EMS Around the World: Modern Changes Impact Austria’s Historical Services

Editor’s note: This is the second in a new bimonthly column profiling EMS systems around the globe.

On Dec. 8, 1881, the famous Vienna Ringtheater burned down completely, killing more than 400. Only one day later the Volunteer Vienna Rescue Society was founded—it was the predecessor of today’s Vienna Municipal Ambulance Service, MA70. This date marks the birth of EMS in Austria (although the Red Cross had already been established in Austria in March 1880, nearly 14 years after the Austrian monarchy joined the Geneva Conventions).

Voluntarism was and still is a defining characteristic of EMS in Austria. The Volunteer Vienna Rescue Society recruited its members out of volunteer firefighter associations and rowing and gymnastic clubs. Education of the so-called “Samaritans” consisted mainly of lectures by surgeons. In spring 1883 the first ambulance stations were installed in Vienna; from 1886 on stretchers were placed in public locations throughout the city; and in June 1897 a new central rescue station was erected in the 3rd District that to this day remains the basis of the Vienna rescue service.

In 1900 a wagon was equipped with eight stretchers and first aid material for emergencies on the Vienna city railway; apart from that, manpower and horse carts were used as transport. In 1905 the first ambulance car was stationed at the central rescue station. Due to development of the city, more rescue stations were built, and military surgeons worked with the ambulance service as part of their medical training.

Similar developments happened in other parts of Austria; in 1889 in Graz, for example, two physicians founded a medical division within the city’s fire brigade that developed into the so-called “medical corps,” which still exists as part of the local Red Cross and consists of highly trained medical students (all volunteers). As local emergency transport divisions popped up within fire brigades all over the country, the Austrian Red Cross, Austrian Fire Fighters Association, and Ministry of War agreed on the use of the Red Cross sign as an identifying feature for these divisions.

With the end of World War I, a period of both financial and political struggles began; money was tight, a lot of funding had been lost, and competencies for ambulance services were unclear. In the years leading up to World War II, and even more during the war, the Red Cross gradually took over emergency medical transport services from the firefighters. Today there is only one firefighter brigade left in Austria that provides EMS (in Admont, in the north of the state of Styria). 

Back in 1938 German surgeon Martin Kirschner postulated that the patient should not be brought to the doctor, but the doctor to the patient “because close to the event the danger to life is paramount.” Following this idea, Austria’s first doctor-equipped ambulance was deployed in 1956 in Linz, as part of emergency services at the Voest Alpine Steel Factory. In the 1980s EMS organizations started to implement MICUs (mobile intensive care units with ambulance doctors), reaching almost nationwide coverage with one unit per county at the beginning of the 1990s.

EMS Organizations

Here is a list of the primary organizations providing EMS in Austria.

Red Cross—The Red Cross is not the only EMS organization in Austria, but it is by far the largest. The Austrian Red Cross, a member of the International Red Cross and Red Crescent Society, consists of nine federal Red Cross organizations, according to the nine federal states of Austria. More than 73,500 volunteers and 8,200 employees work in 139 main and 711 subsidiary branches all over Austria, providing mainly but not only ambulance services in a mixed system—emergency services as well as nonemergency patient transport. 

Other services include: 

• Blood donation; 
• First aid and emergency medical support for events; 
• Health and social services (basic crisis intervention teams, nursing home care, senior care, visitation services, food-delivery services); 
• Disaster preparedness; 
• A broad variety of first aid and advanced first aid training courses for the public, for special target groups such as family members of patients or kids, as well as for the Red Cross’ own volunteers and employees; 
• Youth groups; 
• Tracing service;
• Search and rescue service with canines; 
• International aid and development cooperation;
• Support of international humanitarian law.

Samaritans—The Austrian Samaritans, today part of Samaritan International, evolved in 1927 out of a worker sport and fitness club in Vienna, with the main purpose of providing first aid at sports and leisure accidents. Today more than 51 local branches in all nine federal Austrian states provide a similar array of services as the Red Cross, with more than 6,400 volunteers and approximately 1,900 employees. 

Order of Malta—The Austrian Grand Priory of the Order of Malta founded the Maltese Hospital Service Austria in 1956 as a response to the Hungarian crisis, caused by a political uprising in the neighboring country; it provided refugees with food, clothing, and shelter. In the subsequent years the organization established ambulance services in close cooperation with the Red Cross, but its main focus remains on social services due to the religious (Catholic) background of the Order. Its approximately 1,850 volunteers in six of our nine federal states provide home patient care, services for and activities with the physically and mentally disabled, sick, lonely, and elderly persons such as day trips, special events, and even pilgrimages to Rome, Lourdes, and Assisi.

