AN HONOR! - Dräger

Communities cannot do without volunteers– they are the backbone of society

AN HONOR!

WHAT LIES BENEATHDetecting various substances in sewage p. 50

AILING FORESTSHow droughts and pests are affl icting them p. 24

AGAIN AND AGAINRecycling is the key to sustainability p. 44

Dräger Review

123

First issue 2021 Volunteers – the backbone of a free society

Dräger ReviewTechnology for Life 2021

66READY FOR ANY SCENARIO

In Berlin, a treatment center built at short notice is providing additional peace of mind

during the coronavirus pandemic.

56EXPLOSIVE JOB

Mine clearance divers defuse and lay mines. One false move

could be fatal.

6VOLUNTEERS

STEP FORWARD! Adversity generates empathy. Yet it takes skill and expertise

to provide effective help in such circumstances.

2 DRÄGER REVIEW 123 | 1 / 2021

CONTENTS #123

Communities cannot do without volunteers– they are the backbone of society

AN HONOR!

WHAT LIES BENEATHDetecting various substances in sewage p. 50

AILING FORESTSHow droughts and pests are affl icting them p. 24

AGAIN AND AGAINRecycling is the key to sustainability p. 44

Dräger Review

123

First issue 2021 Volunteers – the backbone of a free society

Dräger ReviewTechnology for Life 2021

The articles in Dräger Review provide information on products and their possible applications in general. They do not constitute any guarantee that a product has specific properties or is suitable for any specific purpose. Specialist personnel are required to make use of the skills they have acquired through

their education and training and through practical experience. The views, opinions, and statements expressed by the persons named in the texts as well as by external authors of articles do not necessarily represent those of Drägerwerk AG & Co. KGaA. Such views, opinions, and statements are solely the opinions of the people concerned.

Not all of the products featured in this magazine are available worldwide. Equipment packages can vary from country to country. We reserve the right to make changes to products. Up-to-date information is available from your Dräger representative. © Drägerwerk AG & Co. KGaA, 2021. All rights reserved.

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www.draeger.com

4PEOPLE GOING PLACES

Esther Nies works in intensive care at Maastricht UMC, Albrecht Broemme oversaw the “Jafféstraße Coronavirus Treatment Center” project in Berlin.

6A QUESTION OF HONOR

All over the world, millions of volunteers give up their spare time to work for nothing but the benefit of society.

18HEALTHY FORMULAS

Algorithms are instructions for computers. How they work, what they

can do, what we expect.

24IF YOU GO DOWN TO THE

WOODS TODAY … … you’re sure of a big surprise.

Stricken by environmental influences and the climate, some pests are

really ravaging our forests.

30NO ISLE OF THE BLESSED

If people are isolated or cut off, they lead a riskier life. Whether on an island,

in space, or in Antarctica.

36THE BIG DIFFERENCE

In the past, the world of medicine barely acknowledged the fact that men and women

are different. This is now changing.

40A SAVING LOOK

EIT is a technique that permits medical staff to look into the lungs when

the patient is breathing – it visualizes different regions.

44WASTE IS A VALUABLE

RESOURCE Recycling decommissioned products

is a bit like mining – with many treasures to recover.

50FISHING IN MURKY WATERS

Modern methods can be used to detect the presence of diseases,

among other things, in sewage.

56UNDERWATER HUNTERS

The standards are high, the work is dangerous: Mine clearance divers

are among the elite below water.

62GOOD FOR THE CLIMATE

Eco-conscious anesthetists are saving money – and reducing

their carbon footprint.

66BETTER TO HAVE THAN TO NEED

A treatment center was built in Berlin within the shortest space of time

in the event of a coronavirus emergency.

73OUR CONTRIBUTION

Products from Dräger found in articles in this issue.

74ALMOST WITHOUT TRACE

This closed-circuit breathing apparatus enables bubble-free diving.

This can be vital.

GIVING EVERYTHINGBirgit Heinze is the deputy coxswain on

a search and rescue vessel; one of 800 volunteers at the German Maritime

Search and Rescue Association. Professionally, she works in the

emergency department of a hospital in northern Germany.

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“Helping the most seriously ill on the road to recovery or making their situation more bearable when a cure is no longer possible – I find that very fulfilling! My aunt, a pediatric nurse, often talked to me about her work. That is what inspired me to take the same career path – and it was definitely the right one! Even at school, and later during my degree, I helped out at a care home. I learned the basics there. At the age of 17, I enrolled on a nursing course at university and wanted to work on an intensive care unit from the very beginning. I like the challenge of critical situations, when you have to act quickly, like

in the case of heart failure. Then every single member of the team has a role to play. The intensity of this cooperation is something quite special. No two days are the same on an intensive care unit. It is also really important for me to help the relatives through this diffi-cult time. We usually have three units, each with nine beds; I then care for one or two patients. The Covid-19 outbreak has changed that. We suddenly had a high number of se-riously ill patients and increased the number of intensive care beds to 54. I had to care for three patients at the same time. The relatives were no longer able to visit the patients, and

sometimes didn’t even dare to pick up the phone to make a call for fear of disturbing us. I was very happy when the first wave passed, however we are now in the middle of the second wave. I sometimes wish that people could be made to watch a film about a real intensive care unit in order to grasp the fact that anyone, regardless how old and whether they have any previous underlying health conditions, can become very, very ill. Please follow the coronavirus rules. Besides really helping us, it is also the best way of making sure that you and all those who are close to you stay healthy.”

NO TWO DAYS ARE THE SAME´

Esther Nies, 26, intensive care practitioner at Maastricht University Medical Center

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FROM AROUND THE WORLD PEOPLE GOING PLACES

5

A LIFE DEDICATED

TO DISASTER MANAGEMENT

Albrecht Broemme, 67, was the head of Berlin Fire Department and THW

president before retiring in 2019. Last year, he became project manager

of the “Jaff éstraße Coronavirus Treatment Center”

“I spent my entire professional life – half a century – involved in disaster management. Even as a schoolboy, I wanted to learn things that would enable me to really help people. I started out in 1970 as a volunteer at the Federal Agency for Technical Relief (THW). Later, while studying for my electrical engineering degree, I became interested in the fi re service. I had to make a decision at some point, so I ultimately left the THW and became a trainee fi refi ghter with Berlin Fire De-partment in 1977. After qualifying as a fi re assessor, I went through the entire fi re service hierarchy. The worst fi re I ever experienced was in a high-rack ware-house, together with a colleague. We found ourselves in a burning hall after a fl ashover. As the building collapsed, we ran outside and were incredibly relieved to have made it. At that moment, we heard two crack-ing noises shortly after one another in the immediate vicinity. A turntable ladder had been knocked over as the building collapsed – fatally injuring the basket crew as it crashed to the ground. I will never forget the sound of the impact on the cobbled street. I was appointed head of Berlin Fire Department in 1992, before moving back to THW as president in 2006, where I stayed for 14 years. I retired in 2019. A friend from China who came to my farewell celebration said to me: “Watch out, the coronavirus will aff ect us all!” He was proven right, especially for me personally. In March, the Berlin Senate asked me to take on the role of project manager to build the Jaff éstraße Coronavirus Treatment Center by May. We managed to do it (see p. 66). And as a retiree, I was able to bring my 50 years of experience to the role.”

DRÄGER REVIEW 123 | 1 / 2021

AMONG THE RUBBLEIt was mainly volunteer units, including the German Federal Agency for Technical Relief (THW) and @fire, that searched for survivors following the explosion of ammonium nitrate at the beginning of August 2020 in the port of the Lebanese capital Beirut

DO SOMETHING!It is said that volunteering is the backbone of our society. This is true – and there

are many different aspects to it. The first part of this cover story looks at the sometimes astonishing motives, while the second takes a look at volunteering closer to home.

TEXT STEFFAN HEUER


FOCUS ENGAGEMENT

Candice Lin has her hands full working as a food scientist in San Francisco. Yet every week she spends several hours shopping for Spanish-speaking families and elderly people who are no longer able to leave the house due to the coronavirus pandemic and are reliant on donations or assistance.Lin also volunteers on the phone to call potential voters and is one of the founding members of the Mattson Foundation set up by her employer.

Henry Schönrock comes from Freest, a fishing village on the Baltic Sea. He is a boatbuilder by trade, and has spent two

decades travelling halfway around the world as a freelancer building exhibition stands, before volunteering three years ago as a sea rescuer in his community. He now also runs a joinery and is a coxswain at the German Maritime Search and Rescue Association (DGzRS). Schönrock and his colleagues are called out roughly 50 times a year to help stricken seafarers in the vicinity of Peenemündung.

José Andrés moved from Spain to the US when he was young, where he rose to become a celebrated Michelin-starred chef. He is just as well known for his World Central Kitchen charitable foundation,

which, since 2010, has set itself the goal of supplying people in need all over the world with food after natural disasters. Volunteering to cook for thousands of his fellow human beings is something that comes completely natural to Andrés. Following the Haiti earthquake in 2010 and Hurricane Maria in Puerto Rico in 2017, he stood at the cooker among the ruins with a team of helpers to relieve the distress – and exert political pressure.

Three people. Three places. Three different motives for voluntarily giving up their time for society. The motiva-tion doesn’t always have to come from a P

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well-known religious, private, or state aid organization. It is often personal reasons that prompt people to work on a voluntary basis. Many people – or so it seems – want to contribute their time, money, and knowledge to a good cause. Depending on the country and cultural milieu, different structures are in place that fund such volunteering and make it possible in the first place. People can volunteer for a wide range of organizations, including the voluntary fire service and the German Federal Agency for Technical Relief (THW). They can also help to distribute food at the Tafel food bank, look after schoolchildren, integrate migrants, undertake environmental clean-up work, or volunteer as a specialist, such as a nurse or doctor, in crisis-stricken regions.

