Trauma Services in Germany
Frank Wurmitzer
Outline
Trauma Service in Germany
Frank Wurmitzer, MD
Arthroplasty Fellow
Orthopaedic Service
Auckland City Hospital
Introduction
• personal information
• German Health System
• Trauma service
Federal Republic of Germany
• size 357,092.90 sqkm
(NZL 270,534 sqkm)
• population: 82,4 mio
• 231 people per sqkm (NZL 16 p/sqkm)
• gross national product per capita $30,690 USD
• (NZL $25,920 USD)
German history
turbulent
up/down
violent
famous
Medical Health System Germany
Medical insurance compulsory!
No funding from the government!
Ministry/Department of Health
Complex Insurance-System
German health system
statistics
• 10.7% of gross domestic product (GDP) (4th place behind USA, Switzerland and France)
• 234 billion Euro per year ($ 460 billion NZ)
• 3,287 Euro per head and year (11th place)
• 4.26 million health-related worker (10.3%)
German health system
statistics
• 2166 acute-hospital with 531,300 beds
• ca 1000 rehabilitation/recovering hospitals
• 394,400 registered doctors (59,000 GP’s, 58,900 specialists in own practice, 146,300 in hospitals)
• one doctor of 298 people
German Insurance System
4 types
• 1. public insurance
• 2. private insurance
• 3. work related insurance
• 4. welfare
Insurance
• hundreds of insurance companies
• Chip-Card (like a Credit-Card)
• out-patient treatment
• in-patient treatment
• dental treatment
• out-patient and home care
• (Doctor hopping !)
1. public insurance
• all employees
• solidarity principle !
• between 13-15% of salary
• 50% employee and 50% employer
• max. circa 500 Euro per month (ca. 1,000 NZD!)
• validity restricted (location, hospital, doctors)
Private insurance
• employers/independent worker/high salary
• restricted access !!!
• rate is age/gender/health related, independent from the salary (eg. women 30%
more expensive)
• free choice of doctor, hospital, single room with en-suite, special food,
TV-entertainment …
work related insurance
• employer has to pay the rate
• only employees insured during their work and travel from/to work
• accident/injury
• occupational disease
• (similar to ACC)
welfare
• unemployed (some)
• homeless people
• not insured tourists
• refugees/asylum-seeker
• no chip-card
• only emergency treatment
• hospitals can’t refuse emergency patients
trauma in Germany
• 8.37 million injured people in 2006
• 10.2% of Germany’s population suffer from an injury/trauma
• 19.479 fatal injuries (0.02% of population)
• major trauma mainly from traffic, home, free-time activities
trauma statistics in Germany
organisation of trauma
• Special trauma service in hospitals
• High density of Level I trauma centres
• orthopaedic trauma is part of trauma surgery (trauma-surgeon)
rescue system
• rescue: start of trauma service
• high density of rescue centres
• by law: major trauma – a doctor has to be at the side within 15 min !!!
• rendezvous system !
rescue system
• helicopters manned with a special trained doctor, pilot and paramedic
• 107 chopper bases countrywide
• rendezvous system (with ambulances)
rescue system
• ambulances manned with 2 paramedics
• minor and major trauma
• transport of patient into the hospital
• first aid
• rendezvous with doctor
rescue system
• special cars with:
• emergency doctor
(special training)
• and one paramedic
• full equipment except transportation of the patient
• rendezvous with ambulance
rescue system
• emergency doctors outside the hospital
• special training
• employed full time or part time
• very popular jobs
rescue system
• rescue stations countrywide in hospitals, fire dept. or as independent
organisations (eg.red cross)
• service 24/7
rescue system
• special rescue bases:
• coastline of Baltic Sea/North Sea
• alpine rescue service
• (beach patrol?)
rescue system: major trauma
• rescue patient
• stabilize patient
• transport patient asap to the next suitable and available trauma center
• short distances
• no delay
• loads of severe (multi)trauma arrive at the hospital !
trauma service
• co-ordinating center
• regional service
• contact between rescue – hospital via radio/phone
• check availability of beds/ICU/service
• feedback hospital/rescue team
• hospital – preparation
trauma service
• hospital – trauma center
• emergency deparment
• ED: specialist of all medicine branches
• no ED-doctors !!!
• each discipline has one doctor on call in the ED 24/7 ! (registrar and
consultant)
• handover of patient
trauma service
• special room for major trauma patient (shock-room or resuscitation-room)
• special equipment (anaesthesia, ultrasound, x-ray, CT-scan, ECG, small
surgery)
shock room management
• manager/co-ordinator: trauma surgeon !!!
• teamwork between trauma surgeon, anaesthetist, surgeons other specialities
shock room
• 1 anaesthetist and 1 technician
• responsible for ATLS A/B/C
shock room
• 1 trauma surgeon (consultant)
• 1-2 registrars (junior and/or senior)
• up to 2 nurses
• radiographer for x-ray
• radiologist for CT
shock room: trauma surgeon duties
• history
• examination
• diagnostic (eg. ultrasound)
• treatment (initial)
• co-ordination (OR, further diagnostic, other specialities)
OR duties: trauma surgeon
• OR procedures
• (bone, belly, thoracic, vascular, neuro, plastic)
• assisting special procedures done by other surgeons
post-OR care trauma surgeon
• special trauma ward
• daily ward rounds done by trauma surgeons
• ward round done by other secialists on request
• physiotherpy
• social worker
rehabilitation and follow up
• special hospital for rehab/physio
• 3-6 weeks inpatient rehabilitation
• up to 1 year outpatient rehab
• follow up via GP or surgeons in own practise (similar to outpatient clinic
German trauma service
Conclusions:
• (advantage?) trauma cases in one hand !
• special trauma units/hospitals
• trauma teams on call 24/7
• consultant in the hospital 24/7
• scrubbed in all cases
• complex duties
• high efficiency and quality
• loads of severe trauma cases
future of trauma service
• (dramatic) changes since 2005
• due to high specialisation (visceral, vascular, cardiac-lung, neuro, bone)
• due to “European Union” approximation of training programs
• adaptation to the Anglo-American system
• separation of bone, visceral and neuro trauma in training programs
future of trauma service
• The “real” German trauma surgeon is in danger of extinction !!!
• new generation of trauma surgeons is more specialised (but limited?)
• transition period of 5-10 years
carrier in ortho/trauma/general surgery
• hospital for ever or own practice ???
hospital - jobs
• different structure (chief-consultant, consultant, registrar, students)
• chief-consultant – salary + private patients
• other consultants –salary only
• registrars (6years, 50 hours per week by law, different hospitals)
• Med-students (internship)
• (Fellowships are unknown)
• fancy dress
hierarchy !!!
hospital jobs
• law: consultant 24/7 in the hospital and scrubbed in every case !!!
• no clinic (no pre-operative/follow-up) !
• ED: covered by surgeons
• very well-equipped hospitals
• very interesting work
• but: work conditions, workload, pressure, fairness, carrier, salary ?
own practice
• restricted access (one per 25,000)
• practise/permission/licence expensive
• independent work
• work restricted (most conservative treatment or minor surgery/outpatient
only/day-surgery)
• all pre-operative and post-operative follow-ups
• very good earnings (per case)
• but: boring ?
conclusions
• very good health system in Germany
• high quality of treatment
• well equipped and high density of facilities
• waiting lists for elective surgery: public max. 4 weeks, private 1-2 weeks
• trauma immediately
• rescue very fast
• carriers for doctors?
• but: high costs !
|
Ministry
of Health
