On the island of Hooge at the push of a button

It creaks and jolts a little, then the folding bed at Aachen Fire Station clicks into place. Two metres long, 90 centimetres wide, with a white sheet – a welcome refuge in the wall. This is where Kai Kottmann lies down to rest during his 12-hour shift, providing things are not too busy. Some nights he only has to get up and go to his computer four times. Other nights it might be as many as sixteen times. In just a few seconds, he can be there at the scene of the emergency. 'Of course, as a Telenotarzt, you miss out on the time spent in the car on the way to the emergency – time to think and go through some initial scenarios in your head. When you’re sitting at your desk, you arrive at the scene immediately,' Kottmann tells us. The 44-year-old father of two daughters and husband to a gynaecologist has a beard and glasses and is wearing jeans and a shirt – the everyday outfit for the workplace of a Telenotarzt.

His control center in Stolberger Straße in Aachen looks rather like an air traffic controller's desk. Four monitors are arranged in a semi-circle. In front of them, a keyboard, a mouse and a coffee cup. But what is happening on the monitors will be new to many people: telemedicine. For call-outs where the call center staff feel that invasive measures such as intubation or drainage are not urgently required, i.e. the physical presence of a doctor is not needed, Kai Kottmann can be called to the scene via headset or video connection. Every now and then, the fire station shutters are rolled up just outside his window and the emergency rescue team charge out of the courtyard with flashing blue lights. His skills as an accident and emergency doctor and his certainty on legal matters go with them on board the vehicles. Provided he is consulted, the documentation from the call-out comes with them too in real time, including clarification of photos and recordings. 'This means that colleagues from other locations can be called in to help with more serious cases. Resources on the streets that become free can save lives,' he tells us.

Telemedicine with priority

Even in districts with good transport connections, it can take six or seven minutes for the emergency rescue services to arrive at the scene of an accident or emergency. In the case of a cardiac arrest, a patient can expect to suffer neuronal damage after just three minutes if they are not given oxygen. The "Corhelper" app can check the availability of trained first-aiders in real time and help to get them to the scene of the emergency in less than three minutes. There are plans for Kottmann to be connected up to the app too in the future. However, most of the call-outs he attends come via calls from ambulances that are equipped with technology supplied by umlaut telehealthcare GmbH. Since 2014, the team have provided support to around 30,000 call-outs in more than 60 ambulances in 10 administrative districts. During this time, Kottmann and his colleagues have trained a further 75 remote emergency doctors – in Aachen, Kiel, Gelnhausen and Greifswald. 'This makes us quite unique,' he assures us, whilst keeping a close eye on the street map of Aachen on his screen. Some of the coloured dots are moving – ambulances on and off duty, or on call.

Kottmann first encountered the concept of the Telenotarzt in 2007 during his training as an anaesthetist at the University Hospital RWTH Aachen. Two of the first telemedicine projects to be funded by the European Union in the years up until 2013 were the research projects "Med-on-@ix" and "TemRas". 'That was the year when the first iPhone came onto the market. The range of functions was of course not as advanced as it is today,' says Kottmann, looking back. In 2014, he started working as a Telenotarzt himself. The prerequisites for this role were that he had to have attended more than 500 call-outs as an accident and emergency doctor and to have gained a qualification in emergency medicine. He also had to be a holder of an Emergency Resuscitation Certificate (ERC) and a Pre-Hospital Trauma Life Support (PHTLS) Certificate. 'Nowadays we tend to spend more time focussing on Big Data applications and Artificial Intelligence.' Subjects such as these were put on the priority list by the Federal Ministry for Health with their innovation forum "Digital Health 2025".

'I stumbled into it and ended up staying'

Kottmann's skills are used by providers across North Rhine-Westphalia, Hesse and Mecklenburg-Western Pomerania who are given support according to their needs, either by simply being supplied with the required technology – or with the complete package, including the Telenotarzt service, training sessions and the corresponding staff cover. An interesting change of scene came with the research project "HALLIGeMED" in the Institute for Rescue and Emergency Medicine at the University Hospital Schleswig-Holstein in Kiel. From here, district nurses qualified in emergency rescue on the islands of Hooge and Langeness-Oland were provided with telemedical support for almost two years. The project came to an end in 2020 but the technical equipment stayed on the islands; the umlaut Telenotarzt then continued to provide support from Aachen. 'There are approx. 50 call-outs a year on the island where we need the advice of an accident and emergency doctor – the boundaries between the advice provided by a general practitioner and more serious emergencies can get quite blurred here.' It would take up to 30 minutes for a helicopter from the mainland to get to the islands. Kottmann and his team can be connected up to the scene of the emergency via phone at the push of a button. 'The Hooge paramedics station replies, and the camera sometimes swings out onto the terp,' says Kottmann.

He supplies a pragmatic answer to the classic question as to how he came to choose this profession: 'I just stumbled into it and ended up staying.' He was looking for a place to do his civilian service and applied for a job as a driver for the aid agency Malteser International, but they only had one position available, working in patient transport. Thirteen months later, Kottmann, who was born in Cologne, started an apprenticeship as an emergency medical technician and used this to bridge the time whilst waiting to start a degree in Medicine. He was able to move pretty much straight on from there to the University of Aachen. 'With an estimated 30 semesters of waiting time, I probably wouldn't have had a chance nowadays,' he says. But it has now become somewhat easier to gain entry into the emergency rescue profession. An approximate harmonisation of state-specific requirements was achieved through the introduction of the job profile "Emergency Medical Technician" which later changed to "Critical Care Paramedic".

Communication as a new opportunity

'As well as time, one of the key challenges with any rescue is to ensure good communications between the various links in the rescue chain,' Kottmann explains. To help him to do this, he is provided with all the vital data, a video connection to the ambulance and a set of procedural instructions based on guidelines on his four screens in the fire station. The tools on board the ambulance make sure that he has a reliable picture of the happenings at the scene of the emergency at all times and from any location. The vital signs monitor transmits the data in real time via the universal router, the so-called "PeeqBox", on Kottmann's desk at the fire station. On his last call-out, it was suspected that the patient had suffered a heart attack. The critical care paramedics gained the patient's agreement to link up to Kottmann in order to coordinate the medication to be given. Just a few minutes into the conversation, the team realised that the suspected heart attack was in fact a thoracic aortic aneurysm – bulging of the main artery, which requires a completely different kind of treatment. The diagnosis was confirmed later on in the hospital – a team effort, as Kottmann says. In his role as a Telenotarzt, he also sees himself as a mediator: 'In this job, it helps if you are able to show empathy. The team at the scene of the emergency are closer to the actual events, whereas, in my role as a Telenotarzt, I am more of an external advisor, offering security in legal terms and helping the team to make decisions. I already have the feeling that this is improving our team spirit.'

Data is playing an increasingly important role in the communications along the digital rescue chain. At umlaut telehealthcare, communications are encrypted and travel via several mobile phone networks – among other reasons, in order to ensure a stable network even in call-out locations that are difficult to access and to make sure that there are no gaps in the documentation. 'Data sets from audio communications are an increasingly important resource for us, as are vital data, photos and videos from the ECG diagnosis. Our knowledge database gets more precise with every call-out we attend. I would like to see people having more trust in this form of Artificial Intelligence which is coupled with the human sensitivity of our remote emergency doctors,' says Kottmann. Despite the advantages of his job and the flexibility it gives him in terms of his time, he couldn't imagine doing it without sometimes attending call-outs in person. 'Around five times a month, I take on a shift as an actual accident and emergency doctor. I swap my headset for a high-vis jacket and some real encounters – the mix of both worlds is what makes emergency rescue my dream profession.'