THE ECONOMIC FACTOR OF VOLUNTEERINGIn the US in particular, a growing number of companies are focusing their attention on so-called corporate volunteering, for which they release their staff and even expect them to volunteer regularly for charitable causes. Engaging in work on behalf of good causes and talking about it has become an integral part of the activities of many companies, while they also meticulously calculate its monetary value. When these activities, which are organized using apps and social media, are combined with the billions invested by wealthy patrons in carefully chosen causes ranging from epidemic control to education, it becomes clear that volun-teering is also an economic factor used by many states and local authorities to fill a gap.

Statistics show how big the volun-teering business actually is. In the US

alone, for example, there are around 1.6 million charitable (and thus tax-exempt) organizations or “nonprofits.” These organizations employ 11.4 million people, or a tenth of all employees in the country. They received almost 428 billion dollars in donations in 2018, which is almost the equivalent of Australia’s entire national budget. At the same time, they relied on the voluntary, unpaid work of more than 77 million US citizens, a quarter of the adult population. Calculated over the course of a year, each volunteer invested 89 hours on average, with each of these hours (theoretically) worth 27.20 dollars, according to the national membership organization Independent Sector.

Several surveys and studies also try to assess the extent to which people volun-teer for charity in Germany. The Allens-bach Media Market Analysis (AWA) iden-tified 17 million volunteers in 2020. According to the report, volunteers pri-marily volunteer at sports clubs, church-based institutions, and various aid organi-zations. It is also interesting to note that the majority of volunteers in Germany are over the age of 50, have a higher level of education or vocational training, and earn more than the general population. The importance of the appeal to the com-mon good to extinguish fires, pump out basements, and look after elderly people is also demonstrated by a lavishly illus-trated campaign launched by the Ger-man government under the slogan “Do your bit! For you. For all of us.” Whether in North America or Europe, the state, the communities, and many parts of the economy are reliant on volunteers. Young people are often encouraged or even obliged to carry out work in the commu-nity for a year. “Ask not what your country

can do for you – ask what you can do for your country,” said US President Kennedy, summing up this moral obligation in his inaugural address in 1961.

Yet why are people prepared to give up their free time and sometimes even risk life and limb? Experts suspect the reason lies in our genetic code. Firstly, we have so-called mirror neurons, which enable us to perceive the emotional state of our counterpart and empathize with their

FROM THE FOOD BANK ON THE CORNER TO THE CRISIS ON THE OTHER SIDE OF

THE WORLD, MILLIONS OF PEOPLE GIVE UP THEIR TIME AND MONEY FOR OTHERS

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TOP CHEF AND ROLE MODELThe native Spaniard José Andrés has volunteered as an emergency aid worker in disaster regions from Haiti to Puerto Rico for many years. He not only cooks food for people in need, but also campaigns for political and social change through a foundation

pain, as if we were experiencing it our-selves. In addition, scientists have proved that even small children are programmed to actively help others. When they noticed that an adult had dropped something, almost all of them reacted within seconds and picked it up unprompted. The Cana-dian psychologist Kiley Hamlin recorded similar findings in experiments with even younger children who had to help a pup-pet surmount an obstacle.

In the course of socialization, far more complex conflicting situations are thrown into the mix for considered motives. People who help others do so for various reasons – both conscious and subcon-scious. He or she feels better. They join a group of like-minded people and are accepted by them in return. A person’s own life experience will also play a part in how they decide to volunteer and to what extent.

Candice Lin grew up with her mentally ill mother in poor conditions. “I wore clothes from the clothing bank. Our car was sometimes broken down for months on end, which meant that my brother and I had to cycle long distances in all kinds of weather to get food,” she recalls. “Without the social programs and the many differ-ent people who helped me, I would not have escaped the vicious circle of men-tal illness and poverty. It is important to


FOCUS ENGAGEMENT

me that I can now give something back.” And Lin states another reason that com-pels many people to volunteer. “I can bet-ter manage stress and feelings of sadness or anger when I help others. It helps me to see how good my situation actually is.” All in all, she invests between five and seven hours of her time each week in shopping for food for a blind veteran and other fami-lies and offering them a bit of a change – taking into account coronavirus re stric-tions, from a safe distance and wearing a mask.

“ONLY A MATTER OF TIME”For Henry Schönrock, he knew it would only be a matter of time before he would volunteer as a sea rescuer. With its 700 residents, Freest has depended on fishing for generations. “The sea rescuers are ever-present here and thus a kind of necessity in the daily life of an old fishing village. Many families have lost relatives at sea. That is also the main cause of death in my family, ahead of illness or world wars. At some point, you are automatically drawn towards the Maritime Search and Rescue Association. Doing something unpaid that promotes a sense of togeth-erness becomes more important to me as I get older,” says the father of three children. His 17-year-old son is now also on his way to becoming a sea rescuer.

Volunteering brings many different things together: appreciation, altruism, but also a little bit of tending to one’s own ego. The Finnish anthropologist Liisa Malkki, who lectures at Stanford University, has dedicated an entire book to the motivation of volunteers (The Need to Help). Between 1996 and 2012, she interviewed Finnish Red Cross employees about their operations and came to the

conclusion that the volunteers need the help just as much as the people they are helping, albeit for different reasons.

“During humanitarian operations, you essentially have to consider who is playing the role of the person in need,” writes Malkki. People who volunteer for dangerous operations on the other side of the world or make toys or knit jackets at home for orphans are doing so to relieve their own distress – to forget personal problems or traumas, to escape the orderly everyday life (which is seen as boring) in their rich country, and to reinvent themselves in minor and major crisis situations. “People who are part of something bigger can also feel like a member of a community of generously spirited individuals,” says the anthropolo-gist. At the same time, we shouldn’t forget the direct and indirect financial interests that also motivate companies – from the chairman to the ordinary employee – to do things for good causes. Volunteering, foundations, and fundraising appeals are an integral part of the corporate vision and mission. Companies that engage in good work can not only offset the costs against tax, but also promote themselves with these values and attract the attention of customers and potential employees. The buzzword is purpose – in other words, defining the purpose of a venture away from the profit.

Salesforce, which rents out corporate software in the cloud, is just one of many technology firms that cultivate their image through their philanthropical work. On a dedicated website, the detailed list of good deeds is checked off against the UNO’s sustainable development goals. In his memoirs, company founder Marc Benioff writes about a visit in 1996 to

PEOPLE WHO HELP OTHERS UNPAID ALSO FEEL

BETTER THEMSELVES

10 DRÄGER REVIEW 123 | 1 / 2021

FOCUS ENGAGEMENT

the Indian spiritual leader Amma, who advised him: “In your quest to make money and succeed, don’t forget to do something for others.” Salesforce now employs almost 50,000 people, who also volunteer for projects all over the world. “A corporate culture that revolves around diversity, inclusion, and values determines where the best and smartest minds will work,” argues Benioff, who campaigns in his hometown of San Francisco for social issues such as the battle against homelessness, and even supports referendums on the matter by donating millions of dollars.

BRAND CULTIVATION THROUGH GOOD DEEDS“We are living in an affective economy, where companies and organizations want to win people’s favor with strong feelings. Companies do good deeds because it meets their needs –right through to brand culti-vation,” says Jeanne Firth, an economic scientist who has conducted investigations at the London School of Economics to establish how and why people are so willing to give up their time and money. She wrote her dissertation on the people’s motives for providing disaster relief in

RESCUER ON THE HIGH SEAS Henry Schönrock traveled all over the world as a fitter, before returning to his fishing village on the Baltic Sea. He is now a voluntary coxswain at the maritime search and rescue station in Freest in Mecklenburg- West Pomerania and has also recruited his 17-year-old son for voluntary work

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her chosen hometown of New Orleans – and came across an astonishing mix of altruism and egotism among those who cooked for poor families and created vegetable gardens in deserted quarters: “I don’t actually care what people’s motives are for helping somebody, as long as they help. Yet at the same time, you have to bear in mind that some people do it for economic reasons. Some companies, primarily the smaller ones, manage their charitable activities and even foundations from their marketing departments.” The lines between economic interests and altruistic support are often blurred here. Firth points out that some notable chefs, who wanted to save the famous New Orleans lifestyle which revolves around good food and jazz, after Hurricane Katrina in 2005 used their star status to buy properties at cheap prices, polish their image, and expand their empire.

In public opinion in the US, working for the common good is essentially viewed as the number one civic duty. “Since Carnegie and the other industrial robber barons of the 19th century, we have lived with the notion that philanthropy and voluntary work starts where the state can no longer afford it. This misconception has been exported all over the world, while the social safety net has been continually dismantled since the Reagan era,” says Firth. The individual’s voluntary work distracts from the bigger systematic problems which should actually be sorted out by the state, adds the economist. Well-inten-tioned citizens – often at the behest of their church – get involved in building new homes in poor districts instead of taking to the streets to protest against the fundamental reasons for poverty and homelessness. And if the volunteers follow

the priorities of a wealthy patron or an influential foundation, it not only conceals society’s errors, but also circumvents the democratic search for consensus.

