Personal Protection and you!

Today I was working with a Paramedic student, who has just started his field rotation last month. He had been an EMT before he went to P-school and gained a good years experience during that time. We took over the ambulance from the early shift and as per usual I would step outside with them and have a cup of coffee and a cigarette and we would chat a little. My student went straight to the ambulance and started inspecting and checking the gear and medical supplies.

A few minutes later, after having finished my coffee, I joined him at the ambulance. And, like I do every day, I hung my jacket on the little hook next to my seat and started my daily paperwork. I looked over to his seat and didn't see his was nowhere to be seen. He had just finished checking the back of the rig and came to me, so I asked him where his jacket was. He told me it was upstairs in his locker, "why do you ask, it's summer and I won't be needing it" he continued. I was a little taken aback by that and told him that if I were to catch him at an MVA without his jacket, we would need to have a serious talk.

A few days back I was chatting with a paramedic from Texas and she asked my why we were all wearing our jackets at an MCI call in 100° F (39°C) weather. My immediate response was to ask her why I wouldn't be wearing one and if they don't wear jackets during MCI or MVA situations, to which she replied no. I was shocked and here is why.

Our jackets are a vital part of our Personal Protective Equipment for a number of reasons, all of which are standardized by the European Commitee for Standardization (CEN) in so called Euro Norms (EN). Firstly and most obviously it has to protect us from weather influences, mainly the rain and the cold (EN 343). Then they need to fulfill certain high visibility requirements (EN 471) in regards to background color (usuallay a bright red, yellow or green) and reflective striping, giving us the necessary proctection to work in flowing traffic without the need to wear additional (traffic) vests. Something I have yet to see in the US, where EMS uniforms are typically composed of dark colored materials - usually navy. Uniforms that I would not feel comfortable working with on any street, road, or highway.

Sample image of a typical German EMS jacket, like the one my service uses.

Another, to me, important fact is that it protects me from mechanical influences to a certain degree. Especially on an MVA scene there will be glass and metal parts scattered around and all sorts of sharp edges that I don't want to cut myself on. Our jackets are made from sturdy materials in order to prevent that from happening. I remember all to well an incident in my first days on the job. It was summer and we were called to an MVA with a person pinned in their car. I don't remember the exact particular, but what I do remember is that Fire had to take down the roof of the car in order for us to extricate the patient. After they had done so the b-pillars, half cut off, stuck up in the air and while I was leaning into the passanger cabin I cut my forearm pretty badly on the sharp edges of said pillar, leaving me bleeding like a stuck pig. That thought me to always wear my jacket on sites like that.

The same is true for helmets. Rarely do I ever see my colleagues wear helmets. Granted the situations were the use of helmets is actually waranted are few and far between, but even then the changes of seeing EMS personnel wear helmets are next to none, in my experience.

An MCI drill. One of the rare occasions, where everyone turns up in full PPE.

I have always been wondering why things are how they are, in that respect. Maybe it's lazyness. Maybe it's because it doesn't look cool - yes our helmets do look ridiculous. Maybe it's something a lot of people don't give it a lot of thought, because in the vast majority of medical calls, those kinds of precautions don't have to be taken. Maybe, sadly, something has to happen first, in order for them to rethink.

Maybe we should take a look at the Fire services. Whenever they turn up on a scene they will generally wear they full bunker gear and helmets. Be it waranted or not, no questions asked. Even in 100 degree weather. And they will keep in on until their commanding officer allows them to take it off. I realize, that this is not the case everywhere on the globe and yet I have the feeling that firemen, in general, show up dressed for the worst.

Firemen - full PPE even while just standing around.

In fact, many times, when not working a fire I would say that they tend to go overboard. Leaving us with another problem alltogether: heat exhaustion. Naturally their bunker gear is not only a whole lot heavier than our clothing, but keeps a whole lot warmer. Yet, they somehow make it work by taking turns, taking rest breaks to hydrate whenever necessary.

I would very much like to hear about your views, protocolls, guideslines, recommendations.

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.

EMS in Germany

Here's are Post I just wrote at Chronicles of EMS. Enjoy.

I just recently joined this site and I instantly fell in love with the project. I think this is great way to facilitate social media to broaden our horizons by looking across borders, exchange valuable information and education, and to see how the same thing, namely EMS, is done in a completely different fashion elsewhere.

