Provider level comparision between countries, especially U.S.A. and Germany?

[Bernhard]

Hi,

in Germany we experience a new step in medic qualification. There is a law pending, that will really boost the education and professionalism. The name of the new profession "Notfall-Sanitäter" is kind of weird, but we will get used to this in say 20 years, I'm sure.

Background: in Germany, at the moment there are about two non-professional levels ("Sanitäter", "Rettungs-Helfer") and two professional levels ("Rettungs-Sanitäter", "Rettungs-Assistent") where the latter is a real protected profession with a state certified (nationwide) one year education followed by a one year internship.

Now they want to introduce a new level, the "Notfall-Sanitäter" as protected profession, nationwide state certified, full three years education (including internships) and most notable: you need a paid job contract to be allowed to get into EMS school. At the moment anyone can (and usually is forced to) pay the school at own expense - in future an organization has to pay for it and will select the staff far more closely. Hopefully this will raise not only the overall quality in prehospital care but profession awareness and - most important - pay.

For international discussion (and update of the Wikipedia page about german EMS) it would be helpful to have an understanding, to what U.S. level the education is comparable. Any other nation is appreciated, too.

At the moment, it's about the following - as I see it:

1. "Sanitäter" (50-70 hrs course) = "Advanced First Responder"
   
2. "Rettungs-Helfer" (160hrs course, some internship in hospital and EMS) = "EMT Basic"
   
3. "Rettungs-Sanitäter" (520hrs including 160hr "Rettungs-Helfer" theory, 160hr internship in hospital, 160hr EMS internship and 40hr additional theory training just before exam) = "EMT Intermediate/Advanced"
   
4. "Rettungs-Assistent" (1 year theory and clinical internship, 1 year EMS internship) = "Paramedic".
   

How would this shift, when the new "Notfall-Sanitäter" (3 year education needing a paid contract with a EMS organization) is in effect? Since "Paramedic" is considered the highest level (?), this then would be the "counterpart" in my view.

What would you think?

Thank you very much!

Bernhard

P.S.: upgrade to the new level will be possible only with taking a test - I sure have to spend more time on EMTcity to stay on top of things!

[chbare]

I'm not sure mate. This is something that your country should define. There may be a grandfathering or transition process. With a one year to three year jump in educational requirements I would bet all the older paramedics will need additional education to make the transition.

[Bernhard]

I'm not sure mate. This is something that your country should define. There may be a grandfathering or transition process. With a one year to three year jump in educational requirements I would bet all the older paramedics will need additional education to make the transition.

Oh, no need to discuss the level itself. Upgrade requirements are already defined - I'm lucky to have enough EMS years under the belt to not beeing required to attend the mandatory 3-6 months upgrade course for younger colleagues (I have to learn all for myself instead to prepare for the upgrade test). And I'm aware that there is no real comparision, since there is no direct official acceptance of levels, speaking of work-permit or such. It's just a try to get an idea how to discuss with fellow EMS providers from all around the world without constantly having to explain the complicated german names.

At the moment I'm fine to say, I'm "like a paramedic" (since Rettungs-Assistent is the highest level of prehospital care beside emergency physicians - BTW it's not only one year but a second one having to serve on the street as trainee). But is this really near the truth? What are the nowadays levels of paramedicine in U.S.? Thinking about it, this could get far more complicate than intended...

[Bieber]

In Kansas we have...

First Responder - Don't know much about it, to be honest.

EMT - One semester.

Advanced-EMT - An additional semester and a replacement for the previous EMT-Intermediate. The new AEMT will have more drug options, including some cardiac drugs if I'm not mistaken...

Paramedic - Formerly Mobile Intensive Care Technician (MICT). It's a mandatory two year degree (Associate's) program in this state.

I think the rest of the country is moving to this scheme as well, except that paramedic remains non-degree in most other states (but most states have an Associate's option). I think the NREMT (National Registry of Emergency Medical Technicians) is calling them NREMT, NRAEMT, and NRP now too. Every state is kind of different in what their individually require (to meet or exceed) the National Registry's standards, and many of them have different titles for their state-specific certifications as well. I also think that for most paramedics in order to recertify to meet the NREMT's new educational standards they have to take a transition course. Not something we have to do here so I honestly don't know much about it...

