Sunday, May 9, 2010

EMS in Germany, Part II

I wrote an article about EMS in Germany the other day and ran out of time to give you a little more in-dept look into our system. I've been pretty swamped lately, but I've found some time to write up part two.

The who is who of German EMS:

Unlike in the United States where EMS is provided by a multitude of agencies, many of which private, we can narrow it down to six agencies in Germany. The main four are non-profit NGOs, which provide a multitude of services above and beyond EMS. These services include blood donation services (and blood banks), public first aid education, disaster relief and emergency management, humanitarian aid overseas, outpatient nursing/care services, nursing facilities, meals on wheels, hospitals and even kindergartens. In essence they are huge networks that cater to public health, public education... well the public in general. Most of which is financed by donations or at cost-covering fees.
While many of the services are rendered by volunteers, EMS has in recent years moved away from employing volunteers. Nowadays it's safe to say that, apart from a handful exceptions, EMS in general is staffed by professional personnel.

These organizations are:

  • The German Red Cross: Undoubtedly the biggest aid network worldwide and also the biggest EMS provider in Germany (with an estimated market share of 50-60%).
  • The Order of Malta (Malteser): A branch of the catholic church in Germany.
  • St. John's Ambulance (Johanniter): A brach of the German protestant church.
  • Samaritan Union (literally "Worker-Samaritan-Union"): A union that historically formed in the time of the industrial revolution, to aid workers and craftsmen. Which, by the way, is how the St. John's Ambulance Association came to be in the UK. Part of SAINT (Samaritans International).
The other two are:
  • Fire Departments: Mostly in the northern German states, aswell as in major cities.
  • Private EMS agecies: Privates are few and far between. Although present, they play a rather small role in German EMS.
The Role of Fire in EMS:

I'm often asked "Is there Fire based EMS in Germany?" Well, yes and no. Yes, there is, but not how you would imagine it to be (coming from the US).

While in many US systems Fire - and by Fire I mean actual Fire engines - play a huge role in EMS, you will generally not see engines responding to medicals in Germany. The concept of an ALS staffed engine providing first response until an ambulance takes over the patient for transport is a very strange idea to us, and not practised over here.

German fire departments differ to much from American FDs in order for this to work. One of the main differences here is what I call centralization. We tend to centralize our fire resources in a small amount of stations, whereas in American cities you can find a (single engine) fire station every couple of blocks.

Take my hometown Wiesbaden, for example. With a population of around 300,000 we are considered a major city by our standards - tiny by US standards, but thats not the point.
While we have 9 MICUs (at night; 15 during the day), we only have 4 fire engines stationed at three fire stations. And, while a typical Amercian station usually houses less than a handfull of apparatus (engine, ladder, sometimes a batt. chief, and maybe one other vehicle) our stations 1 and 2 house up to two dozen fire apparatus. And they don't even provide EMS.
If you were, for sake of argument, to transplant my city to America, I'm sure it would have at least 8, maybe 10, fire stations and just as much engines, but only maybe 4 or 5 ambulances.

So if fire provides EMS over here, and many departments do, they will not employ fire apparatus to medical call. They will staff EMS vehicles shown in part I of my blogpost and respond to calls.


What to do with a patient?

As an American you might think this is a stupid question. Begin treatment and haul him to a hospital or get him to sign a refusal and be done with it.

It's not that simple over here. Fortunately so, because first of all we get to say No. Yep, you heard me. You want to go to the ER for a stubbed toe or a toothache at zero-dark-thirty at night? Not happening! A freedom that many American EMS providers envy us for.

But we don't just say No, because we are mean and don't care for our patients. We can say No, because we have system in place for sub-acute or non-emergent patient care.
Unlike the UK our health care system is not what you would consider "socialized medicine" or goverment operated, but everyone is health insured and health care is basically free. Or should I say almost free, as this is not entirely true, but it would take books to explain it otherwise, so let's just roll with it for now.

As a result of this, public health as I perceive it is better. People see their GPs more frequently and prevention is better. But people get sick, like anywhere else in the world. It's what happens then, that makes the difference.

Assume you call 112 (the German counterpart to 911) for a runny nose, run-of-the-mill cold, or strained ankle from a soccer match past sunday. While in the US and ambulance would be dispatched to you right away (if you insist long enough), a German dispatcher will advise you to call your GP or give you the location of the location of an urgent care clinic and have them treat you for your non-emergent medical condition. During non-office hours we have a service especially for this kind of clientel, basically an on-call doctor service. They make housecalls and see patients for non-emergent conditions at night and on week-ends and treat a multitude of patients that don't necessarily have to be seen at an ER. So why go to the ER, when you can have your inner ear infection examined and treated in the comfort of your own house? Thus keeping our ER clear for "real emergencies".

Apart from that we have another major advantage. We have emergency physicians on scene. That gives us many treatment options that American paramedics don't have. Many emergent medical conditions, acute asthma attacks for instance, can be treated at home and in many cases can be left at home without the need to be taken to a hospital.

Another thing I've noticed, and that only became apparent to me after watching Justin Schorr of Chronicles of EMS talk about the expiriences he has made in the UK, is that the public trusts our clinical judgement. People don't tend to demand to be taken to a hospital over here. They listen to us when we tell them it's not necessary to go to the ER. They take our advice and go see their GP in the morning for minor things. I'm not talking about neglecting your patient, what I'm talking about is sound clinical judgement and involving the patient in an informed decision. Very rarely have I had a patient ask me to take him to a hospital after explaining his medical condition and talk his treatment options through with him.

To me that's an invaluable freedom and part of my personal EMS 2.0. Our system is far from perfect and many things are in dire need of improvement, but it's a start.

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