User:Winnie-MD/sandbox/RettAss

The German Paramedic is a profession in the Emergency medical services in Germany. Here, the profession is called Rettungsassistent. It is a rather new job description, being introduced by law in 1989 by the German Bundestag. The Rettungsassistent is the primary profession in emergency-type prehospital care. [TOC]

History[edit]

After World War II, prehospital care in Germany was in its infancy. It was rather usual that patients were being brought to a medical practice or hospital than medical professionals coming to a patient. In some cases, the German Red Cross used to provide an ambulance service, which was more comparable to a medical taxi. With the increase in individual motorized traffic at the beginning of the 1950s, road accidents increased too, leading to a great number of casualties and fatalities. This encouraged the formation of several emergency services, one of the first being the Johanniter-Unfall-Hilfe e.V., a subsidiary of the German Order of St.John. These services not only transported patients, but had limited means of treating them on-scene, as well as being faster on the secene of accidents. In then 1950 and 1960s, EMS was primarily done on a voluntary basis by volunteers with only minimal training in emergency medicine. In the 1970s however, the profession of Rettungssanitäter was introduced, with a training curriculum being the same in all states of Germany. This lead to a more professionalized approach. In 1989 it was deemed neccessary to find a new profession with even more knowledge and skills. This was when the Rettungsassistent was created. In contrast to the Rettungssanitäter, the Rettungsassistent is a board-certified profession, whereas the former is merely a description of an occupation.

Training[edit]

Individuals who want to become a paramedic have to undergo 2 years of training at a college, which are mostly private-owned but controlled by the state. With the exception of Thüringen and Sachsen,wich cover the tuition fees partially or even completely students will have to pay for their training by themselves. Tuition fees have a range of 2.500 through 4.500 Euros, depending on college, state and organisation. Typically, firefighters, policemen and members of the armed forces who undergo training do not pay tuition fees, here the employer will cover the fees.

Curriculum[edit]

The paramedic training consist of two major parts: schooling and internship, almost evenly divided into two one-year terms. In his first year, the student will learn the theoretical basics of his profesion, including invasive procedures.Incorporated are several weeks of in-hospital internships, typically in casualty wards, operating rooms and trauma units. The theoretical training is divided into several major parts:

basic anatomy
body functions
internal medicine
neurology
gynaecology
urology
paediatry
disease patterns of the above
traumatological injuries
pharmacology
law, rights and duties

Furthermore, the student will be taught skills in treating patients. This includes:

basic diagnostic skills (blood pressure, heartrate, glucose level, saturation)
advanced diagnostic skills (using and interpreting ECG, auscultation, neurological examination)
intravenous, subcutaneous and intramuscular application of medication
treatment of internal diseases like myocardial infarction, pulmonary edema, hypertension
treatment of traumatological injuries like fractures, amputations, cuts and bruises
endotracheal intubation and ventilation

The first year ends with a board examination wich covers all the knowledge a paramedic must have. In the second year, students have to do an 1600 hour internship in the EMS to further their skills. Usually, they start as 3rd man on a transport ambulance to observe and learn and are gradually brought into the game by riding 3rd seat on an emergency ambulance. Sometimes, paramedic-students who also have the qualification of Rettungssanitäter are used as second on a two-man team. However, all the time the student will be under supervision by a Lehrrettungsassistent. After completing their year of internship, there will be a closing meeting after wich, should the student be deemed fit, he will be awarded the title of Rettungsassistent.

The training can be shortened under specific circumstances. Students who hold the title of Rettungssanitäter are allowed in most states to shorten their theoretical training^[1] and, if they already worked in EMS for some time, only need to do a shortened internship, depending on the state they do the training. In Sachsen-Anhalt, the internship usually consists of only 480 hours.