DONATIONS ALSO HELPIn extreme cases, citizens who feel affected by certain issues don’t even need to lift a finger, because they can buy their way out of the work by making a donation. Such donations increasingly come in the form of conscience-neutral consumption rather than via the charity box at the checkout. A growing number of companies are appealing to the good in people by bringing out a special product range or donating a certain amount of their sales revenue to a good cause when they want to increase sales. The sociologist Lisa Ann Richey from Copenhagen Busi-ness School calls this new phenomenon “compassionate consumption.” This involves a brand and celebrities getting together to find and promote a cause. At the end of the day, the campaigns tend to stimulate consumption in rich countries rather than help those affected. In any case, the company definitely benefits from such campaigns, according to Richey’s summary in her book Brand Aid, even if the aid effort itself is a flop.

None of this should distract from the important, valuable, and often indispens-able contribution volunteers make every day to help people in need. However, people should always remember that money generally plays a role even where good deeds are concerned: Benjamin Franklin founded the Union Fire Company in 1736 – the world’s first voluntary fire service, according to historians. He is known all over the world – not least for the fact that his portrait adorns the 100-dollar bill.

VOLUNTEERING IS A MATTER OF THE HEART – ESPECIALLY FOR THOSE

WHO WERE ONCE ALSO IN NEED

THE HELPER SAYS THANK YOU Candice Lin relied on the support of her fellow human beings and was able to work her way out of poverty. Now, the food scientist regularly shops for elderly people and disadvantaged families to give something back to society P

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Building bridges, supplying entire communities with drinking water and power – or securing buildings at risk of collapse: Germany’s Federal Agency for Technical Relief (THW) takes on big tasks. And yet many operations are on a smaller scale, often in the immedi-ate neighborhood. Just like on this Sun-day morning in the branch of a bank in

Ginsheim-Gustavsburg (Hesse). Following a break-in, two external doors are hang-ing off their hinges, the entrance to the safe-deposit boxes has been demolished. The job of the crew with the blue cloth-ing and yellow helmets is to secure all destroyed openings with wooden boards and screw fixings so that the building can be handed over to the tradespeople

the following day. Curious looks from the bakery opposite are also focused on the blue equipment vehicle. Who is busy here with angle grinders and saws? The operation is just an exercise, the build-ing is set to be demolished shortly, but the scenario is realistic, explains unit leader Dennis Butscheidt. That’s because securing a damaged building is one of the

BLUE BLOODFrom the natural disaster to the destruction of critical infrastructure:

Almost 80,000 people in Germany volunteer for the Federal Agency for Technical Relief (THW), an organization actively involved in disaster management.

TEXT PETER THOMAS

QUICKLY ON THE SCENEFollowing the serious explosion in the port of Beirut in August

2020, volunteers as well as search and rescue dogs from the

THW’s SEEBA rapid-response group were on the scene

tant for the role of German disaster manage-ment and for the identity of the volunteers. If the THW is called upon by foreign gov-ernments, it must act quickly. To this end, there is the Center for Foreign Logistics (ZAL), which opened in Mainz in 2010. This unit, in which sealed aluminum cases are stacked as high as the ceiling, is supervised by Germany’s Federal Aviation Office. All of the material and equipment stored here is ready to be directly loaded onto a plane.

IN PACKED CASES: PART OF THE EQUIPMENT IS ALWAYS READY TO GO

FOREIGN AIDThe THW was founded in 1950 as an orga-nization for German disaster management. Nonetheless, there is a long tradition of aid operations abroad – like here following the serious explosion in the port of Beirut

responsibilities of Technical Unit N (“Emergency Supply and Maintenance”), established two years ago and set to be part of all 668 local sections of the THW in the future.

OPERATIONS ABROADFounded 70 years ago, the Federal Agency for Technical Relief is also known for its operations abroad: earthquakes, flood disasters – or the serious explosion in

the port of Beirut in August 2020. The Rapid Deployment Unit Search and Res-cue Abroad (SEEBA, founded in 1985) and the Rapid Deployment Unit Water Supply and Treatment Abroad (SEEWA, set up in 2004 to supply drinking water in disaster regions) are mainly called on to assist in exceptional situations.

Statistically, such occasions account for a tiny proportion of the roughly 10,000 THW operations each year. Yet they are impor-

FOCUS ENGAGEMENT

“There are around 10,000 pallet spaces in the warehouse,” says Fabian Kehr. The IT systems technician is part of the ZAL’s five-strong team. Rescue equipment and high-power pumps are kept in the ware-house alongside everything needed to set up entire camps. The dispatched units are able to remain self-sufficient for ten days. There are even smaller kennels, complete with blankets, to house the search and rescue dogs. The THW also keeps medi-cal equipment in the containers. A data-base provides information on the status of the equipment. Items are booked in and out using bar codes and a handheld scan-ner. The THW has assigned a specific loca-tion for every item rather than opting for a space-saving “chaotic” storage approach. “This serves as a fallback solution – in the event of a power outage, for example,” says Kehr. At the THW, there is a tradition of providing assistance throughout the world, stresses Gerd Friedsam. The former spe-cialist subject teacher at Germany’s Fed-eral School for Disaster Management has been the president of the THW since Jan-uary 2020. “The first foreign operation was in 1953. In Holland, we helped to over-come high tides and extensive flooding,” says Friedsam. Back then, the THW had around 3,000 volunteer members.

It has carried out operations in more than 140 countries since then, and has con-stantly grown: Today, it has almost 80,000 volunteers. At present, 15 percent of these volunteers are women. Then there is the youth organization and up to 2,000 places each year for the Federal Voluntary Ser-vice. More than 6,000 new volunteers have joined over the past year, with around 80 percent of them aged 35 or younger. “The THW’s work with children from the age of six and with young people is particularly

important for its future,” says Sabrina Heinz. The physician assistance student grew up in a typical THW family and now supervises the local section of the THW Youth in Rüsselsheim, among other things. Gerd Friedsam is proud of such traditions and talks of families who are now actively involved in the THW in the third genera-tion. When he talks about “blue blood,” the president, whose office is in Bonn, is not talking about the nobility, but rather the unity within the organization. In pic-tures taken when it was first founded, vol-unteers can mainly be seen with shovels, wheelbarrows, and sandbags. Nowadays, there are heavy trucks, cordless power tools, excavators, and radio technology. And it isn’t just the equipment that has changed. “In terms of its structure, the THW of the early days is incomparable with today’s modern organization,” says the president. It has constantly improved and adapted to the new demands of disas-ter management and civil protection.

CHANGED RISKSKeeping track of risks and continuously reassessing them is essential to disaster management, confirms Gerold Reichen-bach. The former member of the Ger-man parliament (SPD) has been actively involved in the THW since 1976, and was a member of the steering committee of the THW’s national association and chair-man of the Hesse regional association. In his role as reporter for his civil protec-tion and disaster relief section, he co-pub-lished the 2008 book Risiken und Heraus-forderungen für die öffentliche Sicherheit in Deutschland (Risks and Challenges for Public Safety in Germany). One scenario in the book dealt with the outbreak of a pandemic caused by a SARS virus trans-

mitted by humans. This is precisely what has happened in 2020 – with differences in terms of infectiousness and mortality. SARS-CoV-2 is also keeping the THW busy, says Gerd Friedsam. Among other things, the organization has built a testing center, advised crisis teams, and delivered protec-tive equipment purchased by the govern-ment to public facilities. The fact that the THW’s tasks have become more diverse is reflected in the roughly 1,000 THW techni-cal units and their specialized tasks. One area focuses on damage to critical infra-structure such as the drinking water and energy supply, communication networks, and transport routes. Among the extraor-dinary groups are units that specialize in building bridges (including temporary railroad bridges up to 120 meters long)

WELL EQUIPPED This high-bay storage system with ready-to-use modules is also part of the Center for Foreign Logistics. Bottom: Cristoforo Cascino, THW training officer in Mainz, with breathing apparatus (Dräger PSS 5000) and helmet (Dräger HPS 4300)

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and blasting (when drift ice threatens a bridge, for example) as well as the supply of drinking water with laboratories and mobile waterworks.

THE ROUTE INTO THE THWThe professional backgrounds of the vol-unteers are diverse. Alone in the team involved in the exercise at the former bank branch there are clerks, schoolteachers, forest managers, and engineers, plus young apprentices and students. What they all have in common is the desire and willing-ness to help. While some want to use their professional qualifications, others simply enjoy the change from their normal job. Many people also find their specialist area in the course of their volunteer work. Like Günter Steinmüller and Peter Münch, both are employed in technical positions in the automotive industry. The chairman of the local section in Rüsselsheim and his depu-ty have developed into logistics experts over the years. Their location close to Frank-furt Airport is the personnel hub for all of the THW’s foreign operations. The neigh-boring local section in Groß-Gerau takes care of the catering. “When the availabil-ity request arrives in the middle of the night and around 50 crew members need breakfast early in the morning, you need to be able to improvise,” says Steinmüller, recalling past missions. A team of around a dozen volunteers from the local section makes sure that all processes and supervi-sory tasks are taken care of, says Münch.

Anyone who wants to volunteer for the THW must complete the basic training, explains Cristoforo Cascino, chemical pro-cess technician, who also serves as the THW’s training officer in Mainz. On aver-age, 15 new volunteers take their exams here each year. The qualifications they can

THE DESIRE TO HELP UNITES PEOPLE – ACROSS BORDERS AND DISCIPLINES

TAMING HIGH WATERS Flood operations are also among the jobs regularly handled by the THW.The specialist skills required here come under the Water Damage/Pumping Technical Unit. Besides sandbag dams, high-power pumps are also important tools in combating the water

16 DRÄGER REVIEW 123 | 1 / 2021

FOCUS ENGAGEMENT

“WE WERE ABLE TO GIVE PEOPLE PEACE OF MIND”

Anesthetist and THW volunteer Katharina Lederer is part of the Rapid Deployment Unit Search and Rescue Abroad (SEEBA). In August 2020, she went to Beirut after the serious explosion in the port. SEEBA is Germany’s only serious urban location and rescue unit.

