Paramedics in Germany

The development of the German prehospital EMS system is largely based on the history of the unique influence of volunteer aid organizations, particularly the German Red Cross. After 1945 especially, surgical departments of several German universities played a major role in developing an Advanced Life Support system. Due to the heavy volunteer involvement the government was very passive in regulating the EMS system development, as this was mostly done by the volunteer aid organizations themselves. As volunteers cannot meet the demands for paramedic education anymore, EMS is changing its face in Germany. The so called volunteer aid organizations employ 90 % of all paid EMS professionals. Volunteers are mostly only seen as First Responders, the role of EMS physicians developed because of the largely Samaritan oriented work of volunteers. Most of the costs of today’s EMS are covered by the health insurance system as well as through taxes, and fees. In the last 10 years German EMS has made a large step towards maturity. The development of a paramedic profession, the increased scientific research in the area of emergency medicine, the integration of European emergency services and professions as well as economic demands have already influenced EMS in the last few years and will continue shaping the development of EMS in the future.

Paramedic Profession
In 1989 the German government issued the Federal Paramedic Act (RettAssG), introducing a state regulated two year training program for paramedics (Rettungsassistent = rescue assistant). The goal was to create a qualified assistant to the ambulance physicians that occasionally run on EMS calls. The fact that in 70% of all emergency calls only ambulance personnel respond was neglected.

In 1995 the Federal Physicians Chamber, granted paramedics (RettAss) the right for intubation, IV canulization and drug administration if a physician is not present at the scene of emergency and the paramedics are qualified and supervised. In practice paramedics already performed many of these skills as it was included within their curriculum, but based on a poor legal basis. The physician chamber's recommendation has no legal status but is observed as a very important expert opinion. The legal status of the above mentioned measures can only be obtained when acting in accordance with § 34 Strafgesetzbuch "Rechtfertigender Notstand" (German Penal code; "State of Emergency"), namely committing a felony (i.e. causing bodily harm - IV canulization) for the benefit of a higher good (preserving the patients life). This specifically requires the paramedic to have called in for an emergency physician, the absolute need for the measures he is about to take and proven skill.

Due to rising costs in health care, today many ambulance physician systems are in jeopardy. In 2005 or 2006 the government wants to revise the Federal Paramedic Act and extend the training into a three year comprehensive training program, specifically granting paramedics legal rights to perform certain medical procedures (e.g. midwives, health practitioners, psychotherapist). These skills will be extended based on local medical director authorization.

In Germany EMS nurses do not play a role. Most critical care transport and all helicopter EMS only employs paramedics and emergency physicians. Just some paediatric transfers - mostly incubator transfers - are accompanied by a paediatric nurse (and maybe a paediatrician). This is also true for air medical transportation (fixed wing) or long distance medevac (stretcher).

Invasive Skills of paramedics based on various current local protocols:

 * IV canulization
 * Endotracheal intubation without relaxation
 * needle decompression
 * defibrillation
 * drug administration (nitroglycerine, analgesics, diazepam, salbutamol, glucose 40%,Adrenalin, IV fluids, etc.)
 * other skills

EMS professionals in Germany

 * RH - Rettungshelfer (320h training program (equivalent with EMT-Basic, only allowed on ambulances in SOME states such as Niedersachsen)
 * RS - Rettungssanitaeter (equivalent with EMT-Intermediate/Paramedic, works on BLS or ALS unit)
 * RettAss - Rettungsassistent ( (equivalent with EMT-Paramedic+ACLS Provider ), works on BLS or ALS unit)
 * LRA - Lehrrettungsassistent (Paramedic with additional qualifications to train and instruct
 * NA - Notarzt(=Emergency_physician) M.D. with a certificate in prehospital emergency medicine, responds to all life threatening emergencies

Roles of paramedics:
Team leader on emergency ambulance, Assistant to physician on doctor staffed MICU, flight paramedic (HEMS Crew member [Helicopter Emergency Medical Services]), Paramedic on Critical Care Transport Team (2 paramedics, 1 physician), EMS dispatcher (RettAss + 2 years experience + course), EMS Supervisor / Station commander, EMS instructor/educator.