Paramedic Profession[edit]

After completing his training, the Rettungsassistent, should he find an employer, will work as teamleader on emergency- and patient-transport-ambulances. Also, he can act as driver of an NEF, a special sedan-sized vehicle used for transporting an Emergeny Physician (Notarzt) on scene. Here, he will assist the Notarzt during treatment. His job includes all tasks he has learned. Basically, in absence of a physician, he is responsible for a complete diagnostic on a patient as well as giving him the best treatment he is able to provide. Unfortunately, the Rettungsassistent does not have a de facto permission to perform treatment of his own, i.e. application of medication or invasive techniques. This is reserved for physicians.^[2] Under supervision of a qualified physician, he is allowed to perform every technique he learned and is proficient in. Should the need arise to perform such treatment without supervision, exist a rule called Notkompetenz (Emergency powers), which theoretically allows him to do so. This includes, but is not limited to:

Application of specific medication
- Adrenalin during CPR
- 8 Gramms of Glucose when treating hypoglycaemia
- β₂-Sympathomimetic drugs as aerosol against obstructive pulmonary disorders
- Benzodiazepines for epileptic seizures
- Nitroglycerin for an AMI
- certain Analgesics agains pain
- IV-Electrolytes against hypovolaemic shock
IV-cannulation
Defibrillation
endotracheal intubation without relaxation ^{[disambiguation needed]}

However, this rule does not qualify as a law, but merely a guideline by the Ärztekammer (Federal Board of Physicians)^[3]^[4] and is always subject to local procedures and guidelines. In theory, a Rettungsassistent will violate several federal laws when performing treatment of his own. However, when treatment is necessary to avert death or severe debilitation of a patient, he may revert to State of Emergency laws^[5] and will probably go free.

Other emergency medicine professions in Germany[edit]

Besides the Rettungsassistent', there are three other professions in German EMS. The lowest would be the Rettungshelfer with only basic skills, followed by the Rettungssanitäter, wich used to be the most advanced paramedical profession. Ranking above the Rettungsassistent is the Notarzt, a Physician with extra training in Emergency medicine. All professions are deployed according to their skills, not meaning that a Rettungsassistent' would not occasionally take his seat behind the wheel of a patient transport ambulance. There are ambitions in Germany to get rid of the people only posessing the qualification Rettungshelfer or Rettungssanitäter in the non-voluntary areas of the German EMS. This is founded in the assumption that even today these two do not posess the skills for todays modern and complex Emergency medicine.

Qualifications in German Emergency medicine
Profession	English counterpart	Training			Jobs
Profession	English counterpart	School	Hospital internship	Ambulance Internship	Patient transport Ambulance (KTW)	Emergency Ambulance (RTW)	Notarzt- einsatzfahrzeug (NEF)
paramedical
Rettungshelfer	EMT-B	4 weeks	none	none	driver	driver (occasionally)	-
Rettungssanitäter	EMT-I	4 weeks	4 weeks	4 weeks	crew chief	driver	driver
Rettungsassistent	EMT-P	6 months	6 weeks	1 year	crew chief	crew chief	driver
medical
Notarzt	Emergency physician	6 years	2 years	60 runs	-	-	crew chief

Further education and qualification[edit]

Recertification[edit]

After completing training, paramedics do not need to be recertified after a specific time liek in other countries. This means theoretically, someone having earned the title of Rettungsassistent in 1991 might very well be on the educationary level of that time. However, most municipalities order their EMS personnell to do a certain amount of further training within each year, typically 30-40 hours.

further qualification[edit]

Paramedics can acquire further qualifications, enabling them for different or higher paid jobs within the EMS. One of them is the HEMS crew member training, after wich the Rettungsassistent posesses the necessary qualification to work on a rescue helicopter. This includes assisting both the pilot and the emergency physician, the former during flight phases (i.e. navigating, spotting landing sites), the latter in treating the patient.

Another qualification is the one of Lehrrettungsassistent, a Rettungsassistent qualified to teach and supervise paramedic students during their training. Paramedics have to undergo a special training where they will be taught the use of teaching strategies.

For senior paramedics with a lot of expertise there is the qualification of Organisatorischer Leiter Rettungsdienst (OrgL). This qualification is closely related to mass casualties. A Rettungsassistent assuming this position will be responsible for organizing patient flow and transport during such a desaster, as well as coordinating forces during those events. Although it is just a 2-week course, most municipalities demand additional leadership training in desaster units (i.e. eader of a medical platoon) before the qualification is granted.