Bernhard

Guess not. The bomb was carefully placed in August 1945, think the juristical responsibilities for such a gift are timed-out now. Financial part is interesting, though. Authorities already denied beeing responsible for the explosion damage, since this was the only reasonable way to get rid of the dangerous thing. The bomb experts are paid by the state anyway, there is a case-independent budget, actually 700'000 EUR per year alone in Bavaria. State of Bavaria and City of Munich may bear the own public safety costs by goodwill (police, fire, EMS, disaster relief organizations), I assume. There were no legal reasons to declare the "case of disaster", which would have opened a special state fund - but State of Bavaria and City of Munich can take this, they're healthy enough. They even announced a special fund for short term economical emergencies of the victims. Most probably the owner of the construction site is liable to compensate all other costs. If not: most people here are insured on their appartments and belongings, but usually not for war related damages. However, a very strange thing already happened: insurances have announced to make an exception and pay for the bomb damage...I think that's part of their advertising, since the risk is rather low for another such case. So this would be settled rather easy, except some detail problems and forever lost personal belongings (photographs, memorabilia, unique art and so on). At least, noone was hurt. Craftspeople (especially glaziers) and construction companies have a big time there now. In the aftermath there was an interesting information, I just read about: more than 70% of the bombs on german cities were dropped by British air forces and they did an aerial image before and after each bombing for damage assessment. Those pictures are very valuable information for the bomb sweepers today. However, recently the UK denied usage of their images for private companies due to "copyright issues"! Bavarian state already paid a lot of money to use those pictures, but apparently is not allowed any more to forward them to the private owned companies doing the actual work. There are negotiations now, but I think, that's really crazy. They still make money from the bombings and obviously want to raise the price! There is a reason we try to get the money back from all of you WW2 allieds on Oktoberfest!

Scenario, you run in (I just did last night...): 31 y/o male wanted to lift his 2 y/o son and hurt his own back. Half sitting/half lying on the couch. Apparently orientated, but speaks only a foreign language noone of the team is able to understand much, so verbal assessment is a bit tricky. We narrowed it down to: severe back pain, probable herniated vertebral disk, unable to move due to pain, dumb feeling in the legs. Problem: he's the only adult, father of a 5 month old son and his 2 y/o, caring for them when the mother works night shift in a factory. Mother was reached by phone and could quit work, but needs at least one hour to come home with public transport. The family recently arrived here, speaking only very broken german, knows noone in the neighbourhood, no relatives available. Noone to care for the kids until mummy is home! Treatment of the patient was straight forward: monitoring (SpO2, ECG), i.v., analgesic drugs (Ketamine/Midazolam), O2, transport on vacuum matress to hospital with neurological/chirurgical capabilities (20 minutes away). But what to do with the kids? How would you have handled this call? Do you have a plan for this? Just curious...

