casualty incidents. organisatorischer leiter ("organisational leader") and/or einsatzleiter rettungsdienst ("ems chief on scene") – a rettungsassistent or notfallsanitäter whose role is to organize tactical ems aspects during mass casualty incidents (i.e. communication, staging, transportation). lehrrettungsassistent or praxisanleiter rettungsdienst ("paramedic instructor") – a rettungsassistent or notfallsanitäter responsible for the education and training. hems crew member – a rettungsassistent or notfallsanitäter who works as medical aircrew, responsible for assisting the pilot and the physician on a rescue helicopter. einsatzsachbearbeiter / leitstellendisponent – someone who works in a dispatch center, most ems dispatchers are obligated to obtain the level of rettungssanitäter or even notfallsanitäter as well as platoon or squad leader of the fire brigade, depending on local regulations. an additional dispatcher training course completes the skill set for dealing with emergency number calls and coordination of emergency and non-emergency responses. wachleiter (station commander), schichtleiter (shift commander) and rettungsdienstleiter (ems chief) are administrative roles, mostly requiring experience in the ems field and additional administrative skills, often regulated by state laws. qm-beauftragter (quality management representative), mpg-beauftragter (medical equipment representative) and hygiene-beauftragter (hygiene representative) are other administrative roles, often required by laws and regulations. overview in the german system, not only paramedics and emt's, but also physicians have recognized roles and skill levels. the following table will give a brief overview about the major qualifications and their place within the german ems structure. german system of prehospital care non-emergency public health system profession english counterpart tasks hausarzt/allgemeinarzt general practitioner treating patients in medical practice. if patient is not ambulatory, making housecalls. typically only responding to own patients during practice hours. kassenärztlicher notdienst gp "on call" gp on call after hours, visiting patients not requiring ems, but responding to calls throughout assigned area. emergency emergency medical service emt english counterpart training jobs school hospital internship ambulance internship patient transport ambulance (ktw) emergency ambulance (rtw) physicians response vehicle (nef) rettungshelfer emr / emt 2 weeks 2 weeks 2 weeks driver driver (occasionally) driver (occasionally) rettungssanitäter emt 4 weeks 4 weeks 4 weeks crew chief driver /patient care driver rettungsassistent paramedic emt-p 24 months 10 weeks 1 year crew chief /patient care crew chief /patient care driver notfallsanitäter paramedic emt-p 1920h 720h min. 1960h crew chief /patient care crew chief /patient care driver notarzt emergency physician 6 years 18 months (during med school) min. 50 runs - - crew chief vehicles ground ambulances the german ems system's vehicles come in a wide variety of shapes and sizes. all of its vehicles must conform to most aspects of the requirements of european standard cen 1789 as reflected in the german standard din en 1789 (types a-c) or german standard din 75079. the visual identity requirements of the european standard are not yet being followed. the three major types of vehicle are: the krankentransportwagen (ktw), a van-type ambulance used for non-emergency transport. it conforms to din en 1789-a1/a2: "patient transport ambulance single/multiple patient" the rettungswagen (rtw), a larger van used for emergencies. it conforms to din en 1789-c "mobile intensive care unit" the notarzteinsatzfahrzeug (nef), a station wagon or small van. its purpose is to bring the notarzt (emergency physician) to the scene of the emergency, when required. it conforms to din 75079 additionally, the mehrzweckfahrzeug (mzf), or multi-purpose vehicle – often referred to as a notfallkrankenwagen (n-ktw) or kombinationsfahrzeug (kom) – serves a dual role as patient transport vehicle and as backup for emergency responses and usually conforms to type b of din en 1789. other vehicles that are also employed include neonatal units for special pediatric care and transport, intensive care transport units (itw) for transporting icu-patients from hospital to hospital with an emergency physician on board, ambulances for obese patients, special infectious transport units and disaster response supply vehicles. ems in germany "rettungswagen" of the kiel fire department "krankentransportwagen" of the neumünster fire department emergency physician response vehicle (notarzteinsatzfahrzeug) from fire department iserlohn specialized emergency physician response vehicle (notarzteinsatzfahrzeug) for children mercedes-benz t2 in use as a neonatal emergency ambulance (baby-notarztwagen) air ambulance airbound ems is an integral part of german ems system, patient care and transport costs are covered by health insurances. germany has a well-developed air ambulance network, consisting of primary ems helicopters, interhospital transport and dual use helicopters. most of them are operated by germany's largest automobile club adac, the non-profit "deutsche rettungsflugwacht e.v." (drf) and the german ministry of the interior. germany is completely covered by ems helicopters, however most of them operate only during daytime. medical crew includes both a notarzt and a notfallsanitäter additionally qualified as hems crewmember. medical crews mostly are provided by associated hospitals or cooperating ems organizations, the operating entity provides the pilots. depending on helicopter type there may be an additional flight technician assigned to the crew. as of the year 2015, adac operates 35 helicopters (ec135, h135, ec145, h145), where as the drf provides 30 (ec135, h135, ec145, h145). the helicopter fleet of the ministry of the interior operates 12 rescue helicopters (ec135, h135), pilots provided by the bundespolizei. there are also private intensive transports, in close cooperation with assigned hospitals. some private ems helicopters for interfacility transport add to this fleet. some multi-purpose police helicopters may perform additional emergency response and transport when required, those crews often are trained as rettungssanitäter, medical staff will be provided by ground units in case. in addition, adac and drf operate a fleet of fixed wing air ambulances, including jets, primarily to provide foreign repatriation service to their club members. other companies (often health insurances) provide foreign repatriation services for their customers as well, mostly with rented aircraft and medical staff. several military operated helicopters are designated for air-sea rescue operations (asr/sar in context of icao and imo regulations) and may assist in civil mass casualty scenarios. german army operates four helicopters in sar service (airbus h145; two in niederstetten, one in nörvenich, one in holzdorf), german navy operates two helicopters