Ms. Lederer, how did it feel when you were sent on yourfirst foreign operation with SEEBA?We are actually always prepared for it: The packed bag is on standby, the immu-nizations are up to date. But when I heard the words “We are flying” the night after the accident, the practiced exercises were suddenly very real. I can deal with the pressure during the operation quite well because of what I do for a living.

What were the team’s tasks on the ground?Our roughly 50-strong team was supported during the entire operation by two paramedics and two medical doctors. On the ground, we went with them around the area destroyed by the explosion to search with the dogs for survivors. Inciden-tally, among the extensive medical equipment was a Dräger emergency ventilator.

What kind of emotions were triggered within the team when youwere no longer able to rescue survivors from the rubble?Every international team was deployed by the authorities in areas that had already been searched with a negative outcome. So it was mainly about confirming that there were no more survivors in the rubble. Neither the population nor we therefore considered our mission a failure. Instead, we were able to give people the peace of mind that work on the difficult cleanup operation could now begin.

What is the contact like with the locals during such an operation?We learned quite a lot about life in Beirut; we were put up in a German– Lebanese school and were able to chat with the teaching staff. We were pleased that we were able to leave most of the consumables we had brought with us in Beirut; medical supplies for the hospitals and masks for the schoolchildren to prevent the spread of coronavirus.

obtain later on include breathing appara-tus training, explains Cascino, pulling the mount from the side of the equipment vehi-cle holding two Dräger PSS 5000 breath-ing apparatus kits. The THW has adopted Fire Service Regulation 7 (FwDV 7) relat-ing to the handling of the breathing appa-ratus technology. “Besides the PSS 5000, the THW also uses Type HPS 3500 and HPS 4300 helmets,” says Guido Linge, sales engi-neer at Dräger. Yellow HPS 4300 helmets are THW standard, adds Linge. The THW has purchased color-coded versions for for-eign operations. That’s because individu-al roles are identified by the color of the helmet on international missions (see also Dräger Review 122: p. 38 ff.).

NEW RECRUITSMany volunteers come to the THW over many different paths, be it through friends, college courses, or their jobs. This was also the case for the anesthetist Katharina Lederer, who works in Frankfurt. The doctor is a SEEBA member and joined the team during the foreign operation in the Lebanon in August 2020 (see the interview). “I was working as a paramedic at the time, and I became aware of SEEBA in the course of a conversation at the emergency depart-ment of University Hospital Marburg. I was immediately interested. After completing the THW’s basic training and various oth-er courses, I became a SEEBA paramedic.” Lederer has been familiar with the ware-house for the foreign missions for a num-ber of years, because she also looks after the medical material: “This also includes checking packing lists and expiry dates,” she says. After all, the material must be imme-diately available for the next operation so that it can be transported to the airport and flown to the scene of the operation. P

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THE MACHINE WHISPERERS

For centuries, algorithms have been driving the economy and the world of science and technology to new levels of performance. In the meantime, however,

there has been a growing fear that mankind could lose control of its own rules. Where do the risks and opportunities lie? An analysis of the situation.

TEXT FRANK GRÜNBERG


HOSPITAL ARTIFICIAL INTELLIGENCE

n the UK, the exam grades of school students in their final year will not be calculated by computers after all. The gov-ernment had actually developed an algorithm specifically for this purpose. So what happened? Since students were unable to take their A-level and GCSE exam as a result of the corona-virus pandemic, the Department of Education asked teachers nationwide to predict the grades their students were likely to get. However, this resulted with the grades being much high-er than the average grades achieved in previous years. The rea-son: Many teachers clearly based their predictions on individual best grades. The factors on the testing day which can interfere with many an exam played no part.

Accordingly, the government decided to take corrective mea-sures. With the aid of an algorithm, the average grade achieved at the schools in question in previous years was to go towards determining the grade. This resulted in many students getting far worse grades – although more so at state schools than pri-

vate establishments. Had the algorithm penalized poorer stu-dents and benefited the more affluent ones? The suspicion led to huge protests. The consequence: The government withdrew its own rule in mid-August 2020. An isolated case. For now. That’s because there is growing skepticism about the power of algorithms. Some critics now see in them the cause of almost all of the world’s ills. Frank Schirrmacher, the publisher of the Frankfurter Allgemeine Zeitung (FAZ) who died in 2014, held them responsible for nothing less than the erosion of solidarity within society – and the triumphant rise of digital capitalism.

The voices calling for caution are also growing louder in the healthcare sector. The use of algorithms could help to improve patient care, but it also raises questions about dis-tributive justice, protection against discrimination, and there-fore about trust in the healthcare system as such, according to the authors of a study (Algorithms in Digital Healthcare) published in 2018 by the Bertelsmann Foundation and the Cologne Center for Ethics, Rights, Economics, and Social Sci-ences of Health (ceres). “In our view, we as a society there-fore need to come to a widespread understanding of which

PHYSICAL CONTACTbetween man and machine – algorithms are finding their way into new areas of our lives, including the field of medicine

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developments we should collectively endorse and pursue, as well as a sense of where our ‘red lines’ must be drawn.”In actual fact, algorithms are nothing more than clear instruc-tions. They describe, step by step, how a goal can be achieved; how something like a shelf can be put up with planks of wood, screws, and brackets or how thermal energy can be convert-ed into kinetic energy. Other examples include calculating the shortest distance from A to B or securely encrypting an e-mail. Algorithms use text-based, mathematical, or digital codes to do this. The key thing is that the instructions are clear and always lead to the same results.

A MODE FOR DEVELOPERS: THE HUMAN BRAINAmong the oldest recorded algorithms are cooking recipes, writ-ten around 4,000 years ago in China. One of them perfectly meets the core algorithmic definition: Mix two eggs, 250 grams of but-ter, a tablespoon of sugar, and 200 grams of flour, knead the dough and bake it for half an hour at 180 degrees Celsius. These

ULTIMATELY, AN ALGORITHM THAT WORKS DOESN’T HAVE TO BE TO EVERYONE’S TASTE

ingredients are used to produce a cake. And if it then looks like the picture in the cookbook, the algorithm has worked perfect-ly. This is also the case if it ultimately doesn’t taste good. Cook-ing recipes are a reflection of a fundamental problem of algo-rithms: Even when they work perfectly, they still by no means lead us to a perfect result. At the same time, they are now doing ever more things. While their primary purpose in the past was to help us complete tasks more quickly and easily, they are now increasingly focused on interpreting and manipulating human behavior. They recommend advertisements when shopping online, provide evaluations of our creditworthiness, or deter-mine which information we get to read on our social media apps.

Tech companies such as Amazon, Google, and Facebook build their business success on precisely these sets of rules. They now instill such incredible abilities in digital machines that they have a rather uncanny effect on many people. Algo-rithms are simultaneously finding their way into new areas of our lives – including the field of medicine. Unlike previously, algorithms are no longer only applied to linear systems, but

HUGE DATA CENTERS

– like this one in Saint-Ghislain, Belgium – are needed for ever more

complex algorithms, which then recommend advertisements when we shop online, provide

evaluations of our creditworthiness, or determine which information we get

to read on social media apps

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20 DRÄGER REVIEW 123 | 1 / 2021

also networked systems. Methodically, the developers are being guided by the human brain. The brain consists of a complex network of individual nerve cells, the neurons, which do very simple sums independently of each other. They are linked to one another via synapses, which are not hardwired from the beginning. “Frequently used synapses grow stronger over time,” explains the scientific author Christoph Drösser in his book Total Berechenbar? Wenn Algorithmen für uns entscheiden (“Totally Predictable? When Algorithms Make Decisions for Us”).“Their signals then have a bigger effect on us than those that are used less often. We call this learning.”

SPURIOUS CORRELATION: A GOOD ANSWER TO THE WRONG QUESTIONResearch into neuronal systems received a massive boost in the 1980s. The reason for this was the huge progress being made in the field of computer technology. Back then, the discipline was still known as chaos physics, because the clear principles of cause and effect could no longer be grasped. Today, terms such as “machine learning” and “artificial intelligence (AI)” have become established. They reveal where the journey is heading: inside the human being, one of the most complex sys-tems of all. The AI developers’ aim is to understand and predict mankind’s social, mental, and physical behavior as precisely as possible. In this regard, neuronal algorithms are not rock-et science. Just like other algorithms, they are based on the methods that a computer masters quickly and correctly when it comes to identifying recurring patterns: comparing, filter-ing, sorting. However, they are no longer directly optimized by an engineer or programmer, but by means of automated train-ing using known data sets. Software programs use these data sets to vary a basic algorithm until it delivers the best approx-imation of the test data. The better this works out, the bigger the likelihood that the algorithm describes reality. The prob-lem: Without the data sets used to train the algorithms, the way in which they function cannot be conclusively understood. However, many of these data sets are not publicly accessible, because they are in the possession of Internet firms or govern-ment agencies, such as the material used for facial recognition by cameras in the public sphere. The consequence: The citi-zens are unable to comprehend or scrutinize the way in which the algorithms work. Even though they influence our daily lives in unprecedented ways, they remain largely non-transparent.

