit is always dispatched parallel to you. So you needed a certain set of skills to compensate for the time the PRU needs to reach you. The scope of practice differed widely across the country. In some counties/cities the RA was onlöyallowed the same skills as a RS. Some expanded the scope of practice due to geographical or staffing problems.

Again, within the service I work for, the scope of practice for RAs is beyond the national standard. Here RAs are allowed (and trained) to: IM injection, nasal application of drugs, CPAP, thx. needle decompression and manual defibrillation. The set of drugs is expanded to: ASA, amiodarone, H1-blocker, furosemid(lasix), heparin, ibuprofen, ipratropium, lorazepam, midazolam, naloxon, ondansetron, prednisolon and H2-blocker.

*NFS* - Notfallsanitäter ("Notfall-" emergency and "-sanitäter" medic) - comp. to *Paramedic* - 3 years of training:
Introduced in 2014 it is considered the successor of the fromer intermediate level. A nationwide transition plan was executed to upgrade EMT-Is/RAs to Paramedics/NFS. This included additional training for RAs depending on how long they were on the job. The NFS is now considered the new care giver in an ALS ambulance and assistant of the physician in a PRU. By law and local protocols, he is now able to treat a patient without the presense of a physician. The scope of practice is that of a RA in addition with: fixing dislocated fractures, IO access, cardioversion, ext. pacemaker and analysing a 12-lead to do so. Your set of drugs is expanded by: atropin, scopolamin, novalgin, ketamine, urapidil and controlled substances, mostly morphine.


From the perspective of my working environment, the step from RA to NFS seems quite small. The main difference is, that we switched from a "state of emergency procedures" in abscence of a physician to "general practice". From the national perspective, the step is huge. You still depend on your medical directors protocols but law guarantees that you can at least perform a skill you recieved training for in a "state of emergency" even though your protocols don't allow it. You are acting within your own, full personal responsibility.

What a wall of text. I decided to split my thread into several paragraphs. For now this is everything to say about qualifications (non-physician). Next I will write something about how the service I am working for is organised.

Feel free to ask questions if you want.


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## Summit (May 23, 2018)

Thank you for posting that! I look forward to reading your next post.


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## Kais (May 24, 2018)

In things of organisation and operations, a majority of the ems in germany is based on charity organisations like the red cross or equivalents like the Order of Malta, Order of St. John or Workers Samaritan Federation. The biggest player is the red cross. Some states entitle the red cross with the responsibility to perform ems and the emergency call taking/dispatching. This leads to a monopoly for the red cross. It's a huge issue adressed in the last 2 years and for now. There are other states (mine, NRW) which handle these things completly different. The oversight of ems belongs to each county or city. These entities can entitle 3rd parties (again red cross and equiv. or private) or entitle own departments to perform ems. In case of a larger city, this will be the FD for most of the cases. There are some mixed versions of this. For example: I've started my career in a FD based ems, but was under the contract of a charity organisation. You drive the FD ambulances, you are stationed in a firehouse, but you are by no means in any way related to the FD. It's a miserable situation. This is often done to cut costs in salaries or to compensate for a shortage of firefighters. In my home city, the current situation is a mess. It's a FD based ems, were FF/EMTs FF/PMs and PM employees, who are under contract of the FD, staff the ambulances. Supported by charity organisations which staff FD ambulances, and a private ems with two ambulances of their own. We are speaking of a mid-sized german city of 600k pop.

But, there are some very good and organised ems systems in germany as well. The county I work for (300k pop.), has its own public safety department for non law enforcment affairs. This includes three branches: ems, fire and civil protection.This department operates the emergency operations center, where all 112 (911) related calls are taken. The ems branch consist of over 200 full-time emts, paramedics and physicians. The fire branch is a collective of all towns fire brigades within the county. There is no full-time fire brigade - only volunteers. The civil protection part is done by the red cross and others. They are equipped by the state itself and support ems and fire in case of a major incident. The red cross has vol. stations across the county. They do medical coverage of festivals or sometimes first responders in case of a call-peak. We are in close relation to them regarding training and supporting their stations.

The ems stations are spread across the county to cover most of it. Its a challenge, geographically spoken. The county is pretty much covered with hills/mountains, lakes, reservoir lakes, rivers and ravines. The map looks very fissured one can say. Beside that, we have several towns and communities, the largest with 24k pop. We have 13 BLS ambulances, 13 ALS ambulances and 6 physician response units in active service. In additon to that, we have a command and control squad, consisting of a mobile command center, an ems incident commander (flying car) and a lead physician (flying car). Due to the more or less rural area, we need a lot of HEMS support with critical patients. A severe trauma or ICB needs an airlift to be evacuated in time to a gih level trauma center or neurosurgery (<-- word?). We dont have an own HEMS (sadly) but we are covered by 2 rescue and 3 intensive care helicopters.
All our employees work for the same agency, wear the same uniforms and are trained and equipped identically. We work 24hrs shifts with 48-72hrs off-time. Payment is among the best in the entire country (yes country!). Our gear and equipment is state of the art. This is not common for germany, believe me.

I promise I will support this thread with pictures    showing you our ambulances and equipment, how we treat some calls and what kind of training we have.

Edit: here is one of our ALS ambulances followed by the PRU. They are bout to meet with a rescue helicopter to hand over their patient for medevac after a motorbike accident.


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## Kais (Jul 4, 2018)

Sorry for neglecting this thread. I've worked much to push my carrer to the next level. I am about to enter a new field of work and have to do some internships. Becoming a flight-medic is an interesting choice of career


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