Paramedics in Germany

The German "Paramedic" is a profession in the Emergency medical services in Germany. Here, the profession is called "Rettungsassistent".It is a rather new job description, being introduced by law in 1989 by the German Bundestag.The Rettungsassistent is the primary profession in emergency-type prehospital care.__TOC__

History

After World War II, prehospital care in Germany was in its infancy. It was rather unusual for patients to be brought to a medical practice or hospital rather than medical professionals coming to a patient. In some cases, the German Red Cross used to provide an ambulance service, which was more comparable to a medical taxi. In West Germany the Fire Departments provided 24/7 service as a professional service. With the increase in individual motorized traffic at the beginning of the 1950s, road accidents increased too, leading to a great number of casualties and fatalities.This encouraged the formation of several emergency services, one of the first being the "Johanniter-Unfall-Hilfe e.V.", a subsidiary of the German Order of St.John. These services not only transported patients, but had limited means of treating them on-scene, as well as being faster on the secene of accidents.In then 1950 and 1960s, EMS was primarily done on a voluntary basis by volunteers with only minimal training in emergency medicine.In the 1970s however, the profession of "Rettungssanitäter" was introduced, with a training curriculum being the same in all states of Germany. This led to a more professionalized approach.In 1989 it was deemed necessary to find a new profession with even more knowledge and skills. This was when the "Rettungsassistent" was created. In contrast to the "Rettungssanitäter", the Rettungsassistent is a board-certified profession, whereas the former is merely a description of an occupation.

Training

Individuals who want to become a paramedic have to undergo two years of training at a college, which are mostly private-owned but controlled by the state. With the exception of Thüringen and Sachsen, which cover some or all of the tuition fees, the students will have to pay for their training by themselves. Tuition fees have a range of 2.500 through 4.500 Euros, depending on college, state and organisation. Typically, firefighters, policemen and members of the armed forces who undergo training do not pay tuition fees; here the employer will cover the fees.

Curriculum

The paramedic training consist of two major parts, schooling and internship. These are almost evenly divided into two one-year terms.In the first year, the student will learn the theoretical basics of this profession, including invasive procedures. Incorporated are several weeks of in-hospital internships, typically in casualty wards, operating rooms and trauma units.The theoretical training is divided into several major parts:
* basic anatomy
* body functions
* internal medicine
* neurology
* gynaecology
* urology
* paediatry
* disease patterns of the above
* traumatological injuries
* pharmacology
* law, rights and dutiesFurthermore, the student will be taught skills in treating patients. This includes:
* basic diagnostic skills (blood pressure, heartrate, glucose level, saturation)
* advanced diagnostic skills (using and interpreting ECG, auscultation, neurological examination)
* intravenous, subcutaneous and intramuscular application of medication
* treatment of internal diseases like myocardial infarction, pulmonary edema, hypertension
* treatment of traumatological injuries like fractures, amputations, cuts and bruises
* endotracheal intubation and ventilationThe first year ends with a board examination wich covers all the knowledge a paramedic must have.In the second year, students have to do a minimum 1600 hour internship in the EMS to further their skills. Usually, they start as a third person on a transport ambulance in order to observe and learn from the trained professionals. Sometimes, paramedic-students who also have the qualification of "Rettungssanitäter" are used as second on a two-person team. However, at all times the student will be under supervision by a "Lehrrettungsassistent".After completing their year of internship, there will be a closing meeting after which, should the student be deemed fit, he or she will be awarded the title of "Rettungsassistent'. The award is issued by the Ministry of Health.

The training can be shortened under specific circumstances. Students who hold the title of "Rettungssanitäter" are allowed in most states to shorten their theoretical training [ [http://www.gesetze-im-internet.de/rettassg/__8.html §8 RettAssG - Federal Paramedic Act] ] and, if they have already worked in EMS for some time, only need to do a shortened internship, depending on the state they do the training. In Sachsen-Anhalt, the internship usually consists of only 480 hours.