The potential consequences of this lack of transparency were brought to light by an AI project – so legend has it – set up by the

WHITE-BOX OR BLACK-BOX?THE DRÄGER PERSPECTIVEStudies show that self-learning algorithms perform better than many doctors when assessing CT or MRI images, for example. The reason: The machines are fed with information from top experts. With the aid of these algorithms, patients can therefore also benefit from this knowledge, even if they never meet the specialists personally. “Such benefits also filter through to the areas in which we supply medico- technical products,” says Frank Franz, head of advanced analytics and algorithms at Dräger. However: “We still only use deterministic algorithms, also known as white-box models, in products so that we always know the output when given a particular input.” Black-box models, known as non-deterministic algorithms, do not offer this security. That’s because they follow statistical methods that do not provide 100 percent prediction certainty. Algorithms with an uncertain residual risk, however, are not granted approval in the area of life- sustaining medical equipment. So what can be done? “In order to prove that a self-learning algorithm functions reliably, you need large quantities of data to train and validate the algorithm,” says Franz. “Patient data in particular, however, is subject to strict data protection laws. This dilemma must be solved.” That is why Dräger is pursuing a graded strategy. One thing is certain: “We must be able to explain the functions and especially the results of these processes in an under- standable and transparent manner,” stresses Franz. “This is the only way in which we can prevent users from getting the fatal impression that somebody is dabbling around in their affairs unchecked.”

The full interview with Frank Franz, head of advanced analytics and algorithms at Dräger, can be read here – simply scan the QR code.


HOSPITAL ARTIFICIAL INTELLIGENCE

FROM THE RECIPE TOARTIFICIAL INTELLIGENCEThe history of algorithms can be broken down into fi ve phases – each still has an impact on the way we live today.

approx. 4,000 BCFood recipes are

carved in stone. This is revealed by discoveries in China, for example,

which describe how to make cheese(photo: a lump of cheese from

Xinjiang / western China). Nowadays, instructions are often

supplemented by pictures or diagrams in order to make them

easier to understand.

approx. 300 BCIn the Egyptian city of Alexandria, the

mathematician Euclid defi nes ruleswith the aid of algebraic formulae.

The algorithm named after him describes how the greatest

common divisor of two integers can be calculated. To do this, he uses

the fact that the greatest common divisor of two numbers does not change

when you subtract the smaller number from the greater one.

1877The German engineer Nicolaus August Otto

fi les his patent for the fi rst combustion engine. The algorithmic character is

also refl ected in the name: The four-cycle engine.

1843The British mathematician Ada Lovelace combines

in table form machine commandsto create a complex program – writing computer history in the process. It is the fi rst algorithm

in the world that instructs a mechanical computer to provide

a result that has not been calculated by a person

in advance.

approx. 780–850The mathematician, astronomer,

and geographer al-Khwarizmi teaches in Baghdad. He is now considered the man who gave

algorithms their name. In Latin, he is known as Algorismi.

US Department of Defense. According to the legend, the Penta-gon ordered software from AI developers that was supposedly capable of spotting camouflaged tanks using satellite images. The researchers trained their neuro-software using 50 photos featuring landscapes with camouflaged tanks and another 50 photos featuring landscapes with no camouflaged tanks. The aim of the training was to ensure that the software would then be able to reliably identify landscapes with camouflaged tanks. The subsequent testing phase with 100 further photos – 50 for each scenario – also produced the desired results. Among the generals who performed the test with their own photos, how-ever, the software no longer worked at all. And it would be some time before the researchers identified the error: They had shot the 100 landscape photos featuring camouflaged tanks in nice weather, but the 100 photos without the tanks in bad weather.

The software had actually learned to distinguish between sunny and cloudy weather. It was no less demanding, but it didn’t solve the task that was set. Experts refer to cases like these as “spurious correlations.” In the healthcare sector, spurious cor-relations can quickly have fatal consequences and cause people harm. Self-learning systems are increasingly being used here

62The mathematician and engineer Hero

of Alexandria, known as Mechanicus,

develops the fundamental principle of the steam-powered

engine. It converts thermal energy

into kinetic energy.

1769The British engineer James Watt fi les the

patent for the fi rst real steam-powered engine

– the industrial age begins.

MECHANICAL PHASEALGEBRAIC PHASEDESCRIPTIVE PHASE

– to predict mental illnesses among users of social media, for example, to support medical therapy decisions, or to restore mobility to paralyzed people. The authors of the Bertelsmann study therefore warn against looking at technological progress alone. They call for a wide range of accompanying measures on various levels, starting with training for medical staff on the definition of standards used to prevent such spurious correla-tions and extending to the need to deal with questions posed by an independent “ethics of algorithms,” as well as with the issue of algorithm oversight.

ALGORITHMS NEED AN ETHICAL BASIS“Instead of focusing on human action, ethics of this kind – in the sense of a subdiscipline of machine ethics – would be ori-ented toward ethical rules intended to apply to all machine-learn-ing systems and processes,” they write. “In particular, it would be a matter of determining – and then programming – rules through which moral norms could be recognized and ethical dilemmas resolved.” The British government clearly hadn’t reflected on such matters. Otherwise it would probably have avoided pursuing the wrong course with algorithms. P

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HOSPITALARTIFICIAL INTELLIGENCE

KRANKENHAUS THEMA

2016The DeepMind

software AlphaGo from Google manages to defeat

the exceptional South Korean player Lee Sedol 4:1. Go is considered the

most complex board game of all.

1903The US entrepreneur Henry Ford founds the

Ford Motor Company and builds cars on a moving

assembly line for the fi rst time. Ford is considered the inventor of revolu-

tionary mass production methods.

1965Gordon Moore, co-founder

of the chip manufacturer Intel, formulates the law that bears his

name. It predicts that the processing power of chips the size of

a fi ngernail will double every 18 to 24 months. This eff ect gives

the development of new algorithms an enormous boost.

1968The ARPANET

(Advanced Research Projects Agency

Network) is founded – the predecessor of

the Internet, the biggest data

collection machine of all time.

1950The British mathemati-

cian Alan Turing develops a method that can deter-mine whether a computer has the ability to exhibit

intelligent behavior equivalent to that of

a human. By doing so,he lays the foundations

for research into “artifi cial intelligence.”

1951The US mathematician Marvin Min-sky builds the fi rst neurocomputer. With just 40 synapses, the machine

simulates the behavior of laboratory rats looking for the fastest way out of a labyrinth.

1997IBM’s computer

Deep Blue beats the then Russian chess

world champion Garry Kasparov.

Kasparov had won the previous year.

2005Stanley, the fi rst self-driving car from Stanford University,

wins the DARPA Grand Challenge. The autonomous robotic car

is the fi rst to successfully complete the211-kilometer course through

California’s Mojave Desert driverlessand error-free in just under seven hours.

1941The German

computer scientist Konrad Zuse builds

the Z3, the fi rst fully automatic,

freely programmable computer.

DIGITAL PHASE NEURONAL PHASE

GOING WITH THE FLOW? Algorithms infl uence our

daily lives in unprecedented ways. At the same time,

they are often opaque


PURE DESTRUCTION The alarming toll of recent years is

clear to see in Eifel National Park

24

FOREST PESTS

he best v iew can be obtainedfrom very high up: Anyone who wants to get a good overview of the state of a German forest in the third year of a severe drought should ideally use special satellite cameras. Hundreds of kilometers above the earth, their lenses are focused on the crowns of our trees. Remote sensing is a powerful tool used to take stock of our forests. Some sensors can collect images with ground resolutions well below one meter. They measure how green and vital the forests are. Not just in Europe, but worldwide. Much of the data is a cause for concern: The man-made wooded landscapes created over the course of the centuries may soon no longer be able to cope with the new climate.

A WORRYING DEVELOPMENTEven though summer 2020 was not as dry in Germany as in the two previous years of extreme drought – the average rainfall was nine liters per square meter below the ideal figure – and it was warm, 1.1 degrees warmer than average for the period between 1981 and 2010. High evaporation levels and dry soil denied the beleaguered tree population the desired recovery. Summer heat and mild winters allow the predators of the flora to thrive. Bark beetles are among the most prominent and feared members in the menagerie of hundreds of thousands of species. More than 100 of these species can be found in Germany; there are around 6,000 species worldwide. The larger eight-toothed spruce bark beetle (Ips typographus) is the monster of them all here. As a

beneficiary of climate change and monocul-tures, it ravages dried-out forest land.

OPERATION “ANTI-BRUMM”From not quite such a high vantage point as a satellite, everyone can get an idea of the sit-uation for themselves. The spruce dieback in the Harz region, noticeable for miles around by the gray wasteland or already cleared areas, has become a symbol of the plague – because such a small insect is capable of causing such huge devastation. Based on the figures, the damage inflicted on timber by bark beetles

in recent years is akin to a plague of locusts in slow motion. A good six percent of the spruce harvest in 2014 was damaged by insects. Just five years later, the figure had increased more than tenfold to 63 percent.

By the end of 2020, official estimates predict a total loss of 285,000 hectares of forest area and more than 178 million cubic meters of damaged timber. The situation is so dramatic that Ger-many’s forestry people have even called in the army to help. The soldiers started by hunting beetles in the forests of Saxony: Oper-ation “Anti-Brumm.” They then did the same in the eastern Harz region and elsewhere. Using meter-long bark scrapers, felled spruces were debarked to exterminate the larva. Masks were only needed here to provide virus protection while traveling to and from the location, because the bark beetle is nontoxic and non-allergenic. The same cannot be said, however for all of its insect relations. Anyone who has to deal with the oak processionary in a professional capacity, for example, needs respiratory protection

GOOD ENOUGH TO EATClimate change is increasingly threatening forests and urban parks.

