emergency medical services in germany emergency medical services in germany emergency medical service (german: "rettungsdienst", lit. "rescue service") in germany is a service of public pre-hospital emergency healthcare, including ambulance service, provided by individual german cities and counties. it is primarily financed by the german public health insurance system. 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. after world war ii, prehospital care in germany was in its infancy; in most predominately rural areas the german red cross provided an ambulance service. in west germany the fire departments provided 24/7 service as a professional service in some cities and urban centres or towns. with the increase in individual motorized traffic at the beginning of the 1950s, road accidents also increased, leading to greater numbers of both injuries and fatalities. this encouraged the formation of several other emergency services, for example the johanniter-unfall-hilfe e.v., a subsidiary of the german order of st. john. still, the ems role was primarily done on a voluntary basis by individuals with only minimal training in emergency health care, using simple transport vehicles with almost no medical equipment. however, more and more it became evident, that not only transport saves live of patients, but treating them on-scene. the need to professionalize emergency health care was picked up by several university medical centers in the late 1950s and 60s (cologne, frankfurt, heidelberg and munich). the idea to "bring the doctor to the patient, rather than the patient to the doctor" was already born before world war ii, now rediscovered mid-1960s. the result was the evolution of a type of emergency physician called a notarzt who dealt primarily with providing emergency medical care in the out-of-hospital setting. the service delivery model that this approach describes is commonly referred to as the franco-german model. in the late 1960s and early 1970s, advanced demands lead to the establishment of helicopter ambulance services, dispatch centers, radio communication and general better organization of ems as well as scientific approaches to provide better emergency care. the first emergency medical technicians were trained by some fire departments, organizations, and even universities. in 1977 the first nationwide educational standard for non-physician emergency medical providers was introduced, the rettungssanitäter. the system was largely improved in the 1980s and 1990s, leading not only to the then-new profession of rettungsassistent (1989) but also to the availability of modern medical equipment in outdoor quality. in the year 2015 the new occupation of notfallsanitäter was introduced, including a three-year education and training for the role as high professional emergency care provider as well as a substantial assistant to the emergency physician on scene. today germany has a dense net of emergency services available, providing emergency care at a high professional standard. organisation responsibility in germany the individual states are legally responsible for the provision of emergency services, but typically delegate these responsibilities to the district level ("kreis" or "kreisfreie stadt"). municipalities, including both smaller communities ("gemeinden") and cities ("städte") are given responsibility by the state for equipping and operating fire departments ("feuerwehr"), emergency medical systems ("rettungsdienst") and disaster response ("katastrophenschutz"). german law mandates the provision of fire and rescue services, including ems, staffing and equipping according to levels which correspond to local population. in independent cities, this is usually provided directly by the fire prevention bureau ("amt für brand- und katastrophenschutz"). unlike fire protection, the task of providing ems, while legally mandated, is not necessarily performed directly by the district. if it is, it will be operated as a "kommunaler rettungsdienst" ("county ems"). in some cases, local municipalities will provide the service directly, usually through a full-time staffed fire department. ems may, however, be contracted out by the district to a number of other potential service providers, including both community non-profit organizations and privately-owned companies. thus, ems in germany may be provided by any of the following: the local fire department the joint medical services of the german bundeswehr (army) the county ems agency the "johanniter-unfall-hilfe" (abbr. juh, the german counterpart to st. john ambulance) the "malteser hilfsdienst" (abbr. mhd, the german counterpart to order of malta ambulance corps) the "deutsches rotes kreuz" (abbr. drk, the german national red cross society) the "deutsche lebens-rettungs-gesellschaft" (abbr. dlrg, lit. "german lifesaving foundation", primarily for providing water rescue) the "arbeiter-samariter-bund" (abbr. asb, labor-samaritan-alliance, part of the european "samaritan international (saint)") privately owned companies leadership in germany, ems is a component of one of the key tasks (public safety) which every municipal government is required by law to perform. as a result, there are strict regulations regarding qualifications, job performance, ems system performance including response time, and the types of vehicles and equipment required. compliance with those regulations is usually evaluated with respect to effectiveness and meeting public need by the local cities/communities, assisted by specialised physicians. typically, community or service area ("rettungsdienstbereich") employs a medical director, (ärztlicher leiter rettungsdienst), with a role that is similar to ems medical directors elsewhere. the medical director is responsible for the creation and issue of regulations, protocols, and standards of care on behalf of the community. compliance with such regulations and medical protocols is mandatory for both ems provider organisations, and for their personnel. the medical director usually performs these tasks with considerable latitude. regulations and protocols may be developed and issued at the discretion of the medical director, who is required to govern their actions according to the general guidelines and financial guidance provided by his county or municipality. the position medical director is that of a consultant, and in some german states is required by law. roles as in many other places, in germany, the ems system performs two major functions: emergency services – responding to all calls concerning immediate danger to the life and/or health of a person. this is the core component of the service, which is called notfallrettung or rettungsdienst in german. this service addresses acute onset illness and injury conditions, such as myocardial infarction, or accidents with severe injuries, to name just two. non-emergency services – arranging and performing