In one bomb raid over a city there were typically thousands (!) of such and bigger bombs used. Pattern changed, but usually there were "roof crashers" (big explosive bombs to blow the roof away) and then a lot of ignition bombs (phosphor) to cause heavy fires in the then unprotected houses. Bomb sizes usually ranged from 100kg to 500kg bombs. Lots of germans have relatives in the parent or grandparent generation who witnessed such bomb raids and survived (or not) in the bunkers. Almost all big german cities were target of allied bombings, mostly civil targets by the way - industry and infrastructure often wasn't there anyway. My mother was saved multiple times by my grandmother in such a bunker, where other babies died. Usual cause of death was not only the debris or heat but often the lack of oxygen, if the buildings around the bunker were burning and consuming all the oxygen. A special threat were bombs with chemical fuses: they had a time delay between several hours and up to several days until they exploded. A mechanism involving chemical acid slowly destroying the fuse holder was used. This was to hit responding firefighters and rescue squads, so to disturb help after a bombing. Such time bombs now cause a lot of trouble when still unexploded in the ground - as was the case here in Munich now. Normal contact/pressure fuses usually are rather easy to defuse (but don't try this at home!) and then transported to a deposit. In one of the pictures you can see the things they used to point the explosion upwards and to catch the shrapnels and blast wave. First an earth wall to protect near buildings and to direct the pressure upwards. Then a lot of sandsacks to support the directing and protecting. This was packed with special mats for catching shrapnels. Then a lot of dry and pressed hay was used to cover the whole thing, lightweigth but compressed hay seems to be perfect for catching shrapnels AND taking a lot of energy of the explosion. Even if it catches fire, but that was addressed by staging several firefighting capabilities. It's cheap and was easily available. Problem was the time factor and the sensitivity of the bomb. They simply didn't dare to make this all very exact. This would have been a danger to all workers involved. All in all, there were no injuries or death, so I consider it as a success. Some (few) owners of burned property may see this in another view, but what would have happened when that thing has exploded by random? Formerly, there was a famous restaurant located at this spot for the last 30-40 years until they recently demolished the house and now intend to raise a larger building. Every construction site in german cities is a probable finding spot for unexploded bombs. Experts try to detect them by old aerial views of the bomb raids, but that's no exact science. Metal detectors are easily disturbed by all the other things you usually find in city soil (cables, canal systems and so on). So, every construction worker and excavator operator in a german city is aware about the dangers and when hearing the "cling" should immedeate contact police who in turn activates the regional bomb squad (for war bombs usually a private owned company). Yeah, that was an impressive sight and I'm glad I live in a time and place where we're not in constant danger to get such a bomb on our house as my grandparents got: they were totally bombed out, loosing all their belongings - at least they survived.

Well, OK, it was almost 70 years ago and we all know why. A 250kg bomb of U.S. origin from World War II was found on a construction site right in the city of Munich (where the real Oktoberfest takes place in a few weeks). It had a chemical fuse, still active - and too dangerous to defuse on spot. This leads to evacuation of about 2500 inhabitants and closing down a whole quarter of the city, affected was a circle of 1 kilometer radius. Fire department and police led the people out (only one had to be forced, most were total cool), disaster response groups of Red Cross and Maltese Cross cared for those who found no other shelter. EMS and volunteer disaster transport groups assisted those who were not mobile enough. Several staging areas collected forces of fire, EMS, police and German Federal Agency for technical relief. Some emptied fire stations were filled with volunteer departments from outside areas. After two days trying to defuse and finally preparing one of the biggest explosions Germany had seen since WW2 within a major city, they forced the bomb to detonate in the evening of August, 28th. The following video was released by a private citizen and shows the impressive fire ball: After the blast there were several fires on the roofs and in the streets. First reports talked about "Chaos", but Munich FD was able to get all of those fires under control in less than 30 minutes. There were no victims or injured persons. Some structures were damaged, but only slightly - however, most windows broke in a radius of several 100 meters. Civil engineers checked all buildings and there was only one with significant problems. Though, several apartments still are uninhabitable due to broken windows, shattered glass and damaged furniture. For those still without an intact home, the city authorities organized hotel rooms. All emergency shelters could be closed a day later. The images of the first 30 minutes show streets in flames: http://www.focus.de/..._did_40939.html and http://www.merkur-on...ia&firstslide=1 . Main cause for the fires were hot splinters and the hay they used for controlling the explosion. In preparation they piled up around 100 tons material in earthwalls, sandbags and special mats for directing the explosion. Hay bales were used to damp the explosion and catch splinters, which obviously worked rather good despite beeing the cause for several fires. But, as said above, it was under control rather fast. During this events there were several other remarkable emergencies despite the "normal" daily emergency business in a million people city, including a severe collapse on a construction site (totally unrelated to the bomb) wtih multiple injured persons. I wasn't involved in the whole setting but know several key players very well. EMS hadn't much to do, only to transport several handicapped and sick people. A lot of work was done by the volunteer groups who prepared the shelters and cared for the evacuees. It's not uncommon for german cities to have several buildings evacuated due to old WW2 remains from time to time. According to a spokesman of the State of Bavaria in 2011 there were around 1000 findings with 40 tons of explosives, mostly ammunition from WW2 but including 214 unexploded bombs. In Munich there were around three findings this year, but all others could be defused on spot. 2010 in another german city, Göttingen, there were three fatalities among bomb experts when they tried to defuse a bomb with the exact same mechanism as the Munich bomb now. I myself was involved in two incidents of WW2 bomb findings around here, where we had to evacuate some streets. So at least this bomb is history and I hope my next incident report will be about an interesting shift on Oktoberfest. See you there!

