Baveria(Germany) Standard Ambulance and System description

[krumel]

Hi,

as many of you pointed out that you are interested in "how the EMS in Germany works and looks" I thought I will make this short presentation.

First of all the background:

The EMS System in Germany is a so called "state duty" (in opposition to communal or federal duties). Each state has it's own laws....

In Bavaria (where I mainly work at the moment) the system is unique.

The state does all tasks that can be performed state wide such as buying the rigs and the med. tech., charge the insurances (remember: everyone here has one), etc.

So the state buys the ambulances and left it over to the so called "care providers". Those care providers (which in Bavaria is mainly the Red Cross) get the instruction to "get this ambulance 24/7 on this position" and get paid for this, not for the calls they respond, etc. Where an ambulance (and how long) will be positioned will be decided after a structural analysis every 2 years.

(For example by company has 4 ambulances 24/7, 2 which work for 15h, one which works for 16h)

The idea is that the ambulances which make a lot of money (by responding to a lot of calls, for example in an urban EMS) are cross-financing the rural stations which only respond to one or two calls a day but are required by law to exist. (State law says: 95% of all street adresses have to be reached within 15 min)

The car:

The ambulances are bought by the state and left over to the care providers. To make the cars cheaper, the state buys about 100-200 rigs every time... And they are all the same (same chassis, same motorization, same construction). Due to this in case an ambulances crashed it's easy to replace it by an backup ambulance even from another company.

The ambulances will be replaced every 200.000 km (124274 Miles).

Note: In most parts of Germany the seperation between BLS and ALS Ambulances does not exist. There are only "Patient transport Ambulances" (although often they are equipped better than most US BLS Ambulances) which normally do not respond to emergency calls (or just as a first responder) and those ALS Ambulances.

ALS Ambulances (so called "RTW" or "Rettungswagen") are stuffed normally with one "Rettungssanitäter" (comparable with an EMT-I) and an "Rettungsassistent" (comparable to an EMT-P).

Although "Rettungsassistent"/EMT-P is very well trained (1200h hours of very intense theoretic training, 400 in the hospital, 1600h as a trainee on the rig under the supervision of another "instructor EMT-P) they are only allowed to perform i.V.'s, intubation (without any meds), defib, and give some drugs (mainly Glucose, adrenaline, some inhalatives, diazepam and tramal) (changes by the local protocol... We are allowed to give Ketanest, Midazolam, prednisolon, Dimetiden, needle decompress...But were outstanding..Only two other counties are known to are allowed that much) when an emergency physican is on it's way to the call and won't be there fast enough to perform the intervention.

The hole "advanced care" normally lays in the hand of those emergency physicans who are transported to the scene with an "Notarzteinsatzfahrzeug"/NEF, a care comparable to any other "Fast response" car around the world. Those cars will be driven by an EMT-P.

(In some urban areas there are special "ALS" Ambulances where the emergency physican is directly part of the ALS Ambulance)

For special situations there are also "pediatric fast respond vehicles" (staffed with an pediatric critical care physican and one EMT-P) and critical care transport vehicle (stuffed with an critical care physican and normally with one or two EMT-P which are registred ICU-nurses as well) available.

The cars are mainly Mercedes Benz Sprinters (due to supply difficulties there was one serie with Volkswagen Crafter, but this chassis is nearly identical), motorized with 110/ 150 (KW/PS) Diesel engines.

Due to federal and EU Law the "light and signal" section is...well... can't compare it with an normal US ambulance....

The hole chassis and the box has to be very stable (9 G is required for everything) so in case of an crash they normally are pretty stable.

Here are some pictures: (This pictures are not my private pictures cause I'm not allowed to take any photos at work now)

(Backsite with "Stollenwerk" Stretcher - a German Stretcher brand, comparable to Stryker...We had Stryker...But *cry* to expensive)

(the cabinet section in the front area of the patient compartment)

(Overall view)

(Another back view with the main "care provider" seat. Note the cabinet on the left. Here all O2 is stored in its own "steel cage": 2x 10l bottles for the ambulance and the backup 2l bottle for the respirator or airway set.)

(Site entrance with the backpack and the pediatric back. The care providers can decide what system they want to have. Most stations decide they want to work with one backpack and a seperate O2 source (etc. from the inhalation system of the respirator or an own O2 set), some work with a "case system" -as we do although I for myself hate it- with two cases, one for circulations and trauma, one for airway)

(Night view with all lights on..As I said before: Not to be compared with US ambulances..... )

All pictures are linked from the page of the Red Cross Obernburg-Miltenberg (thanks to them). Further pictures can be found on their site here.

(Common emergency Physican vehicle operated by the FD)

(and yes, for the emergency physican vehicle we're using other brands than mercedes, too. BMW and Volkswagen are also very popular.)

Edit:

I found a video of my ex-partner (*cry* the one and only Porno-Boy) which demonstrates pretty good the sound of an typical german ambulance:

http://www.myvideo.de/watch/2447999/Rtw_Bl...hrt_in_Muenchen)

[mrmeaner]

Good info! If I don't ask now, someone else will shortly; what are the care levels and what are the training standards for those levels?

Thanks for the post.

[krumel]

Just edited the main post while you posted;)

[mrmeaner]

Damn mind readers.

[krumel]

Little addition:

Most places in Germany can be reached by so called "Rettungshubschrauber"/RTH (comparable to Trauma Helicopters) with 15 Minutes.

In opposition to the system of the trauma helicopters in the USA those Helicopters are mainly used to bring the emergency physican to the (not only trauma) scene.

It's often the case that the emergency physican boards the ALS Ambulance, performs the advanced care and accompanies the ambulance to the next hospital (where the doc will be fetched by the heli again).