the transport of non-emergency patients (i.e. transfer to, from, and between hospitals). this service is called krankentransport in german, and provides service to non-ambulatory patients with low-acuity or chronic conditions, or to those who are recovering from acute care situations, and who lack the ability to use other means of transport (i.e. by taxi, own car or public transport). in addition to regular emergency and non-emergency services, there are mobile intensive care units micu stationed in most of the major cities. these units correspond to the critical care transport function found in other places. they are brought into action whenever a patient with a serious and complex medical condition, requiring advanced levels of support during transit, needs to be transferred between hospitals. this service usually applies to intensive-care unit patients, hence the german name intensivtransport. while not formally affiliated with the ems system, the general practitioner (gp) frequently interacts with that system. in germany, it is still commonplace for physicians to make house calls for those patients who are not able to visit a medical practice. additionally, most cities and counties run a service called ärztlicher hausbesuchsdienst (physician home call service), which provides a gp to make housecalls for all people in the specific area. the physician will not only respond to patients from their own practice, but will also visit and treat patients all over the area. the gp service is delivered and maintained by an organisation known as the kassenärztliche vereinigung (union of health fund approved physicians) and is usually only used for minor illnesses (i.e. fever, common cold), where a hospital stay is not necessary but the intervention of a physician may be advisable. the availability of this service provides a better treatment option to those patients who, in other ems systems, might generate low-acuity ambulance calls or emergency department visits. occasionally, the visiting gp will contact the ems dispatcher and order a krankentransport, should it be determined following medical assessment, that the patient could be cared for in a safer and better manner in a hospital. emergency telephone numbers the european emergency number for the fire brigade and emergency medical services, also in germany, is 112. this number can be called toll-free from any phone (fixed-line, mobile or phone booth). the german police is available toll-free at 110 (or alternatively via the 112 operator). dispatchers speak german, often english and the languages of neighboring countries in border areas; in some bigger cities (i.e. berlin, hamburg, cologne or munich), they might also understand other language(s). although it is not official, some mobile phones accept the american "911" as an emergency number in germany, but it will not work from fixed-line phones or phone booths. personnel there are different specified qualifications in german ems: the emt level (rettungssanitäter), the paramedic level (rettungsassistent, notfallsanitäter) and the emergency physician (notarzt). in german ems system, the first level of pre-hospital emergency care is given by paramedics, in life-threatening situations backed up by an emergency physician on scene. thus the paramedic scope of skills include a set of advanced life support (als) treatments, they have to work until an emergency doctor is on scene. then the paramedics (and other medical staff on scene) act under direct medical supervision of the physician. other (non life-threatening) emergencies are handled solely by the paramedic ambulances without a physician on scene. emergency physician (notarzt) the emergency physician, or notarzt in german, must be a physician with a notfallmedizin (emergency medicine) board certification, issued by the state chamber of physicians. in order to obtain the board certification, a minimum term of residency in a specialty related to critical care medicine, additional training in techniques of anaesthetics and critical care medicine, and passing of a board examination is required. the position is technically open to any physician who completes the board certification process. once on scene, the notarzt is responsible for all tasks associated with physicians in the field, acts as the crew chief and provides medical direction to all subordinate ems staff. emergency physicians are dispatched along with a paramedic ambulance according to several standard dispatch criteria (indication catalogue, "notarzt-indikationskatalog"), including myocardial infarction, dyspnoea, potential severe trauma, unconsciousness, life-threatening intoxication and needed pain management. non-physician ambulance crews may request assistance from a notarzt via dispatch as well. usually, the emergency physician gets to the scene in a separate vehicle, a notarzt-einsatzfahrzeug (abbr. nef, emergency physician's vehicle). paramedic level (rettungsassistent and notfallsanitäter) there are two non-physician emergency professions in germany, which are regulated and protected by german federal law: rettungsassistent (two-year education, outdated since end of 2014) and notfallsanitäter (three-year education, effective since 2015). for detailed description see article "paramedics in germany". emergency medical technician (emt) level lower-level qualifications enabling a person to work in ems are the rettungssanitäter (520-hour training) and rettungshelfer (not standardized, around 240 hours out of the rettungssanitäter curriculum). both are not protected titles by federal law, but based on a national agreement of the german state ministry boards of 1977. the training of a rettungssanitäter is within a 520-hour program, including 160 hours theoretical classroom education, 160 hours hospital training, and 160 hours of ride-along in ems, followed by a 40-hour final course with a state exam or an exam at a school accepted by the state. a rettungssanitäter with this exam is allowed to work nationwide. the rettungshelfer basically is a person on the way to the full trained rettungssanitäter. the level is not well-defined (varies from state to state or organization to organization), but mostly includes the 160-hour theoretical course and 80 hours of the ems internship, but no state exam. depending on the state in which they work, those in the rettungshelfer role are usually the drivers of non-emergency patient transports, with a rettungssanitäter acting as crew chief for the vehicle. in most german states, for emergency ambulance service, those in the rettungssanitäter role are often the drivers of emergency ambulances and act as an assistant to the rettungsassistent and notfallsanitäter. additional qualifications some additional qualifications and roles closely connected to ems include: leitender notarzt ("leading emergency physician") – a notarzt with medical leadership responsibilities connected to mass