Pests are also affl icting them. Professional pest control is often insuffi cient. Experts are endeavoring to fundamentally modernize forestry.

TEXT SILKE UMBACH

ENEMY NUMBER ONEThe bark beetle

primarily damages spruce trees. Drought years have

turned it into a pest

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and a splash protective suit, because the caterpillars of the gray-ish brown moth produce a treacherous poison. In the six stages between the egg and independence, it is produced from the third onward. “The caterpillar’s short stinging hairs are prob-lematic,” says Björn Marzahn, spokesman from Hamburg Envi-ronmental Authority. Each one is said to have around 600,000 of them. “They contain the venomous protein thaumetopoein, which can cause severe irritation of the skin and airways.” Since the hairs are just 0.2 millimeters long, with a diameter of 0.005 millimeters, they can be scattered several hundred meters by the wind. What’s more, they and their poison last for years. Even the abandoned nests of the insect that lives in big groups remain dangerous. Caution must therefore be exercised when arborists get close to them. Protective clothing and filtering face masks are then mandatory. Once they reach the top, there are several nontoxic ways of controlling the caterpillars. The nests can be bonded with glue so that the stinging hairs can no lon-ger fly around. You can also spray them with hot water, which doesn’t damage the tree. They can also be vacuumed away. Here, too, the right air filtration is important – the pest control experts use asbestos-certified industrial vacuumed cleaners in the highest protection class. No stinging hair can escape and the vacuumed nest is incinerated as hazardous waste.

SELF-PROTECTION FOR ARBORISTSBut how do the arborists ensure that none of these hairs end up in their lungs? The disposable FFP masks now very familiar to everybody are common, as are half-masks with particle fil-ters. It is much more comfortable and pleasant in the heat – as the summer is the main danger period – with a powered air-pu-rifying respirator, as Ingo Hinrichsen from Dräger knows only too well. He extends an invitation to try it on. There is always a fresh, gentle breeze beneath the protective hood; the system holds back the hazardous substances, including aerosols. The powered air-purifying respirator (Type: Dräger X-plore 8000) is worn on the back with a waist strap. And since everyone is now familiar with wearing an air-filtering mask over the nose and mouth, the difference soon becomes clear: It is much less tiring breathing like this compared to breathing through an FFP mask, and even the goggles do not fog up. The active air supply also means that

ONE BORES, THE OTHER STINGS – PESTS ARE CHALLENGING HUMANS

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Destructive labyrinthThe spruce bark beetle (Ips typographus)

ravages the most vital part of the conifer trunk.

Bast

Bark

Larva

Mating chamber

Borehole

Boring dust

1–6 mm

Beetle Pupa Larva

CHAMBER OF HORROR Once the male has created the chamber,

the beetles mate in it. The larvae also grow here,where they cause further damage. Once they have pupated, they move onto other trees.

26 DRÄGER REVIEW 123 | 1 / 2021

FORESTPESTS

breathing with the unit is not subject to any of the usual time limits demanded by occupational health and safety regulations, according to Ingo Hinrichsen – there is greater resistance when breathing through an FFP mask, and this exhausts the wearer. Accordingly, they are required to take a break after 120 minutes.

With an active air supply, meanwhile, the user can work in the tree for a longer period. At the beginning of September, the processionary had already been vacuumed out of 430 oak trees in Hamburg; the total figure for 2019 was 460. Every district in the city is infested. “The moths are thought to have arrived in the north almost ten years ago on a truck,” says Environmental Authority spokesman Marzahn. The habitat of virus-carrying ticks has also been shifting northward to ever higher latitudes for a number of years. They have already reached the Emsland region.

For the forest itself, however, such pests represent little threat. The tick feeds on animals and humans, and oak trees and moths largely keep each another in balance off the beaten track; the feeding intensity of the leaf-devouring caterpillars is nowhere near on the same scale as the bark beetle invasion. The longer vegetation period associated with the warming of Central Europe allows the pest to burrow beneath the bark, completing up to three generations in favorable years; the drought lowers

the ability of conifers to resist pests by affecting the flow of resin. And every beetle generation is around 40 times greater in num-ber than the previous one. This plague is undoubtedly the big-gest sign that the tree population in Central Europe will change significantly – and has to change if it is to be sustainably man-aged for future generations.

REMODELING PROJECTIt still looks bleak for the spruce, the most common type of tree in Germany – it occupies a quarter of the entire forest area. “The spruce has always been the bread and butter of our forestry,” says Norbert Panek, forest conservationist and, since 1986, prin-cipal co-founder of the now thriving Kellerwald National Park in northern Hesse. “It was always good to handle and is ready to harvest for timber after only 80 to 100 years.” Only? Clearly, forest experts think in different dimensions to those of us who are used to more fast-living industries. “Beech trees need 120 to 140 years, oak trees even longer.”

Why is it hitting the large spruce population so hard? “The spruce tree actually originates from the highlands,” explains Panek. “It became genetically altered in the cool, rainy cli-mate. That is why it does not put down deep roots and suffers so

TRANSFORMING NETTLES The caterpillar of the oak processionary produces an allergen that is harmful to the skin and bronchi


much during droughts. “Of course, we didn’t discover all of this only yesterday,” says Panek. Many people say that the spruce is an at-risk tree species. We have to remodel our wooded areas to make them mixed forests with a high percentage of deciduous trees, but that hasn’t happened as yet.”

DECISION TIME One reason for this comes down to the incentives – the main demand on the market is for coniferous timber, and timber sales remain the key source of income for private forest owners. And all of this despite the fact that the forest has so many fans. Most people love the forest and worry when something is wrong with it. There is inadequate compensation, however, for the role it plays in the interests of the common good, says Panek: “Forests are places of relaxation, they store water and bind carbon diox-ide, which they absorb from the atmosphere. They also have a significant cooling effect. Anyone who has ever walked through a dense forest in high summer will notice that the temperature here is ten degrees lower.” The beech, Panek’s favorite tree, plays a big part in this – it is one of the “shade tree species” with a dense canopy, thereby shielding the forest floor from the sun.

Its future is also not completely certain, because there is also a beech bark beetle. In recent years, this pest has also appeared more frequently in Germany, although so far not with the same vehemence as its relative that specializes in coniferous wood.

The next few years will be critical. The approaches that exist for preserving the forests cover a broad spectrum. The choice will also depend on the extent of climate change in Europe, which remains uncertain. The market of possibilities ranges from options put forward by ecologically minded experts like Norbert Panek or the popular forester and author Peter Wohlleben to the forest economists who see no contradiction between intensive produc-tivity and sustainability. It will probably all boil down to a com-petition between the concepts. Experiments to replant native species between the regional climates of Central Europe are already under way, while untouched mixed forests – in national parks, for example – are largely being left to their own devices. Although they are being monitored, of course. There is at least a consensus that plenty of work lies ahead. Whether beneath a protective hood while working on a caterpillar-infested tree or in a control room monitoring forests via an earth observation satellite, either next summer or over the coming decades.

CHANGING INCENTIVES FOR FOREST OWNERS – THEY COULD BRING ABOUT

SUSTAINABLE FORESTRY

WELL EQUIPPED Splash protective suit, special vacuum, and an X-plore 8000 Series powered air-purifying respirator: A reliable method for controlling the oak processionary P

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FOREST PESTS

X-PLORE 8000: ALSO PROTECTS IN HOSPITALS

Dr. Sarah Engel, a physician in the Anesthesiology and Intensive Care Medicine Department at University Hospital Schleswig- Holstein (Lübeck Campus), on the measures taken by her team during the Covid-19 pandemic.Seldom has there been such a global focus on personal protective equipment and especially respiratory protection as in this year: The coronavirus pandemic brought the need to familiarize not only specialist staff and at-risk groups, but entire populations with the differences between surgical face masks, filtering face pieces (FFP2/FFP3), and technical precautions for purifying the air in entire rooms as well as air for personal use. While surgical face masks (for nose and mouth protection) and cloth face masks have been adopted in everyday life, emer-gency service professionals and hospital staff need to rely on equipment that offers

far greater protection. Those who are involved in anesthesia or ventilation are considered to be at the maximum risk of exposure when treating Covid-19 patients. “Infectious aerosols can be produced when treating infected patients,” explains Dr. Sarah Engel, a physician at University Hospital Schleswig-Holstein (Lübeck Campus). “Breathing usually works by air flowing into the lungs as a result of nega-tive pressure.” This changes when the patient is ventilated via a mask or tube: “Air is now channeled into the respiratory tract using positive pressure – causing aerosols to form and stir up. As such, the clinical staff are always surrounded by potentially infectious material.”

For Engel and her colleagues, this means: Strict “standard operating proce-dures” had to be developed and observed from now on during the pandemic. A double-check principle helps to prevent mistakes here; it is designed to protect

both patients and staff equally. Just like across the entire healthcare sector, the hospital in Lübeck was equipped for every eventuality in the spring. The Plexiglas visor joined the half-mask and protective clothing. A project group also tested a powered air-purifying respirator (Type: Dräger X-plore 8000), and Sarah Engel joined the group. “The principle is as follows: Beneath a hood, which covers the head and shoulders, positive pressure is generated by a blower fitted with a virus filter so that no contaminated aerosols can penetrate it.” Furthermore, unlike disposable materials, breathing is not impeded, even during demanding activities and there are no limits imposed on how long the hood can be worn – so besides the regular work breaks, there are no interruptions to patient care as a result of having to change equipment. Personal perfor-mance tests, such as climbing stairs wearing the hood and unit, were completed successfully.

