[Emergency medicine tomorrow].

Emergency medical services (EMS) systems represent and important part within our health care system. However rapidly changing basic conditions define the need to reconsider current structures and objectives of the German EMS system and to implement appropriate modifications. The steadily decreasing number of emergency physicians advises to delegate more and more "technical" duties to paramedic personnel. In contrast the mobile intensive care unit will be reserved to cases in which complex treatment strategies or decisions have to be undertaken (i.e. thrombolysis). Moreover, the emergency physician's role will deeply expand beyond individual medical assistance. The most urgent duties Medical Advisers for Emergency Services will have to comply with are: 1. to develop plans of action and guidelines for paramedic personnel and 2. to secure a consistently high level of emergency medical care. As a consequence of ongoing structural reforms in the German Health Care System (ie. the implementation of diagnosis related groups, DRGs) emergency medicine will break down with traditional EMS structures. In contrast emergency medical departments of large hospitals will be reorganized to deliver both prehospital and in-hospital emergency medical care ("Centers of excellence"). Devoted to comply with clinical pathways this concept will improve medical efficacy as well as economic efficiency. The breakdown of traditional social structures as well as the increasing number of psychosocial emergencies constitute a major challenge to out EMS system. As it is not suitable to strictly differentiate medical from social emergencies we urgently need to establish integrated psychosocial networks. For a long period of time the role of the emergency physician has been restricted to the stabilisation of disturbed vital functions. To assure the competitiveness of the German EMS system it will be indispensible to expand our scope of practice. As anesthetists we should not hesitate to take over our new position as "managers in acute care medicine".