The conference of the German Ministries of Public Health has recently reached a decision which, in summary, states that in the future only those medical measures (diagnostic and therapeutic) which are evidence-based will be reimbursed by the insurance companies. The present article, based on the introductory remarks of the congress president of the 4th DIVI Congress in Hamburg, attempts to demonstrate that, in most instances, this procedure cannot be followed in the area of emergency and disaster medicine. In Germany, prehospital emergency medicine and inhospital intensive care medicine are considered as two parts of an unique concept. Prehospital emergency medicine is regarded as prehospital intensive care medicine and inhospital intensive care medicine as a continuation of prehospital emergency medicine with better facilities as well as diagnostic and therapeutic modalities. Three papers published in 1994 and 1997, respectively a) Pepe, Abramson, Brown, ALCS does it really work? b) Bickel, Wall, Pepe et al., Immediate versus delayed fluid resusctation of hypotensive patients with penetrating torso injuries, c) Conners, Speroff, Dawson The effectiveness of right heart catheterization in the initial care of critically ill patients. have been selected to show that a variety of important measures routinely practiced in intensive care medicine are rarely based on scientific evidence, This leads to the question as to whether aspects like endotracheal intubation, fluid resuscitation, or the PA catheter can only be applied in emergency and intensive care patients if their benefit can be clearly demonstrated, In many instances, however, this is not ethically acceptable as, e.g. endotracheal intubation in cardiopulmonary resuscitation after cardiac arrest (control groups would not be ethically justifiable). A study on delayed fluid resuscitation similar to the one performed in the US, would not be be ethically acceptable in Germany. The same applies to investigations using the PA catheter, the use of which remains unacceptable, in spite of an intensive discussion at a consensus conference, thus excluding the availability of scientific evidence for the use of the maneuver. In conclusion this means that if health care authorities are planning to reimburse emergency and intensive care measures only if these are evidence-based, most of the described measures can no longer be carried out. This, in itself, is ethically unacceptable. The authorities will have to accept that health care providers will apply a variety of diagnostic and therapeutic measures which are not and will probably never be evidence-based.
