EMS Around the World: Germany Brings the Doctors to the Action

Heidelberg surgeon Martin Kirschner first presented the concept of Germany’s rescue system, in which the doctor comes to the injured person and not the injured person to the doctor, in 1938. 

In Germany the treatment of life-threatening conditions is mainly undertaken on the spot under the “stay and save” principle (though naturally some conditions require load-and-go). At the scene of the event, crews restore basic vital functions and stabilize the patient’s condition.

Uniform standards for the handling of life-threatening conditions, such as Advanced Cardiac Life Support, the European Trauma Course (ETC), etc., apply throughout Germany. 

As in the U.S., Germany has both federal and state laws. Education of notfallsanitäters, the basic level of German rescuers, is regulated by federal law. The tasks and structure of medical emergency services in each state are described and regulated separately.

Notfallsanitäter competence is based on algorithms and the recommendations of scientific societies and the doctor responsible for a given area (arztlicher leiter rettungsdienst). In addition, various activities and standards such as donor access, administration of medicines, and others are regulated by civil and criminal law. 

Financing: Lands, Health Insurance, and Private-Public Partnerships

Germany’s medical rescue and healthcare system is financed by health insurance. Emergency services fall within the jurisdiction of the länder (lands, 16 federal states comparable to those of the U.S.). Each has its own healthcare legislation and funding, but everywhere emergency services are the domain of public institutions.

Sometimes medical rescue tasks are carried out by private companies—as is the case in Berlin, where the fire brigade is responsible under local legislation—but this is rare. Private charities such as the German Red Cross, Order of Malta, and Good Samaritan Society are also allowed to carry out rescue operations. 

In Germany emergency services are called at 1-1-2. Emergency medical services are integrated with fire and law enforcement. To speed up responses, districts have established integrated command centers. The dispatcher, after interviewing the caller, decides which type of ambulance to send. 

Ambulance types include:

• Krankentransportwagen (KTW)—A transport ambulance with a two-person team, minimum one medical officer (rettungssanitater).
• Rettungswagen (RTW)—An emergency ambulance with a two-person team, one paramedic (notfallsanitäter) and a rettungssanitater. 
• Notarzteinsatfahrzeug (NEF)—A doctor’s vehicle used in Germany’s rendezvous system, described below. 
• Intensivtransportwagen (ITW)—A kind of “intensive therapy on wheels” used mainly for transport between hospitals.
• Adiopostransport—A bariatric ambulance for obese patients, with a larger stretcher, staffed by two people. 
• Helfer vor Ort (HvO)—A team consisting of volunteers with basic medical knowledge, traveling in private transport with a rescue backpack and AED, sent as first responders.
• RTF/ITH—RTF are rescue helicopters, and ITH is flying intensive therapy. There are 71 air ambulance stations in Germany. 
• Neonatal ambulances—For the transport of newborn babies. 

Personnel types include:

• Notfallsanitäter (NFS)—Similar to an EMT in the U.S., perhaps a bit more advanced. The apprenticeship lasts three years. However, despite their high level of education, the duties of German rescuers are limited and depend on the land in which they work. 
• Rettungssanitater (RS)—A bit less than an EMT. Training lasting about 160 hours in an emergency (RTW) ambulance, 160 hours of practice, intensive care, and a repeat of the rettungshelfer course. After this training people work in transport ambulances (KTWs). 
• Rettungshelfer (RH)—Persons of this training can work as drivers of KTW transport ambulances. The training usually lasts three weeks. In several states this type of training is extended by several hours and expanded to let the RH drive an RTW ambulance.
• Sanitatshelfer (SH)—The lowest level in professional rescue service. Training lasts from 24–48 hours. After this the rescuer can carry out resuscitation on the BLS level with the use of AED and apply pressure dressings in appropriate situations. People who have completed a course of this type often provide event security and in some states can work as drivers of transport ambulances. 

The Rendezvous System

When an ambulance crew needs the support of a physician, its crew calls for an NEF. The NEFs are often SUVs equipped for ALS care. Depending on the location, one doctor can support 2–4 RTW-type ambulances. Indications for calling include respiratory and circulatory disorders, multiorgan injuries, and acute and sudden pain. The RTW still handles transport. 

In certain defined exceptional situations, such as when a physician is not available, German rescuers can perform interventions like semiautomatic defibrillation, endotracheal intubation without muscle relaxants, supply of crystalloids, and the use of some drugs, depending on the land (e.g., adrenaline, nitroglycerin, benzodiazepines, nonopioid pain meds). Otherwise, under German law, rescuers prioritize noninvasive interventions over invasive ones: e.g., a laryngeal tube before endotracheal intubation, oral glucose before IV. 

The physician in charge of the länder decides on the range of acceptable rescue measures and medications to be administered. Actions compatible with international algorithms such as ACLS (e.g., adrenaline in SCA) are also permitted. 

Conclusion

The difference between American and German EMS is that German rescuers are only “helpers” of doctors. The law restricts their freedom of action, so they cannot use all their knowledge, but just like all over the world, they are nonetheless enthusiastic professionals who devote themselves to saving lives. 

Robert Rajtar is a medical rescuer with 16 years of service experience in hospital emergency department and EMS teams in Poland and Germany. He is an employee of the provincial emergency service station in Szczecin (branch Myślibórz). 

Sybilla Brzozowska-Mańkowska is a specialist in emergency medicine and medical rescue coordinator for Poland’s Lubusz voivodeship. She is head of the hospital emergency department in Gorzów Wielkopolski and holds a doctorate in surgery. 

Mateusz Ignaczak has served in all levels of the German rescue hierarchy and currently works as a notfallsanitater for the charitable organization Arbeiter-Samariter-Bund Deutschland.

Sidebar: Germany Ready for EMS Reform

In a move to raise efficiency and reduce pressure on local hospitals, the German government is finishing preparations for a massive reform of its domestic EMS sector. 

Among the problems requiring attention is an acute shortage of personnel. This trend has been observed in Germany since the 2010s but become more pressing in recent years, affecting both doctors and nursing staff. Recent reports from the Ministry of Health cite a current shortage of 40,000 nurses alone. 

Shortages are mainly attributed to low wages, as well as a large workload and stressful working conditions. Health Minister Jens Spahn believes this, along with other industry’s problems, can be only solved by the design of a new legislative framework for the industry. The Ministry of Health is involved in the design of a major new legislative act. 

Among its elements are special emergency telephone control centers in all states, as well as emergency centers in each German hospital where patients will be sent either to inpatient or outpatient treatment, depending on the severity of their illness. Those centers will operate around the clock, focusing on initial assessment, and will be used by patients as the first point of contact.

Spahn’s plan also increases salaries for most of the industry’s personnel and sets minimum wages. Although it’s been 30 years since German reunification, those living in Germany’s eastern states still earn less than citizens of western regions. 

Eugene Gerden is an international freelance writer who specializes in coverage of the global firefighting, EMS, and rescue industries. Reach him at gerden.eug@gmail.com.