The Lübeck hospital came through the first months of the pandemic well. Fortunately for the region, it has thus far (as of November 2020) been possible to prevent an emergency situation with a high numbers of cases. Yet the proce-dures and routines remain in place: “Even though not everything that we have prepared has been used yet, we are well prepared for what might happen,” says Engel.

If you have any questions about the X-plore 8000 series or require further information, simply scan the QR code and send us an e-mail.

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IN THE ETERNAL ICE The medical care concept at the Alfred Wegener Institute’s Neumayer Station III in Antarctica must function self-suffi ciently for the overwintering season

SELF-RELIANTWhether on an island, at a research station, or in space, what actually happens

when no additional help can be brought in from outside in the event of an emergency? Special strategies are needed in exposed locations.

TEXT PETER THOMAS


RUBRIKTHEMA

Not a single hospital for miles. The Neumayer Station III in the eternal ice of Antarctica must adapt to this risk. That is why there is a well-equipped hospital, including a telemedi-cine link to Germany. Island inhabitants all over the world are familiar with similar challenges – including those on the East Frisian island of Juist on the North Sea coast. An alarm was raised in the early hours of the morning – a fire had broken out in the basement of a hotel. The emergency services successful-ly evacuated dozens of people while work began on extinguish-ing the flames. Locating the source of the fire proved to be diffi-cult. A thermal imaging camera would have been requested from

the next largest support base on the mainland, but in the mid-dle of winter on Juist with its tide-dependent port? “That was really tricky,” says Thomas Breeden, recalling the operation in 2003. The 54-year-old has been Juist’s fire chief since 2004. A helicopter couldn’t be used at the time, so two trained emergen-cy staff from the neighboring island of Norderney took a ther-mal imaging camera and boarded the vessel Bernhard Grubenbelonging to the German Maritime Search and Rescue Associ-ation (DGzRS). Halfway there, the all-clear was given and they were able to turn back. “In the meantime, we had identified the source of the blaze and were able to bring the fire under control,” says Breeden. “After this experience, we purchased our very own thermal imaging camera,” explains the fire chief. Isolated places compel people to reassess those risks that can P

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STRATEGYISLAND RISK

be comparatively well managed in closely linked geographical locations. The corresponding strategies must take into account the resources available in the location and bring them in line with the safety objective. This is always a socially constructed idea which is generally guided by the extent to which it can be managed from a technical perspective and the potential risks. Whether polar station, wind farm, space station, or island, the reality of life in exposed locations permits the realistic assess-ment of such risks. The church on Juist, for example, has been destroyed by acts of nature and rebuilt on four occasions since its foundation around 1400.

TECHNICALLY WELL EQUIPPEDIsolated locations are always characterized by the fact that they are more difficult to access. “We generally have to get by with no firefighting help from neighboring communities,” says Thomas Breeden, explaining the biggest challenge for the fire service founded on Juist in 1898. It currently has 53 active firefight-ers, including eight women. “It can’t be any fewer than that,” says Breeden. The youth fire service, founded in 1978, is important for nurturing the next gen-eration. The fire chief would also like to see more training on the island. The basic train-ing courses should at least be held on Juist, according to Breeden, whose biography is typ-ical of an islander. He spent his younger years on the mainland, trained as a lathe operator, had a career in the aerospace industry and in the German Air Force, before returning to the island around the turn of the millennium.

There are currently no plans for any such training courses to take place on the island, says Daniel Kleinschmidt from the Academy of Fire Prevention and Disaster Management in Lower Saxony (NABK). However, preparations are under way for the digitaliza-tion of parts of the training and development of the firefighters.

It is training evening at the fire station. Next door, the bell tower of the Evangelical Church, also known as the “Rocket” to the people on Juist, soars into the sky. Around 1,500 people live on the North Sea island with an area of 16.43 square kilometers. In such a community on the mainland there would be a fire sta-tion with perhaps space for two vehicles. Yet just as the doors of the church open, a crew bus rolls out of the fire station doors – beside a full-sized turntable ladder, a Unimog, and two fire trucks. “We have a similar amount of equipment to a main fire station,” confirms Breeden. Three sets of breathing equipment also help the fire service to be self-sufficient. The cylinders can be filled using a breathing air compressor in the workshop. Tourism is

responsible for the scale of the equipment inventory; around 130,000 people stay on Juist each year. Local infrastruc-

tures must be prepared for these numbers – not just the waste collection and water supply services, but

also the fire department and rescue services.

COASTAL RESCUE SERVICE FROM HESSE

Anyone who wants to know how emergency medical care is organized on a North Sea island will find the answer in the city of Mar-burg, Hesse. That is where the headquar-ters of Mid-Hesse Ambulance Service of the

LIMITED ACCESS Juist has a tide-dependent port. The ferry can only reach the North Sea island at high tide

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“WELL-TRAINED EMERGENCY CREW ARE ESSENTIAL. WE MUST COVER VARIOUS RISKS – INCLUDING AIRFIELD OPERATIONS”Thomas Breeden, Chief Firefighter on Juist

German Red Cross (RDMH) can be found, with its roughly 900 employees. “In 1992, the RDMH submitted the winning tender to provide emergency medical services on Langeoog, followed by Spiekeroog in 2000,” says manager Jan Orendt. The 40-year-old paramedic is also actively involved in island rescue. From a technical perspective, the equipment used differs considerably from that used on the mainland. Instead of 5.5-ton box trucks, for example, light and flexible panel vans are used as ambu-lances. In addition to the ambulance equipment, the vehicles have the equipment from an emergency doctor’s vehicle on board. “Everything is modular so that we are able to access the beach,” says Orendt. For all the advanced planning, there are still call-outs that require greater improvisational talent than would be the case on the mainland. When the window of opportunity for transporting a patient in a rescue boat is getting ever smaller with the falling tide, for example, or when the team has to split up because a second emergency call is received parallel to the first. In such cases, the emergency staff are happy that they have good contacts with other relief organizations. “That is also why joint training sessions with the German Life Saving Association, fire service and others are so important,” adds Orendt.

STANDARD EQUIPMENTWhat exactly does “island location” mean? As the crow flies, Juist is 20 kilometers away from the nearest fire station in the north.

ISLAND RESCUEMid-Hesse Ambulance Service from Marburg operates on the

islands of Langeoog and Spiekeroog. The new ambulance station on

Langeoog opened in 2019


STRATEGY ISLAND RISK

33

or by boat,” says Elizabeth Millward from Dräger UK. Providing emergency medical care at a polar research station or in space is even more demanding. Visceral surgeon Dr. Tim Heit-land spent one and a half years from the end of 2016 to the start of 2018 working as station manager and doctor at the Neumayer III Antarctic research station maintained by the Alfred Wegener Institute. For ten months of this period, the nine station residents had to be self-reliant. In order to be able to manage the medical risks under these conditions, there is a well-equipped hospital, reports Dr. Heitland, now the AWI’s medical coordinator – from the operating table with anesthesia and ventilation equipment to ECG, ultrasound, X-ray technology, and laboratory diagnos-tics. Even though the doctor would be assisted by nonspecialist members of the team during an operation, they would nonethe-less receive appropriate training prior to overwintering. “How-ever, the anesthesia is managed by the hospital in Bremerha- ven, thanks to a good telemedical connection,” says Dr. Heitland.

All the same, prevention is at the heart of the approach to dealing with the medical risk: The scientists are therefore care-fully examined prior to overwintering. Accident prevention also plays a key role. This is important because something can also happen to the doctor. “It is a risk that is always present on any expedition,” says the medic.

The tide-dependent port in particular makes the island difficult to reach. On the Shetland Islands, meanwhile, it is sheer distance. The fire station in Baltasound on the island of Unst, for instance, is more than 250 kilometers away from the Scottish mainland. However, there are numerous stations operated by the Scottish Fire and Rescue Service (SFRS) on various islands.

THE HIGHEST STANDARDS: WHETHER IN ANTARCTICA OR IN SPACEBesides the 74 manned fire stations, the SFRS operates a further 240 stations that are manned with part-time crews, as well as 42 volunteer fire departments. One consequence of the unique geography is ensuring that there are as few obstacles as pos-sible between the technical interfaces, explains Roddy MacK-innon, equipment manager at the SFRS, using the example of the breathing apparatus: “It is essential for firefighters all over Scotland to use the same breathing equipment.” This inter-changeability is especially important on major operations when teams from various stations work together. That is why the SFRS and its 356 fire stations are equipped with more than 2,000 Dräger PSS 7000 breathing apparatus sets and 5,000 compressed air cylinders. Dräger also supports the fire departments with maintenance services. Our field staff get to the islands by plane P

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“THE FIRST CREW TO FLY TO MARS MUST BE AWARE OF THE RISKS”The anesthetist and aerospace medic Professor Jochen Hinkelbein, 46, is a senior physician at University Hospital Cologne, and until 2019 was president of the German Society of Aerospace Medicine (DGLRM). He oversees working groups for the DGLRM on emergency medicine in space and for the European Society of Aerospace Medicine (ESAM).

Professor Hinkelbein, how important are strategies for medical emergencies in space – on the International Space Station (ISS), for example? They are hugely important. The ISS flies around our planet at a height of 400 kilometers, which may sound like a manageable distance. In actual fact, however, its position in space means that it is very far away from all of the medical resources here on earth. As such, the equipment is highly diverse. It ranges from medication and ancillary resources to an emergency ventilator. The equipment is stored in bags, similar to those on commercial aircraft. Since a doctor is not always present on the station, there is the Crew Medical Officer, who is qualified to administer emergency medicine.