Unfortunately, man, you'll get about fifty different answers anytime you ask about EMS certification levels and requirements in the U.S. The national stuff is, obviously, national, but the state-specific levels seem to get pretty complex. There's a (very) brief overview, though, I'm sure someone else can give you the nationally required hours--'cause I sure don't recall them!

[Vorenus]

I`d say it`ll still be comparable to the US Paramedic - but the Rettungsassistent is already comparable to the Para, hence, with, in some aspects, even more education in certain topics (e.g. A&P) as far as I understand.

Not want to sound to downbeat, but I`m not as cheerful about the new law as Bernhard is. There are some pretty sweet facts about it, like finally getting pay during training, etc.

The most important thing - the work of a Rettungsassistent/Notfallsanitäter (whatever they`re gonna call it) - won`t experience a heavy change, though.

As most of you know, the highest ranking bloke on the streets in Germany is an emergency-physician, therefore our scope of practice is pretty restricted (although we`ve gone through a lot of the procedures and meds in school in detail anyway).

Now, the major point of a new law would be, to expand that scope and making it more secure for a provider to use it, legally. That won`t happen though. Important institutions already implied that there won`t be a change in the scope of practice.

So, in conclusion - more education is always important and should be greeted warmly. Since grandfathering rights seem to be complicated in this case though (I wonder why), it`ll be another few months of school and an exam for already qualified providers.

Naturally - no one can tell, when you should do these months, who`s gonna pay for it (my boss? yeah, that sounds likely...), how you`re gonna live through the months you`re in school without an income, etc.

That`s what`s freaking me out with the new law, and all that circus for more education you`d need for more skills, which you won`t use anyways (as we already had in the old system).

Edited July 31, 2012 by Vorenus

[Bieber]

Do you guys have standing orders or what? I know that out of hospital emergency physicians are much more common there than here, but to what extent? What I've heard is that you guys need an order for everything unless it's a life or death emergency--is this true? Do you guys have protocols or are you able to act independently?

[Vorenus]

Do you guys have standing orders or what? I know that out of hospital emergency physicians are much more common there than here, but to what extent? What I've heard is that you guys need an order for everything unless it's a life or death emergency--is this true? Do you guys have protocols or are you able to act independently?

Well, there is a recommendation from the central insitution of physicians in germany, stating that a Rettungsassistent could use a certain procedure (some meds, IV, intubation, etc.) under certain circumstances (no physician available but called, procedures is needed, etc.). Some say, that`s it.

Still, it`s only a recommendation and not a law (things are really fucked up legal-wise for us around here - which the new law won`t change either...) and the tendency shows, when these kind of things go in front of a judge, that the Rettungsassistent has a good chance of winning-

In practice, it`s always different out there, regarding the use of procedures.

We aren`t bound to protocols, so we are free to make our own decisions.

[Bernhard]

I tend to disagree with Vorenus here a bit, he knows what I mean and we already discussed it. I hope to describe it here in such a way, that Vorenus accepts it, stressing some local factors.

The "scope of practice" of german medics is rather wide. However, it depends a bit what is "tradition" in the area you're working, how the local emergency physicians minds are set and how your employer is backing you. Legally you are able to do more or less anything a doctor may under the same restrictions (except signing for insurance coverage, for final treatment release or in the other case for the death certificate) but most non-doctor colleagues won't stress this since they may get pressure from their doctors or employers. Which is no fun considering the lousy pay, so they may let it go and get a bit cynical (Hello, Vorenus!).

Some central things U.S.- or paramedic-only based EMS folks need to know to understand our system:

• In more than 80% of all cases, we german medics are first on scene without an emergency physician, having to take over full care. Often there is only one emergency physician on the street compared to 5-10 ALS ambulances in a district. This may give an impression about the percentage where the ambulance has to cover a case alone (until the emergency physician is free or a neighbouring or HEMS based physician hops in).
  