Order of St. John—Due to a rising number of traffic accidents, the Order of Malta’s Protestant sister organization, the Order of St. John, founded an ambulance service in Germany in 1952; in 1974 the Austrian St. John’s ambulance service started in Vienna, also in close cooperation with the Red Cross. Volunteers and employed EMS workers in Vienna, two cities in Lower Austria, and one branch each in Carinthia and the Tyrol provide ambulance service and social services similar to the Order of Malta. 

Vienna Municipal Ambulance Service (MA70)—In contrast to the four autonomous nonprofit organizations mentioned above, the professional Vienna ambulance service is part of Vienna’s municipal authority, has no volunteers, and does not offer nonemergency patient transport services. More than 40 ambulance doctors and around 700 EMTs and paramedics provide EMS for Austria’s capital 24/7, in 12-hour shifts out of 12 rescue stations evenly spread all over Vienna. MA70 also offers hospital-to-hospital intensive care transports with a special transporter for ICU beds and neonatal intensive care transport. In addition MA70 has a disaster unit for mass-casualty events.

There are also a few small private organizations, such as the Green Cross and private helicopter services, that operate on a local basis. Traditionally VW buses such as the Bulli, Samba, and the T3, T4, and T5 have been the most common ambulance vehicles in Austria. Mercedes Sprinters are also used. The large MICUs, VW LTs or Mercedes, are gradually being replaced by small physician cars such as the VW Passat or similar.

The Austrian Automobile Organization (sister organization to the American Automobile Association) provides 16 helicopters for emergency medical services and transport all over Austria. In 2016 these “yellow angels” took off 17,814 times, an average of 49 calls a day. Since last year a few of these helicopters have been equipped with night-vision goggles, allowing them to answer calls even after dark. 

Dispatch and Call Centers 

Children learn the national emergency numbers in kindergarten: 1-2-2 for fire, 1-3-3 for police, and 1-4-4 for rescue (medical emergency)—they are in alphabetical order and easy to memorize. In contrast to many other European nations, 1-1-2 is routed to the police and does not serve as a medical emergency number.

Until the turn of the century, each 1-4-4 emergency call was routed to the local EMS station, where calls usually were answered on a “you call, we haul, that’s all” basis. Technical improvements (computerized work stations), enhanced mobility (cell phones), and legal considerations (liability) led to the implementation of centralized dispatch centers responsible for whole federal states. 

Lower Austria’s emergency dispatch center (Notruf Niederoesterreich), for example, is a nonprofit limited liability company jointly owned by the Lower Austria government (66%) and rescue organizations. It serves a population of approximately 1.65 million inhabitants and dispatches more than 1,100 resources (more than 800 ambulances but also first-responder groups; water, mountain, and cave rescue groups; and crisis intervention teams) from more than 200 local branches all over Lower Austria. Notruf Niederoesterreich registered 1.6 million calls in 2016; of these, 250,000 were emergency calls via 1-4-4, more than 61,000 came in via 1-4-1 (the after-hours physician hotline), and the rest via other different hotlines and patient transport service numbers. 

Notruf Niederoesterreich implemented the AMPDS (Advanced Medical Priority Dispatch System) in 2003 and in 2008 became the first central European dispatch center to receive ACE (Accredited Center of Excellence) status from IAED (the International Academies of Emergency Dispatch). In addition, ECNS (a nurse-based telephone triage system) was successfully implemented in 2016, considerably reducing ambulance dispatches to nonemergencies.

Legal Basis

According to Austrian law each community/municipality is responsible for basic emergency services (mainly fire and ambulance) within its borders; communities are free to carry these tasks out themselves or sign contracts with recognized organizations. All Austrian communities maintain their own fire brigades, but only two run their own ambulance services (Admont and Vienna).

All others have signed contracts, mostly with the Red Cross and/or Samaritans, paying for this service through a per-capita quota, the so-called “ambulance Euro,” and more-or-less regular additional funds, usually earmarked for the acquisition of new vehicles.

Furthermore, Austrian law regulates that qualified prehospital medical emergency services (i.e., doctor-equipped ambulances) lie within the responsibility of each federal state. Of course, the federal states also have a choice: Either outsource and pay (again, Red Cross and Samaritans) or employ the physicians themselves and lend them to the organization that provides the vehicles.

Lower Austria, for example, uses both options: In districts with hospitals, the Lower Austria government (which owns and runs all 27 state hospitals) employs emergency physicians; in districts without hospitals, the organizations get paid for providing the doctors.

For a very long time there were no laws concerning the education of volunteer ambulance personnel. Each organization created its own internal regulations; only employed staff had to comply with a law from 1961 that basically granted them the status of an unskilled worker with minimum education. Use of defibrillators became a standard requirement in the early 1980s, but apart from that no additional skills were requested or allowed, not even blood sugar checks—these were considered bodily harm if performed by a nonphysician and could lead to consequences from the employer or even legal prosecution.