That's great! It's written by a cynic old medic, still laughing (and probably lurking on internet forums), isn't it?

This would be the use of public money/equipment on a private company public relations event, plus staff doing things they don't are trained for: washing elephants. I totally understand that the line of command below the political level was against this mis-use,

From the rest of the article and comments I think they mean "get an ambulance in less than seven minutes". Anything other would be a bit stupid since quality of care isn't measured by time to hospital alone (and not by "7 minutes"). BTW, what was the type of the call? Was it stated as emergency? Or was it dispatched as non-emergent transport? The article isn't very clear on this, just speaking of "transport" the whole time. But on the other hand I already witnessed crew doing similar things just to not getting overtime. It's stupid and when it just got common management made a very clear statement about this habit not allowing it anymore. The other way round: did you ever get to scene to relieve colleagues at the end of their shift? I once did it (~20 years ago, incident was just around the station's corner), I know some recent cases and I'm not sure what to think about it. I never did it since then, normally I even wouldn't know where they are when just entering the station for shift change. This surely implies you take the same ambulance from them and not a new one. I would think, if it's their call, they work it - including all the informations they have from the beginning. And doing unsuspected overtime simply is part of the job. I wouldn't expect from my successors to relieve me at scene (sometimes I would've been glad if they appeared anyway, buit that's a totally other story).

All said is true. Just to add some general hints about stress recognition: it's absolutely normal that this incident gives you a most bad feeling and it makes you feel sad. It's totally normal to have it affect your sleep and daily thoughts - but only for the first two weeks! Then it should become better, exceptions are some flashbacks especially in similar situations or when driving by that location. If it takes much longer than two weeks or it even gets worse or you get physical phenomenons by those flashbacks (frequently interrupted sleep, raised pulse, short of breath and so on), then get professional help soon. Until then, what seems to help most in the first hours/days, is to talk about the incident, your actions and the views of others with those who've been with you in a calm setting. If you're more senior, you may remember (and remember others), that the cause of the accident is not your fault and you never had a chance to change something in the fatal outcome, but obviously did help with the other passengers. It's OK to follow up on patient outcome but don't let it get too personal, try to see it more as a quality control issue.

I wouldn't do it and I didn't do it, even if I met my wife in EMS. This said, I don't care much. I don't think this would have blocked resources from a real call (in fact, they probably even would have been faster since they already were on the street) and what does it cost to drive around some corners and ladder up a building? It's not more than an excercise... Better to see equipment used in that than having to witness a real call where someone gets hurt or suffers a loss. Don't take life so serious. It's not that he had stolen anything (just a LEO's heart). The idea is pretty lame, but that's not my decision. However, as an old romantic, I would suggest additionally bringing a large bouquet of flowers next time. EDIT: typo.

Benzos are not required for Ketamine, but they are a friendly gesture... In lower (analgesic) doses the psychotropic effects are near zero, if getting sedative/anaesthetic the probability gets higher. It's kind of a play with unknown probabilities on the given patient. In a side effect this enables you to give Ketamine in higher doses without respiration depressive Benzos, if the actual situation calls for that trick. A large part of your patients will get over it without the psychotropic side effects. But noone really can say how many (I don't have research papers at hand, maybe someone actually can quantify it). So Ketamine is a great tool. As with every tool you need to know, where and how to use it (risk/benefit). But if you allow patients do dose themselves with Ketamine by PCA this simply would raise the probability of having effects as Wendy described. I would consider this an inadequate substitution of better drugs especially if it's due to a bad risk/benefit analysis. But what else, if no better drug is available? However, we're talking about the U.S. here, land of the most sophisticated medical system, if I recall correctly...come on, "drug shortage", really, please?!?