• We may call an emergency physician on scene if needed and are obliged to do so in certain cases (indication catalogue including life threatening emergencies). Which is an advantage in my view since we have a lot of flexibility and a lot of treatment possibilities for critical conditions under full legal protection. After all, a doctor IS a lot more educated even in stranger cases. A good emergency physician will accept the paramedics emergency experience and work in a team, but beeing there for mastering the out-of-routine cases. If the emergency physician is a bad team player, things may be frustrating for the others involved in the team. Shit happens and there may be areas where this is more often the case...
  
• We're usually trained in invasive procedures and drugs, and carry the equipment on the ambulance. The term "usually" states that despite there is a standard nationwide curriculum the real education depends heavily on the school. But the "basic" invasive techniques as i.v. access, e.t. intubation etc. and drugs are always included. Doing thoracal punctions and alternative airways marks the border between pure medic-mills and more sophisticated schools.
  
• We are legally required to do all what is needed and what we're able to do, including the invasive procedures we're trained in. This is especially true in cases where an emergency physician is not on scene in time or at all. We may not delay care or transport then. Happens again and again in a busy area or with multiple victims.
  
• We don't have a duty to transport and are able to deny patients. We can point them to existing emergency general practioners (physicians on call, nationwide service numer 116117) or - given the possibility to have an emergency doctor on scene - may really treat even more acute situations at home. This is rather flexible, reduces costs and needed EMS & hospital resources. But it requires a good decision ability and awareness of legal reliabilities (there are cases where this went wrong, but that's either no fault of the medics or was rather stupid by them).
  
• We don't have standing orders, just guidelines, which are the same for all medical professions, if doctor or medic.
  
• We don't have a real reeducation or recertifiying requirement, it's a lifetime licence - once you're a medic you stay a medic. There are employers with continous education requirements and some local EMS laws needing it, but they can't take your licence away. Usually we talk about 30hrs training per year without test. A good provider and a good employer will do more than that, sure. But it's a fully accepted (and protected) profession, they can't take it away from you.
  
• The licence ("Rettungsassistent") is valid nationwide. No local twists or non-acceptance.
  

So, for beeing a non-doctor it's what you do out of this (and where you work). Legally the same restrictions and responsibilities apply to a prehospital non-doctor provider as for an emergency physician. Only the latter is far better paid for it...

There are tries to define the scope of practice closer, but none of them are legally strict. Vorenus cited the "standard" of the german board of physicians, there are other local standards. All are more or less good hints, but at last there is the own knowlegde and the actual situation what counts. Which may include a lot of hassle. depending on local politics. I was "raised" in a relatively free EMS world here, Vorenus may see it otherwise from his experience in his area of work.

The designated new law ("Notfallsanitäter"), enhancing the education time for paramedic providers to 3 years (now: 2 years) and raising entry level and requirements additionally defines the curriculum a bit more in detail. It's NOT an enhancing in "scope of pracice" (since there is no such limitation here as stated above) but clearly enhances and regulates the "knowledge" standards. This is what some doctor lobbyist organziations are ranting against at the moment, fearing it may wash out their importance - no real thinking medic does want this but they have their politcal reasons (and some very strange arguments). We'll see, the responsible ministry doesn't seem to be impressed much either.

For me, one of the most interesting things in the new education law is the requirement to actually be employed before beeing sent to the medic school. This (and the 3 year duration) will totally rule out volunteerism and those others who just want to get a fast job in EMS between two other parts of their life (school and study or such). They can't pay medic school for themselves anymore! In the long run I expect the labour market and the wages getting more friendly for medics, since employers loose the argument of thousands short-time medics applying for the same job.

[Vorenus]

Pretty good sum up on Bernhard`s accounts - I can`t say that I wasn`t under the influence of personal animosities towards the propable new law while drafting my prior post (still standing behind my arguments, while acknowledging the few good parts about it).

As Bernhard states, our "scope" is pretty much inofficially depending on the region you work in - not saying that care isn`t rendered appropriately in the more "conservative" regions or procedures aren`t done in the needed situations. Point is, in many parts, you could get rather fucked up for doing so by local represantatives as stated above, which is a big failure of our EMS system - that the new law ain`t gonna be resolving (as much as I´ve understood it, as well as the corresponding statements of the represantative societies/organisations).

Edited August 17, 2012 by Vorenus