In 1993 efforts to standardize education for all ambulance personnel resulted in the first drafts of a law aimed at a three-tiered education, the highest level similar to that of nurses. But conflicts of interest prohibited its realization for over nine years—rescue organizations feared the loss of their volunteers, the resulting need to create hundreds of jobs, and therefore massive financial burdens; the federal states’ governments feared enormous financial repercussions because of the need to refinance their ambulance service organizations; and physician associations were also wary. 

Finally, in 2002 the National Act on Paramedics passed the parliament and regulated the education of all ambulance staff, both volunteers and employed personnel:

• Basic ambulance personnel: 100 hours of class, 160 hours practical training (i.e., running calls with the ambulance);
• Emergency ambulance personnel: 160 hours of class, 40 hours internship at a hospital, 280 hours practical training;
• Emergency ambulance personnel with additional skills: basic pharmacology, IV skills, and intubation skills and artificial ventilation (with class hours and internships). 

Organizations were free to offer education to the third level, and soon regional differences appeared: The Lower Austrian Red Cross, for example, does not offer courses in intubation and ventilation skills and also does not acknowledge/allow the exercise of these skills if acquired elsewhere (which stands in contrast to federal law and might be considered illegal, though no lawsuit has yet been filed). Vienna’s MA70 aims to train as many of its professionals as possible in all the skills. The Upper Austrian Red Cross does not offer any level 3 skills education and does not allow exercise of those skills.

The hospital internships proved to be unexpectedly useful. Both nurses and ambulance personnel now get a glimpse of the other side. A new appreciation for both sides’ professional counterparts arose, and long-lasting problems at the emergency department handover declined drastically.

Ambulance Doctors

For once physicians were a step ahead: The law allowing doctors to work as prehospital emergency physicians was passed in 1992. Requirements are:

• Graduation from medical school; 
• Either a three-year internship to become a general practitioner or a five- or six-year internship for a specialty; 
• 60 hours of classes concerning prehospital emergency medicine, including hands-on training plus exam:
  • I. Continuous education necessary every other year (two days of classes and hands-on training);
• Another 60 hours of classes and exercises for ambulance doctors in charge at mass-casualty events:
  • I. Continuous education necessary every four years (two days of classes and hands-on training).

Finances

Modern emergency ambulance services are hardly ever cost-effective; neither funding from the communities and states nor membership fees and donations covers the expenses. Insurance pays only for the transport of the patient, not the material used—so regardless of whether a simple bandage was applied or resource-heavy care was necessary, insurance reimburses the same (very low) amount. If there is no transport (if there’s no true emergency or, for example, after an unsuccessful CPR), there is no refund at all. And billing the patient is not (yet) popular. 

Future Outlook

Calling an ambulance for a ride to a hospital is free in Austria, so it is often used (and abused) for nonemergencies; patients still seem to think the wait time at the ER is less than at the family doctor. Changes in demographics (growing elderly population) and declining numbers of available physicians add to the still-increasing number of (often unnecessary) ambulance transports, thus aggravating organizations’ financial problems. Many ambulance calls are the result not of acute medical emergencies but of social isolation or lack of home care or nursing facilities. 

If ambulance personnel had a broader education and more skills, backed by law, many unnecessary hospitalizations could be avoided. Lower Austria and the St. Polten University of Applied Sciences have taken the first steps in this direction, offering a new three-year course that combines a bachelor’s in nursing and EMT education and qualification; the first students will graduate in 2018. This could hopefully be the beginning of a whole new era for ambulance personnel and nurses, opening up options in community healthcare and moving toward a holistic primary social and healthcare system.  

Resources

1. Redelsteiner C. Von der „Rettung“ zum mobilen präklinischen Dienst. Der Rettungsdienst auf dem Weg zu einem Paradigmen—und Strategiewechsel? Soziales Kapital, 2015; https://soziales-kapital.at/index.php/sozialeskapital/article/view/361.

2. Reisinger A. Rettungsdienst in Österreich (Medical Rescue Services in Austria), master’s thesis, 2012.

3. Weinert S. Die Patientenübergabe: Schnittstelle und Schwachstelle zwischen Rettungsdienst und Gesundheitseinrichtung. Taschenbuch, 2010. 

4. Weinert S, et al. 10 Jahre Notarztwagen Mödling, 1999. 

Susan Ottendorfer is senior emergency physician in charge at the County Hospital Moedling (Lower Austria). She began her EMS career in 1979 as a volunteer EMT for the Austrian Red Cross. She has served as medical director for 144 Notruf Niederoesterreich, Lower Austria's emergency dispatch center, since 2005, and as an emergency physician at the Vienna International Airport’s medical center since 1996, becoming its interim medical director in 2015.