So I would like to take up some of your time and explain our EMS system here in Germany.
While EMS in the USA is very heterogen and varies from state to state, sometimes even from county to county, the German EMS system is very homogen throughout the whole country. From the North Sea to the Alps, it's pretty much done the same way.

To understand where we are coming from, we must first look at the roots of our system. Basically EMS over here developed from the notion of doctors doing house calls, back in the days when there were no ambulances. When someone was sick a doctor (GP) was summoned and he would then treat a patient at his house and only in severe cases would he be taken to a hospital.
Whereas in the US, from my understanding, EMS has it's roots in the military. During the many wars, the US military sought for systems to rapidly expedite wounded soldiers from the battle field and bring them to some kind of definitive care system. EMS evolved from that and took a lot of notions from the military.

In general it's safe to say that while Americans are more likely to "scoop and run" or "load and go", we are more prone to "stay and play". Meaning, and this is a major difference right there, we bring a physician on scene to treat patients and to evaluate the necessity of hospital treatment. As far as I know the only EMS systems to bring doctors on scene are found in a handful of countries in central Europe. Germany, Switzerland (some parts), and Austria are such examples.

Having physician on scene has many advantages. Not only does that give us the full ALS scope, but beyond that also gives us treatment options unavailable elsewhere in the world outside of a hospital setting. On the other hand it leaves us Paramedics, although extensively trained, a very confined skillset. While we are trained and educated in ALS, our scope of practise is merely comparable to an Intermediate level in the US.

Educational Levels of care providers:

Rettungssanitäter (literally "Rescue Medic"; equivalent to EMT-Basic):
A Rettungssanitäter (RS) education is a 520-hour-programm consisting of 160 hours in-class education, 160 hours of hospital internship (preferably ED, intensive care and anesthesiology), 160 hours of field intership (3rd rider) and 40 hours of exams (exam week). The scope of practise includes what you would consider BLS skills, defibrillation with an AED, and O2 administration. LT-D insertion is beeing discussed at the moment and likely to be implemented into their scope of practise.

Rettungsassistent (literally "Rescue Assistant"; equivalent to EMT-Paramedic):
A Rettungsassistent (RettAss.) education is a two year programm (with bridge programm from RN) consisting of one year in-class education, including 11 weeks of hospital internship within that first year. Subsequently followed by a one year 1600 hour field internship as 2nd rider (driver) under supervision of a field instructor.
Scope of practise includes: IV cannulation, Intubation (no RSI), epinephrin for cardiac arrest and anaphylactic shock, glucose for hypoglycemia, betamimetics for acute asthma, benzodiazepines for seizures (mostly Lorazepam these days) and isotonic or full-electrolyte infusions.

Notarzt ("emergency physician"):
A medical doctor with a supplemental education in emergency medicine. Emergency Medicine however is not a stand-alone medical dicipline in Germany. So an emergency physician will likely be an anesthesiologist, internal medicine physician or surgeon, with an extra education in emergency medicine.

EMS Vehicles and staffing:

In general there are only four types of vehicles in our EMS system.

BLS Ambulance:
staffed with EMTs, for non-emergent transports and transfers. Such as transports to for from doctor's offices, non-emergent hopital transfers, nursing home transfers, etc. Sample Image below.

Medical Intensiv Care Unit (MICU):
staffed by at least one Paramedic, some states require dual-medic. All emergency transports and transfers. In life-threatning scenarios an emergency physician will be brought on scene by a seperate chase car (see below) and accompany the transport. Sample image:

Physician Response Vehicle:
staffed by an emergency physician, and an EMT or Paramedic as driver. Usually a station wagon type car or small minivan capable of transporting the staff and medical equipment. Dispatched by default to all life threatning calls, i.e. cardiac arrest, severe shortness of breath, chest pain, MVA with entrapment, etc. Sample image:

HEMS (Helicopter EMS):

Medevac helicopter staffed with a pilot, a paramedic and an emergency physician. Their main purpose are time critical primary (meaning from scene to hospital) and secondary (interhospital) transports. There are approx. 93 HEMS stations nationwide ensuring a coverage grid, that every station has a maximal primary radius of 100 KM. HEMS helicopter are usually in service from sunrise to sunset, with a few HEMS stations keeping up a 24 hour service. Sample image:

(all pictures courtesy of wikipedia)

That should be all for now. Feel free to ask questions. I will answer them as best I can.

Be safe.