But of course they can perform normal "air rescue" as well and are also used for middle range patient transport.

The station nearly the sea and the mountains are normally equipped with an winch, most other helis are able to operate with an "long line".

Due to the high risk of night "outside" landings the normal air rescue helicopters do only operate during daylight.

For interfacitily transport there is a second class of helicopters not so focussed on emergencies, the so called "Intensivtransporthubschrauber"/ITH (critical care transport helicopter). They are able to fly during the night and often stuffed with special EMT-P which are also registred ICU Nurses and and doctor who is an ICU doc.

But of course both types of helicopters can jump in when the opposite type isn't available...

(Christoph 1 - the first rescue helicopter in Germany and my hometown helicopter- performing water rescue together with the emergency divers of the Munich FD.)

(Card of the air-Rescue stations in Germany. Most air-rescue helicopters are operated by the automobile club of germany because historically the helis were intended to mainly respond to MVA's. (The idea came up 1971 in Munich, one of the years with the record of "MVA-deads" took place.

when the MVA's got reduced they started to do normal rescue.)

(Thanks here to the marvellous guys from Munichs Helicopter Nr.1 - Christoph 1- and their page: Their Website

BTW: Nearly all german helicopters are named after the patron of the travellers, the holy St. Christoph. Only some special stations runned by privatet companies and the miliatry rescue helicopters (SAR) are named after another scheme.

Something to the med. equiptment:

The ALS ambulances mostly are equipped with an eletrical suction unit(Weinmann

, an Draege Oxylog 1000 or an comparable respirator of an german brand (Weinmann again ,

an LP12 (AED, Pacer, 3 channel ECG), an hand-held pulse oximeter (mostly Nellcor) and an syringe pump by B.Braun.

(There are rumors that we got the brand new corpuls 3 next year...Would be cool. The most advanced ECG/Defib thing I'v ever seen...Kicks Physio-Controls as a hundret miles wide...)

The emergency physican vehicle normally brings an LP12 with 12 channel ECG, Capno, SpO2 and sometimes NIBP with it... Sometimes also and more advanced respirator (Oxylog 2000).

The helicopters often use Oxylog 3000 and propaq encores for their critical care transport tasks.

And, to improve my mind reader capabilities some information about the "stretcher System"

In the german-speaking countries normally the stretcher isn't lifted in the car by the medics, it will be moved on that "ramp" you could see in the first picture.

This ramp is designed that the stretcher can be driven in it with its own wheels. When the stretcher is looked in, the ramp will be moved to the ambulances normal height.

The stretcher now rests on the so called "Tragentisch" (stretcher table), which can also be position like an OR Table etc. whith trendlenburg, etc.

(see a video here: http://www.youtube.com/watch?v=U0sKCedo7dU )

In addition, some stretcher table can be even cushioned so the patient won't feel the "road" so hard.

[mrmeaner]

LOL! I was going to ask about that! Was the video in the back of the ambo? Is dude that short or do you have a lot of head room.

[krumel]

The back of the new ambo's are normally 2m (6.56 feet) high as required by EU-rules.

(Thanks god...I'm nearly 2m high...Bad for the hair, but it still fits:D )

The shown ambulance is even a kind of "small"...as you can see in the first pictures, there is approm. 120cm (4 feet or so) between the head of the stretcher and the cabinets in the newer one...

And here the last thing I could figure out someone wants to knew:

The shift times;).

In rural settings most stations work with an 12h shift system (change a 7 am and 7 pm normally), some still work with an 24h system which has to be abolished within the next years due to EU law.

In urban setting the stations with "not sooo much" work normally use an 12h shift system, the stations with more calls (downtown, zones with social problems, etc.) use an 8h shift system (normally from 7.am to 3pm to 23 pm or so... Round about...The times differe slightly so not all station's change at the same times.

An normal EMT-P works between 40 and 48 hours a week and earns between 1500-2000 EUR (1900 to 2500 USD) pre tax (which makes normally after Taxes, health insurance -obligatory here-, etc. are paid makes about 1000-1200 € -1200 to 1500 USD post tax) per month.

You normally have between 15 to 30 payed holiday days per year (changes from company to company). Day were you are ill are not counted, in this case you get paid 6 weeks, afterwards the health insurance pays 80% of your income.

If you work overtime normally you add the time to your "overtime depot". When you collected enough time you normally get a day of, sometimes you can also get extra money for it.

The problem here is unemployment...Due to the fact that the paramedic Schools get paid by their students they produce a lot of "paramedic trainees" which do not have any chance to get a job in the ambulance and even if they get their training somehow done there is a very little chance for them to get an job on the rig...Most of them is driving an Patient transport Ambulance, etc...

[itku2er]

Some really good information there thanks for sharing this. Now I have a question, how are the educational requirements for each level of care?

[krumel]

Can't answer, too ashamed....

For the EMT-I (Rettungssanitäter): None

For the EMT-P (Rettungassistent): When you get your EMT-I before: None... If you do it directly from zero: Basic high-school degree (below that there's only "no education/no degree")...

It's a real shame.... But, as written above unemployment is a problem so most EMT's have their A-Level's cause the chiefs aren't even looking at the ones without it....

In Germany the people who want to study medicine often have to wait up to 5 years for it in case their A-Level marks aren't relly god (you need an A+ in all your A-Level topics to do it directly!)..

So many of them start working as an EMT or R.N. before they study, work for a few years full time, than during their med school part time.

(Remember: there's no college in Germany... You go to school from the elementary school to A-Level high school (13 or 12th grade) and then you go directly to the med. school)

[itku2er]

That is interesting so I have learned something and they say you cant teach an OLD dog new tricks. Why are there no colleges over there no funding or just no requirements for advanced education?