Last call: Oktoberfest 2012 starts 22nd of September, medic shift planning in progress, I may place one or two of you into it if it's your wish. See http://www.oktoberfest.de/en/ Considering the price for a beer there: no, it's not a waste for the vendors... Not this year...how did it go?

"Every one has the right to act dumb", as long as it's no danger to others. An adult, alert and consent patient not wanting to be transported has the full right to do so. My duty as a medical provider is to explain the situation and implications in an understandable manner, if possible get a signature (there are patients even denying this, no problem, document and get a witness) and leave him alone. Problem#1: Drugs/alcohol. There is a grey area where patient consent can be questionable. If there is blood somewhere or any other measurable sign of medical condition then it's easier: obviously there may be a self danger and missiing consent. But if it's "just a drunk" then I carefully have to pass him to someone (relatives) who are capable to bring him to a safe bed. Still could overlook something, therefore a close inspection is needed and if he even refuses that, it's time for our law enforcement friends. Always a dumb call, though. Problem#2: Under agers. Even they are allowed to refuse treatment - if I don't respect this I could be charged with kidnapping...but usually there is someone with compulsory control (sp?) available, who can decide. If in doubt and if a severe medical condition is suspected, I can call police. The grey area can be covered by acting quick (blood glucose level measuerement is such a case - no one wants to be sticked but it gives a valuable insight in altered mental state caused by low glucose level: just say "we will take your blood now, it hurts a bit, OK?" and poke - at least he could have said "No!" in the remaining microseconds...). Sometimes just beeing VERY clear ("YOU WILL DIE!") or just authoritive (sp?) "WE DO THIS NOW!" does the trick - the latter especially with under agers. Describing all other outcomes between life and death (the "brain dead diaper user" already mentioned) is another way. Sometimes I threated with police, especially with hurt drunks: "come with us or we have to call the police to care for you...". Another trick is to ask: "Why did you call us in the first place then?" and maybe refer to the relatives: "They want you to come with us! They can't deal with that condition here." Here we have no strict duty to transport and mostly are able to point to a general practioner or even get one for a house call. We would be able to have an emergency physician on scene with lights & sirens, but that won't help much in non-vital cases. However, having a doctor saying the exact same thing often does the wizardry...(and the judge may give the doctor more reputation in medical decisions). If all this doesn't work, well, it's still the patient's problem. He may call again if it gets worse, no problem. That's part of the job security. All in all, as long as the patient can deny and/or complain, all vitals seem to be in order. As stated by others: beside taking the call seriously and professional even in dumb situations, documentation is the key. All this said: yes, i most probably would have handled the original case the same way. And the outcome most probably would have been the same here. The signature on a refusal form is a very hard fact, I don't see a problem here with patient consent. EDIT: just never ever mention the word "suicide". That instantly may get you in psychiatric care for up to 48hrs against your will and enforced by LEOs if needed...

Someone (chbare?) recently mentioned a study here about making a working CPAP system out of a continous flow nasal oxygen canule and a PEEP valve attached to a bag valve mask. This simply adds the "C" to the PAP and seemed to work pretty good when you have no dedicated CPAP equipment. Never tried this yet, though (since we have the equipment). EDIT: oh, was already mentioned. Sorry, somehow I didn't read til the end of the thread...ignore the above.

Oh, that's simple here: no nurses on patient transport by law (rare exceptions in flight intensive care transport, where they are allowed - but most have an additional medic education, since even the interfacility transport helicopters are part of the primary HEMS system and there a medic license is required).

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.

