Emergency medical services in Germany

This article is about the Emergency Medical Services (EMS) in Germany. It will give a brief insight into the topics of organisation, responsibilities and apparatus.

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: In addition, there are mobile intensive care units stationed in all major cities. They are brought into action whenever a patient with a serious condition needs to be transferred between hospitals.
 * 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
 * Arranging and performing the transport of non-emergency patients, i.e. transfer to, from, and between hospitals. This is called Krankentransport

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 of his area.

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. The Notarzt performs all tasks associated with physicians in the field.

Rettungsassistent
The Rettungsassistent is basically in the field what a nurse is in a hospital. Literally, the term means "rescue assistant", meaning he assists the Notarzt in his tasks. The closest profession in other countries would be a paramedic. However, the Rettungsassistent can perform treatment on his own, bound to specific rules and regulations, depending of the Rettungsdienstbereich and state he works in. To become a Rettungsassisten, one is required to Typically, the first step is done in about one year, followed by the exam. 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.
 * undergo 1600 hours of training, mostly theorethical studies plus a 3-month-internship at a hospital
 * pass an exam by a medical board
 * log at least 1200 hours in the field.

Other qualifications
There are two other qualifications enabling a person to work EMS, the Rettungshelfer and the Rettungssanitäter. Those can loosely be compared to an EMT-Basic and an EMT-Intermediate. They are mere qualifications for a job and do not constitute a profession under German law. Depending to the state they are working in, Rettungshelfer usually are drivers of non-emergency patient transports, whereas Rettungssanitäter act as crew chief. Rettungssanitäter are also often working as drivers of emergency ambulances.

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

Vehicles
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: 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.
 * 1) The Krankenwagen(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

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: Depending on the type of the vehicle, there are numerous items which have to be on the ambulance, among them are: 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.
 * 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
 * an ECG monitor
 * Resucue equipment
 * immobilisation equipment like Cervical collars or spine boards
 * equipment for intravenous therapy

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

Rendezvouz system
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.