Paramedics in Germany
Thus the German paramedic scope of skills include a set of advanced life support (ALS) treatments, which they have to perform until an emergency doctor is on scene.
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.
The development of the system "emergency physician" (Notarzt) started, bearing the need for somewhat qualified assistance on scene.
So, eventually in 1977 the original idea was introduced as a 3.5 month (520 hours) training curriculum common to all Länder (federal states) of Germany.
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.
[3] Since then, EMS in Germany has evolved into a formal, well organized structure, with standards for staff training, vehicles, and service delivery.
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 additional internship in EMS wasn't part of examination), 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.
Former Rettungsassistenten can decide to stay in their duty (the title still is protected) or (time limited until end of 2020) upgrade to Notfallsanitäter by taking courses and a supplemental state exam.
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 (clearing airway and oropharyngeal, subglottic and endotracheal intubation), intravenous cannulation or intraosseous infusion, decompression of tension pneumothorax and application of crystalloid solutions, basic medication (adrenaline, glucose, inhaled ß2 agonists/bronchodilators, rectal benzodiazepine, glyceryl trinitrate, analgetics) and resuscitation with an automated external defibrillator.
[6] Usually not included are rapid sequence induction, surgical airway management, thoracostomy and advanced medication.
[9] Essentially, emergency medicine in Germany heavily relies on evidence based guidelines provided by the main bodies of medical scientific organisations.
[11] Specific side entries with shortened courses were defined for applicants with existing Rettungssanitäter education, nurses, active soldiers and police officers with medical training.
A state licensed examination after this first stage permitted the candidate to begin a 1600 hours preceptorship in the pre-hospital setting.
[13] 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.
By law the education has to enable the Notfallsanitäter to perform following tasks on his own: scene assessment and security, assessment of patients especially detecting vital threats, decision about calling in assistance, medical treatment of patients including invasive actions, handling of people in crisis situations, establishing and securing transportability of patients, selection of an appropriate transportation target, monitoring, reporting to receiving facility, documentation, communication, quality management, operational responsibilities for equipment including care for hygiene and accident prevention, assisting in medical treatments under supervision of a physician, independent treatment as ordered by a physician, self-responsible medical treatment according to rules given by a medical director, cooperation with other professions.
Since it is mandatory to have a contract during the education period there is almost no way to get the Notfallsanitäter qualification on own expenses, only exception would be for university students in emergency related degree programs (and, technically, for public servants, i.e. career fire fighters or police officers).
[20] There is no defined side entry for other medical professions, only a general rule for authorities enabling them accreditation of other education.
[24] Generally, the law gives following objectives for the education: A Notfallsanitäter has to be qualified to perform according to scientific standards and with technical, personal, social and methodic competence for sole responsibility and team oriented work especially in emergency medical treatment and transport of patients.
By law the education has to enable the Notfallsanitäter to perform following tasks on his own: scene assessment and security, assessment of patients especially detecting vital threats, decision about calling in assistance, handling of people in crisis situations, establishing and securing transportability of patients, selection of an appropriate transportation target, monitoring, reporting to receiving facility, documentation, communication, quality management, operational responsibilities for equipment including care for hygiene and accident prevention, assisting in medical treatments under supervision of a physician, independent treatment as ordered by a physician, self-responsible medical treatment according to rules given by a medical director, cooperation with other professions.
However, it is also the general public's term for "medical ambulance staff" in Germany, although recognized a bit offensive by some EMS professionals.
After successfully completing EMS education and holding the state exam, paramedics in Germany do not need to be recertified.
The qualification of Einsatzleiter Rettungsdienst and Organisatorischer Leiter (EMS/incident commander) is closely related to mass casualties and will be responsible for organizing staging, triage, treatment and transport as well as communication.
Marketing and sales positions as well as working in technical service or development for manufacturers of medical equipment could be an additional career move for paramedics.
On the other hand, the general structure of German EMS is changing within the European union, more and more towards a time restricted contracting system, leading to heavy competition between organizations and companies.