No, i need not the reputation of a fire fighter or a cop. I don't want or need to be a "hero". I'm proud of what I'm doing good, but I'm aware it requires constant education to stay on top. Yes, I want to be generally respected for what I've learned, know & do now, just as any other profession. No public praises needed, just a better pay. BTW, that may be the point: it's a lot of public relation. Fire dept's seem to put a lot of effort in their reputation, especially if volunteer. That's not bad per se. But they sure have excellent possibilities: action, big technical things, large trucks... Compared to this, our possibilities in EMS are very limited. Action = blood & guts? Who wants to see this? And we know that's not the thing. But we aren't allowed to talk about the most of our incidents directly due to confidentality laws, where fire dept. may publish every small lawn fire or broken water pipe. If we do, noone understands the beauty of a strange ECG rhythm anyway. And what does attract kids in an ambulance? You simply can't compare a 20ml syringe to a real fire hose... But that doesn't cause me to fall on the dark side, starting to whine about lack of public awareness. Rather than that I would like to provide a professional appearance, high level of care and a confident team in even the worst situations. On the long term I think this is what builds up a good public relation. And the EMS provider that spoils this by doing something silly just is a large back step - if career or volunteer. So I spend a lot of my time in training & teaching to get the standards high - if for my career or volunteer group. On the other side, let's look at the real reputation of a fire fighter or a cop: it's very ambivalent. Some may see them as heroes, but a lot see them as prolly beer or doughnut consumers in uniform, lighting fires or beating innocents just for their own enjoyment, beeing in the way rescuing cats out of trees or causing traffic delays instead of solving major crimes. I can't see this ambivalence in EMS public awareness. And I'm glad for this! We have a job to do and we simply do it. That's way cooler than posing in dirty gear making a story out of some others suffering. No, really no hero image needed. Just some random thoughts...

Doczilla: Thank you, now I get it. And again, thank you for providing such an excellent collection of facts!

OK, I'm convinced now that my non-usage of a spineboard is "good medicine". But to convince some of my gung-ho brothers and sisters who think we should use the "new" stuff all the time (spineboards are new here, I grew up with vacuum matresses) I would need a reference for padding a spineboard or properly securing it for transport using blankets and all that. Just to proof how it should be done if it's done - and then to explain that a vacuum matress can do the job better and quicker. Is there any EMS book describing this padding and securing in detail? Or don't they address this?

For rectal applied sedation/seizure control we have only Diazepam (5mg and 10mg tube), if not choosing an antipyretic (because fever may often be the cause for pediatric seizures). However, if I can establish i.v. access soon I prefer Phenytoin for seizure control. Midazolam is in our toolbox, too, but I did never use it for seizures as far as I remember - even in times we had no Phenytoin I rather used Diazepam. It's a known fact that Diazepam stays longer than Midazolam, so the study seems like old news, or do I overlook something? Midazolam has a faster impact on breathing depression, so I'm a bit reserved in using it if airway control may be tricky (rule of thumb: it always is...). Having a longer sedated patient is not my main concern in the prehospital setting, having issues with airway control because of fast or too much sedation is. Be aware that epilepsy patients may have a high tolerance for benzos, I sometimes used 50mg and more (once we used up around 80mg which was all we had on a 50kg woman and still couldn't break her seizures, still breathing and all). Phenytoin always did the work better and I'm glad we have it in the kit since some years now.

Great effort! I've taken the time now to collect our german standards in emergency medicine (there are no protocols here, but some general national treatment standards for medicine in all fields), citing them to support my case in getting rid of the spineboard as "always to use" treatment, like it seems to be seen by some colleagues here... Thank you very much for the valuable input! Some questions regarding your sources: I don't understand those numbers ("to Treat", "to Harm"), can you please explain what you tried to extract there? This I don't understand. When there ARE 87% of distracting injuries, why are they a myth? However, I must admit, I didn't yet try to get hands on the original studies. EDIT: is there any way to have your presentation for "myths in EMS" available?

That's what I thought. Is it really textbook practise? If so: which? What we see here in TV _and_ ITLS/PHTLS courses as genuine U.S. technique is just the board and straps. I wonder why those courses don't address the other issues I mentioned (yes, asking the german trainers didn't provide a sufficient answer, therefore I'm asking those who constantly work with them and whom I trust more on this: you in EMTcity). I have yet to try this - we have a CPR dummy here with additional extremities and significant body weight for rescue simulations. this will be my victim for some braking tests. Poor Anne!

