Paramedics in Germany


Paramedics in Germany are the main providers of emergency care in emergency medical services in Germany. There exist two professional levels regulated by federal law, the Rettungsassistent and the Notfallsanitäter.
Both are able to provide the first level of pre-hospital emergency care. Additionally, they can get backup by an emergency physician on scene. Thus the German paramedic scope of skills include a set of advanced life support treatments, which they have to perform until an emergency doctor is on scene. Then the paramedics act under direct medical supervision of the physician.
Non life-threatening emergencies are handled solely by the paramedic ambulances without a physician on scene.
Other regulated qualifications in German EMS are Notarzt and the more basic emergency technician level Rettungssanitäter.

History

The development of ambulance services in Germany started in the late 19th century. Typically volunteer aid organizations, some private companies in larger cities and so called rescue corps provided ambulance services mostly with very little training or medical background. This more or less lasted until the 1960s: emergency care was provided by volunteer organizations or untrained "ambulance men".
In the late 1960s and early 1970s, however, it became obvious, that a more professional approach is needed. The sending of physicians to the scene was introduced, following the concept "bringing the doctor to the patient, not the patient to the doctor". The development of the system "emergency physician" started, bearing the need for somewhat qualified assistance on scene. A law to establish the occupation of Rettungssanitäter has been discussed, with a 3-year training curriculum. The government however saw difficulties in financing the training of this new profession. So, eventually in 1977 the original idea was introduced as a 3.5 month training curriculum common to all Länder of Germany. This led to a more professionalized approach, but clearly below the level of the intended original law. By the 1980s it became clear that many situations were occurring in which the knowledge level of the Rettungssanitäter was inadequate, especially in cases where a Notarzt wasn't available in time. The developing of pre-clinical procedures demanded additional qualification for treating patients in the field. It was deemed necessary to find a new profession with even more knowledge and skills.
This was when, in 1989, the profession of the Rettungsassistent was created, introducing a two-year education program. In contrast to the Rettungssanitäter, the Rettungsassistent was a state-certified profession with a job title protected by law. Since then, EMS in Germany has evolved into a formal, well organized structure, with standards for staff training, vehicles, and service delivery. Formerly Rettungssanitäter trained providers could get an upgrade to the new profession with proof of 2000 hours experience in EMS. The Rettungssanitäter still exists as a common entry/assistance level for EMS, for volunteer work and industrial emergency medicine.
However, the Rettungsassistent remained subject to discussion, especially regarding length of education, scope of practice, autonomy in emergency situations and differentation to other medical professions, including paygrade. The problems mainly were seen in the early state exam after just one year in EMS school, the more or less undefined curriculum, the main focus on bare assistance to a physician, the possible side entry for other medical professions and the de facto requirement for students to pay for the entire education.
Around 20 years after the introduction of Rettungsassistent law, the German EMS community targeted to an enhanced qualification. Eventually in the year 2013, the law about the Notfallsanitäter came into effect. With January 2014, no more starting courses for the old Rettungsassistent were possible. The Notfallsanitäter law addressed much of the concerns, thus providing a real three year education with a well defined curriculum targeted more on autonomous handling of emergency situations, requirement of a contract with an employer during education and no side entries for other professions. Former Rettungsassistenten can decide to stay in their duty or upgrade to Notfallsanitäter by taking courses and a supplemental state exam.

Scope of practice

The scope of practice of a German paramedic is not specifically defined by a decent law. Thus the allowed standard procedures largely depend on the local medical director and the employer. However, in life-threatening situations, a Rettungsassistent or Notfallsanitäter always has to perform autonomously first diagnosis/monitoring and all necessary ALS treatments until an emergency physician arrives. This includes airway management, intravenous cannulation or intraosseous infusion, decompression of tension pneumothorax and application of crystalloid solutions, certain medications and resuscitation including manual defibrillation.
Usually not included are rapid sequence induction, surgical airway management, thoracostomy and advanced medication. However, this may be trained and allowed, especially for special settings, such as military or remote medical care.
Restrictions in treatment are the scope of training and practice, some laws restricting decent methods to physicians and the fact that concluding therapies are restricted to physicians and licensed practitioners only, with exceptions to certain emergency procedures opened to the Notfallsanitäter. An emergency physician should be called to scene if he can perform other life saving tasks the patient needs, usually regulated by a physicians indication catalogue depending on the service and state.
The definition of skills in the Rettungsassistent education law was not very specific, whereas the definition in the Notfallsanitäter law is very specific in which skills have to be mastered, trained or only known of. Thus, the scope of practice of a Notfallsanitäter is based on a well defined education, which leads to a wider range of accepted standard procedures, including intraosseous access, extraglottic airway, thorax punction, manual defibrillation and cardioversion, external pacing as well as more drugs including opiates.

Algorithms, Standing Orders, Procedures and Guidelines

Beside specific topics such as resuscitation, the use of algorithms in daily work is not usual in German EMS, although they are used in training.
Standing orders, pre-delegated authority and telemetry consultation are becoming more common since introduction of the Notfallsanitäter. In cases not covered by pre-delegation, emergency physicians can be called to come directly on scene. Until then, the paramedic is allowed to perform needed procedures within his skills on his own. Telemetry is mainly used to provide the receiving hospital with data for organising appropriate help in-house, but also in a few areas to seek medical advice with a telemetry emergency physician via video and audio transmission.
Essentially, emergency medicine in Germany heavily relies on evidence based guidelines provided by the main bodies of medical scientific organisations. Providers of medicine have to keep up with the changes in those guidelines.

Competences

The theoretical education for German paramedics include:
Furthermore, the student is taught skills in treating patients, including:
The Rettungsassistent was a two-year education program, established in 1989. This program ended in the year 2013 with the introduction of the three year education program of the Notfallsanitäter.
Literally, the term means "rescue assistant", meaning that those in this role assist the Notarzt during pre-hospital treatment.
The Notfallsanitäter law of 2013 outdated the Rettungsassistent, effective with beginning of 2014. The title Rettungsassistent still is protected by law and those who have this education can perform their duty, but there will be no more starting classes for Rettungsassistent since January 2014.

Access

To be allowed to start EMS school an applicant had to be 18 years old and generally healthy. The needed school education was a basic level certificate of secondary education or similar, or alternatively completion of vocational training.
Specific side entries with shortened courses were defined for applicants with existing Rettungssanitäter education, nurses, active soldiers and police officers with medical training. Another professional education could have been accredited by authorities in general.

Education

The first phase of education included classroom and hospital clinical. It took 1200 hours, this is about one year full-time. A state licensed examination after this first stage permitted the candidate to begin a 1600 hours preceptorship in the pre-hospital setting.
In this second year they usually started as a third person on a transport ambulance in order to observe and learn from the trained professionals. Sometimes, paramedic students who also had the qualification of Rettungssanitäter were used as a full crew member on a two-person team. However, at all times the student was under supervision by a Lehrrettungsassistent.
After completing their year of internship, there was a closing meeting with the training physician and the supervising paramedic. After that, should the student have been deemed fit, he or she was awarded the vocational title of Rettungsassistent. The certificate then was issued by the state Ministry of Health and valid nationwide.