in sar service (sea king; one in helgoland, one in hohe düne). german bundeswehr provides additional air medical evacuation (medevac) planes and helicopters, primarily for military use but used for support in civil crisis situations as well. air ambulance in germany adac rescue helicopter drf rescue helicopter adac repatriation ambulance aircraft others ships and boats for water rescue motorized sleds and special all-terrain vehicles equipment the basic equipment of any ambulance includes: basic first aid kit dressings and bandages basic diagnostic equipment, like blood-pressure cuffs. mobile oxygen unit, equipment for basic airway management portable defibrillator wheel stretcher and blankets vacuum mattress flexible stretcher, also called a reeves stretcher. rigid or collapsible transport chair, also called a stair chair in the united states depending on the type of the vehicle, there are numerous additional items, among them are: ecg monitor (12 lead), pulse oximetry sensor device, capnography monitor medical ventilator rescue equipment like scoop stretcher and spine boards immobilization equipment like cervical collars and splints equipment for intravenous therapy advanced airway management like chest tubes and equipment for surgical airway management emergency surgical equipment special equipment for pediatric and birth emergencies drugs, including a selection of analgesics, anaesthetics, cardiac stimulants, substances for circulatory problems and antidotes. ems equipment and work environment interior view of a ktw: transport chair (left) gurney (middle) paramedic's chair(right). one can also see the o2 – bottles (cabinet in the rear) and the medical ventilator (right foreground) interior of a type c ambulance interior view of an air ambulance helicopter dispatch a workplace in an ems dispatch centre all emergency calls, regardless of the emergency number on which they originate, are routed to dispatch centres; in german leitstelle. at present, most municipalities operate on an integrated system called integrierte leitstelle (joint dispatch), in which all calls involving fire and ems are answered at the same location, and by the same personnel. there have been attempts to incorporate the police dispatch centers as well, more closely mirroring the u.s.-based 9-1-1 public safety answering point concept, however, due to the significantly different nature of the calls, it has been concluded that there are more disadvantages than advantages to this incorporation of all dispatch functions. once a call via the local emergency number is placed, a dispatcher will answer and ask the caller about the nature of the emergency. due to dual training in joint dispatch centers, the dispatcher is able to answer calls concerning both the fire department and ems. while the caller is being interviewed about call specifics, the dispatcher is already working on the computer, which will provide prompt questions, provide advice, and suggest response resources for this emergency. this computer system, while operating in german, is extremely similar to the ampds algorithm used by emergency medical dispatchers in the united states. to illustrate, a call is received in the dispatch center about a possibly unconscious person. the dispatcher will immediately identify the call location, and will then ask further questions, in order to assess precipitating symptoms, specific location, and any special circumstances (no house number, a neighbor is calling, etc.). while this interview is occurring, the dispatcher will enter the command bewußtlosigkeit (unconsciousness) into the dispatch computer, resulting in an automatic suggestion to dispatch of a rettungswagen (emergency ambulance) and a notarzteinsatzfahrzeug (doctor's car). upon entering the address of the patient, the computer will look for the emergency vehicles closest to this address. now the dispatcher can send the whole package over the air and those two vehicles are alarmed, similar to computer-assisted dispatch (cad) in the united states. after sending the alarm, the dispatcher may remain on the line with the caller, providing telephone advice or assistance until the ems resources arrive on the scene. "swissphone de900" digital pager alerting crews emergency vehicles are sent on runs by a number of means. the most common system is by pager, issued to every crew. pagers may operate on either an analog or a digital system. analog pagers will silently listen on the air for a 5-tone signal being transmitted. once the individual signal for that pager is detected, the pager will sound an alarm, and will often open the channel for the crew to hear the dispatcher. further information is being given via radio. the digital pagers will listen on a different channel and once its individual address is transmitted, will prepare to receive a data package. this package normally consists of a short message, providing the address and nature of the emergency as well as additional information. this clears the radio channel of lengthy calls. theoretically, no additional radio traffic is required when using such a system. communication all public emergency services in germany (i.e. ems, fire, police, disaster response) use the same radio system for communication. thus, they can connect to each other with their radio equipment. since the 1950s the units were equipped with radios in the 4m frequency band, handheld units work in the 2m band. this analog radio usage is protected by law for emergency use only. relay stations cover whole germany. with entering the appropriate channel, every radio can reach another dispatch center or agency. since around 2010 a nationwide digital radio communication standard is implemented. this is based on the terrestrial trunked radio (tetra) standards. main advances over the old analog radio system are availability of far more channels and communication groups, encryption possibilities, noise filtering and enhanced signal reliability. to cover whole germany about 4500 base stations are needed. as of august 2015 already 4338 of them are installed and 4323 working, thus about 97% of germany is covered. migration to the new radio standard is ongoing step by step, parallel use of the analog system is planned until around 2020. now there are mobile radio terminals (mrt) for vehicles, handheld radio terminals (hrt) and fixed radio terminals (frt). all radios can be switched between trunked mode operation (tmo) and direct mode operation (dmo). communication with dispatch is done in tmo, on scene communication works in dmo. every radio can be allowed access to the communication of another agency, either when already programmed this way or given access by the dispatch center. organization, infrastructure and security keys are centrally managed by a government authority (bundesanstalt für den digitalfunk der behörden und organisationen mit sicherheitsaufgaben), assisted by a net of authorized and tactical bodies throughout the country. staging and deploying resources there are two different