Oh! I searched about it a bit before writing that much, but obviously missed this thread. Thank you for pointing me to it! (BTW, I had a similar topic started a year or so ago, but this wasn't exactly the same even if it already covered some of the questions a bit, now just wanting to get specific). EDIT: that thread gives almost all the answers I wanted - including study citation etc. I almost intended to write an article about "spineboad myths" in a german EMS magazine, seeing the strange use of backboarding more and more here. This mostly comes from wrong understanding of the U.S. settings and ignoring the other tools we have. Now it seems I just have to ask ERDoc to give permission for translating his presentation! Great! (Spiderstraps) Well, we too. But the patient still is able to move a bit (intended or by driving forces) - especially the legs. I've seen some impressing videos on youtube about providers padding and securing patients with several additional tapes and rolled blankets. But this looks a bit time-consuming (not to say inefficient). However, what would be the real textbook spineboard practise? BTW, what do you about the "lordose gaps" and the pain on the contact spots? The spider straps alone just secure the patient and don't address these issues, or?

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...

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: "Sanitäter" (50-70 hrs course) = "Advanced First Responder" "Rettungs-Helfer" (160hrs course, some internship in hospital and EMS) = "EMT Basic" "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" "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!

Hi, in Germany, at least in my beloved state of Bavaria, we'll see more and more usage of the "spineboard". All new ambulances are equipped with a long backboard since several years and finally the providers apparently found them in the compartments wondering what this thing will do if switched on. And since they start to recognize it as a fancy equipment thingy from THE UNITED STATES OF AMERICA everyone sees on TV series and in movies, it seems to be the greatest gift to german EMS since the invention of wheel(cart)s. As if we never had our beloved vacuum mattresses (since >30 years, probably even lot more) and scoop stretchers (since around 20 years)...on every ambulance by now. Studying various sources and experiencing the backboard in various situations (classroom training, life excercises and rare real calls), I have a certain impression about it's worthiness. In short my point of view is: if used as a "pick up aid" only in situations were a scoop stretcher or other less disturbing techniques don't help, a spineboard is a great thing. Especially in confined space situations and if to carry a patient over sharp edges (where the scoop stretcher usually will hook). However, I really don't see it as a transportation aid in the ambulance. With our vacuum mattresses (required equipment) a patient is more comfortable (one word: lordose) and splinted individually but complete. This includes full protection against sideway movement. But I don't want to really discuss the pro's and con's, so sorry for the long intro, but I wanted you to see where I come from. So, the real questions are: How do you properly fix a patient on a spineboard against side movements? Our backboards seem to be a bit slippery and even if pinned down by a spider strap several body parts can slip sideways. Our modern vacuum mattresses even have a polster between the legs to stabilize them from all sides - how is this adressed in proper spineboard fixing? transport the patient on a backboard in the ambulance? Is there any special hold or something like that? I don't trust a slippery thing simply put on a stretcher...it seems it can go ballistic any time since it could only be fixed with the normal patient straps on the stretcher - which are designed for a patient directly laying on the stretcher including a lot more friction between the fitting surfaces. address the problem of lordose (the "S"-form of the spine), shoulder supporting, and leg supporting (the body is NOT flat!)? Is there a rule about filling those "holes"? make a patient more comfortable for a longer transport? Is there a rule about padding the direct contact parts between board and skin (hip, shoulders, head)? And I mean: "really, according to training books, should be, if done all right and not the quick & dirty solution". How are things really done in US or should be done and how are we influenced by TV over here. I don't like TV to teach me things in EMS...some seem to see it other way round (honestly, i suppose some ITLS/PHTLS trainers just copy things totally unreflected). Any others non-US but using spineboards may be helpful for my understanding of the real thing, too. I sure have made some research, but "padding" and such things are always addressed within a side comment or such in the documents I found. Can't believe that this is just not needed. Thanks for your input, Bernhard P.S.: if someone missed me the last few months - I was still there, but slightly exposed to other things in life. May happen again.