Paramedic Profession

After training has been completed, the "Rettungsassistent" will work as teamleader on emergency- and patient-transport-ambulances. Also, he or she can act as driver of an "NEF", a special sedan-sized vehicle used for transporting an Emergeny Physician ("Notarzt") on scene, assisting the "Notarzt" during treatment.The job includes all aspects of the training that has been received. Basically, in absence of a physician, he or she is responsible for a complete diagnostic on a patient as well as giving the best treatment possible.Unfortunately, the "Rettungsassistent" does not have a de facto permission to perform treatment of any application of medication or invasive techniques. This is reserved for physicians. [ [http://www.gesetze-im-internet.de/heilprg/index.html German Physicians law - Heilpraktikergesetz] ] Under supervision of a qualified physician, he or she is allowed to perform every technique that has been learned in school and training.Should the need arise to perform such treatment without supervision, there exists a rule called "Notkompetenz" (Emergency powers), which theoretically allows this. This includes, but is not limited to:
* Application of specific medication
** Adrenalin during CPR
** 8 Gramms of Glucose when treating hypoglycaemia
** β₂-Sympathomimetic drugs as aerosol against obstructive pulmonary disorders
** Benzodiazepines for epileptic seizures
** Nitroglycerin for an AMI
** certain Analgesics agains pain
** IV-Electrolytes against hypovolaemic shock
* IV-cannulation
* Defibrillation
* endotracheal intubation without relaxationHowever, this rule does not qualify as a law, but merely a guideline by the "Ärztekammer" (Federal Board of Physicians) [ [http://www.bundesaerztekammer.de/page.asp?his=0.7.47.3222 German Federal Board of Physicians: Directives regarding emergency powers for Paramedics - treatment] ] [ [http://www.bundesaerztekammer.de/page.asp?his=0.7.47.5948 German Federal Board of Physicians: Directives regarding emergency powers for Paramedics - medication ] ] and is always subject to local procedures and guidelines.In theory, a "Rettungsassistent" will violate several federal laws when performing treatment alone. However, when treatment is necessary to avert death or severe debilitation of a patient, the State of Emergency laws [ [http://www.gesetze-im-internet.de/stgb/__34.html German Penal Code §34] ] will usually take precedence.

Other emergency medicine professions in Germany

Besides the "Rettungsassistent', there are three other professions in German EMS.The lowest would be the "Rettungshelfer" with only basic skills, followed by the "Rettungssanitäter", wich used to be the most advanced paramedical profession.Ranking above the "Rettungsassistent" is the "Notarzt", a Physician with extra training in Emergency medicine.All professions are deployed according to their skills, not meaning that a "Rettungsassistent' would not occasionally take his or her seat behind the wheel of a patient transport ambulance.There are ambitions in Germany to get rid of the people only possessing the qualification "Rettungshelfer" or "Rettungssanitäter" in the non-voluntary areas of the German EMS. This is founded in the assumption that even today these two do not possess the skills for todays modern and complex Emergency medicine. Every state has different reqirements to crew an ambulance or NEF, see Bavaria, a Driver only is provided sometimes.

Further education and qualification

Recertification

After completing training, paramedics do not need to be recertified after a specific time like in other countries. This means theoretically, someone having earned the title of "Rettungsassistent" in 1991 might very well be on the educational level of that time.However, most municipalities order their EMS staff to do a certain amount of further training every year, typically 30-40 hours.

Further qualification

Paramedics can acquire further qualifications, enabling them for different or higher paid jobs within the EMS.One of them is the HEMS crew member training, after which the "Rettungsassistent" possesses the necessary qualification to work on a rescue helicopter. This includes assisting both the pilot and the emergency physician, the former during flight phases (i.e. navigating, spotting landing sites), the latter in treating the patient.

Another qualification is the one of Lehrrettungsassistent, a "Rettungsassistent" qualified to teach and supervise paramedic students during their training. Paramedics have to undergo a special training where they will be taught the use of teaching strategies. (PPEd & PGCE)

For senior paramedics with a lot of expertise there is the qualification of Organisatorischer Leiter Rettungsdienst (OrgL). This qualification is closely related to mass casualties. A "Rettungsassistent" assuming this position will be responsible for organizing patient flow and transport during such a disaster, as well as coordinating forces during those events. Although it is just a 2-week course, most municipalities demand additional leadership training in disaster units (i.e. leader of a medical platoon) before the qualification is granted.

ee also

* Paramedics
* Ambulance
* Emergency Medical Services
* Emergency Medical Care

References