What are the prospects of even longer stays in space for research? We are working on emergency medicine concepts for long-term projects with a Mars mission in mind: It would take a year to get there and a year to get back, with a year’s stay in between. We are looking at what could happen to the astronauts in this time and how we can prepare for it as well as possible. The conditions are much more extreme than those on board the ISS. For example, telemedicine could not be used for acute emergency treatment if the radio signal takes 40 minutes to get to earth and back again. Instead, there is a research project by the Austrian Space Forum, which is examining the option of video-based instructions for an astronaut with basic medical qualifications from the multidisciplinary team – showing them how to use an ultrasound machine, for instance.

How has risk awareness in manned space flights changedfrom a medical perspective since the beginning almost 60 years ago?The question of medical treatment in space, which is closely linked to ethics, is not easy to answer. This already applies to the ISS, where we are probably unable to transport someone back to Earth for further treatment in the event of a serious emergency. During the first manned flight to the moon and the entire Apollo missions, experts were prepared to accept a rate of up to 50 percent. Nowadays, we want to keep the risk as low as possible. Nonetheless, we need to talk about limited resources of medication and other factors for all missions and especially for a flight to Mars. It will need special medical concepts, but in my view they must be practicable. One thing is clear: The first person to fly to Mars must be aware of the high risks.

LIVING IN EXTREMES The AWI’s Neumayer Station III (left, the operating room) is in Antarctica.

The Shetland Islands (right) in the north of the British Isles are several

hundred kilometers away from the mainland

FLOATING FOR SCIENCEThe anesthetist and aerospace medic Jochen Hinkelbein (left) experiencing zero gravity during a parabolic flight


Women are not men. Even though this is an obvious statement, medicine ignored this fact for decades. Men have dif-ferent reproductive organs, they are taller, heavier, more mus-cular – and they generally have less subcutaneous adipose tissue than women. Instead of the second X chromosome, they have a Y chromosome, which influences every cell from the first to the last day of their lives; not just the sex cells. The Y chromosome has an impact on the entire male metabolism. It ensures that men develop different sexual hormones, produce more gastric acid, have bigger bone surfaces, and possess stomachs and bow-els that empty more quickly. It makes its mark on the cardiovas-cular system and influences the immune system.

The list goes on and on. It shows that women are different. Despite this, they were not involved in clinical studies to test new active agents until the 1990s. What’s more, even the cells and animals used in research were male. The female body didn’t play a major role in the development of new drugs, because researchers didn’t want menstrual cycle fluctuations to distort the results. Furthermore, the thalidomide shock still ran deep, leading to a fundamental reform of the German Medicines Act (Arzneimittelgesetz).

Nobody wanted to even take the risk of an unborn child being damaged by a new substance if a woman inadvertently fell preg-nant during the clinical trial. Following approval of a drug, the doses calculated for the man were simply adjusted to the height and weight of women, without even beginning to take into con-

sideration the significant influence of the gender on the way in which the body processes and is affected by a substance. So it is little wonder that a study by the US Government Accountabili-ty Office in 2001 revealed that eight out of ten drugs that were withdrawn from the market after having been approved harmed women more than men.

In other words, women ran the risk of becoming victims of a male-focused approach to medicine for decades. And even though today’s guidelines require men and women to be involved in clin-ical trials in equal measure, the results are often not evaluated separately along gender lines, but instead all lumped together. As such, almost nothing is known about how people of differ-ent genders react to drugs. Only now are studies being conduct-ed in this field.

SEX AND GENDERHealth and disease are thus not gender-neutral. This insight has led to the establishment of gender or gender-specific medicine. This branch of science investigates the influence of biological and gender-related factors on the health and illness of men and women. The biological factor is referred to in literature as sex, while the social factor is referred to as gender. The difference is significant, because female and male roles as well as soci-ety’s expectations of the two sexes also play an influential role in health and disease. Men take preventive and screening mea-sures more rarely than women, for example, thereby running

THE OVERLOOKED SEXIn the field of medicine, the man was the norm for decades.

Women were considered the “smaller version” of the man – to their considerable disadvantage. Gender medicine is now changing this.

TEXT DR. HILDEGARD KAULEN

36 DRÄGER REVIEW 123 | 1 / 2021

HOSPITALGENDER MEDICINE

UNDERESTIMATEDHEART ATTACK

As a result of unequal treatment, women are up to

3 xmore likely to die

after a heart attack than men.

WEAKANKLES

Women have looser ankle ligaments

than men and are

therefore

2 xmore likely to

sprain their ankle.

SAD OR DEPRESSIVEWomen suff er

2 x more frequently from

depression, which may have something

to do with their hormone status or the stereotypical assign-

ment of roles.

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withdrawnfrom the market after approvalhave damaged women more

than men** According to a study published by the

US Government Accountability Of fice in 2001

Sources: American Academy of Or thopedic Surgeons, Journal of the American Hear t Association, National Institution of Mental Health

SPORT IS A RISKWhen engaging in

sport with fast changes in movement, women

are 2 to

8 x more likely to injure

their cruciate ligament than men.


men. It is precisely the reverse for water-soluble drugs. The blood flow in the organs also plays a role; the volume is lower in wom-en, plus they also exhibit differences in terms of the enzymes they have for breaking down substances in the liver. Some drugs are broken down more slowly than others.

There are also differences when it comes to the excretion process via the kidneys. Women usually have a ten to 25 percent lower filtration rate than men and thus excrete the breakdown products more slowly. This also plays a role in the fact that active agents remain in the body for a different length of time. Wom-en break down the drug metoprolol, for example, much more slowly. At the same time, its antihypertensive effect is much higher in women. They also wake more quickly from propofol sedation and manage with 40 percent less morphine when they have serious pain.

… AND WHEN SEDATEDThat is why gender-specific differences also play a role when it comes to anesthesia. Patients are given appropriate medication so that they sleep during a procedure, have no pain, and do not flinch when the surgeon uses the scalpel. A patient’s conscious-ness is switched off by sedatives, pain is inhibited by strong opi-oids, and uncontrolled movements are prevented by muscle relax-ants. Since sedatives and opioids mutually boost one another and have a higher effect when used in combination than when admin-istered as individual substances, they must be carefully dosed.

Ultimately, every patient – whether male, female, or non-bi-nary – should get as much of a substance as necessary, but as little of it as possible. If the anesthesia lasts too long, it can lead to blood pressure difficulties and the patient only recovers slow-ly. If it is too superficial, the patient is aware of the operation in the worst-case scenario. The SmartPilot View from Dräger is a system that assists anesthesiologists when dosing anesthetic drugs. Based on the administered quantities, it calculates the actual concentrations of the individual active agents, the result-ing depth of anesthesia, and how they will progress if the doses remain unchanged. The calculations are presented in graphic form so that the user can get an immediate picture of the sit-uation. “The SmartPilot View not only calculates and predicts the progress of the anesthesia on the basis of age, weight, and height, but also takes the patient’s gender into consideration,” says Christian Ulke, product manager at Dräger. “Women were included from the very beginning when developing the algo-rithms. As such, the gender-specific differences are also taken into account when calculating and displaying the anesthesia’s

the risk of diseases only being detected at a later stage. Women, meanwhile, visit the doctor more often, but are therefore also prescribed more drugs and are possibly exposed to dangerous drug interactions on a more frequent basis.

And the researchers have discovered something else: Wom-en who turned up at an emergency department with a suspected heart attack were taken more seriously when they were treated by a female doctor than by a male doctor. There are also diseases that are primarily ascribed to women, such as irritable bowel syndrome, osteoporosis, and anorexia. Alcoholism and drug addiction are considered typical male diseases. There is a popular perception that men rarely suffer from breast cancer, even though they can also develop it.

DIFFERENCES IN THE METABOLISM … The fact that drugs work in different ways is due to the gender-spe-cific differences in the way the substances are absorbed, distrib-uted, broken down, and excreted. Depending on how quickly or slowly the active agents are absorbed and broken down again, they either have no effect at all, or a weaker or stronger effect than anticipated. It all starts in the stomach: Since women pro-duce less gastric acid, substances whose absorption is linked to a certain acidity level are not absorbed as efficiently. Other sub-stances are absorbed better, meanwhile, due to the longer time spent in the gastrointestinal tract.

There are also differences in terms of the distribution in the fatty tissue. Since women generally have more body fat, more liposoluble drugs are also stored there. Accordingly, the same dose of a fat-loving drug per kilogram of bodyweight will result in a lower concentration in the blood of women than in that of

10 %That is how much larger the male brain is than the female brain. However, women have a higher density of neurons** Journal of Neuroscience

38 DRÄGER REVIEW 123 | 1 / 2021

HOSPITALGENDER MEDICINE

progress with the SmartPilot View.” When developing the soft-ware, Dräger’s IT specialists used systems from the aerospace industry as a benchmark. “In the cockpit of a plane, the pilot sees information on the so-called primary flight display that they cannot always see by looking out of the window – such as the type of terrain or the artificial horizon,” says Ulke. “The software supports anesthesiologists in a similar way. They can thus make better decisions as to whether or not the medication needs to be adjusted.”

GENDER MEDICINE HELPS EVERYBODYBoth genders benefit from the fact that doctors are familiar with the gender-specific symptoms of diseases and know how drugs need to be dosed for men and women. Take heart attacks, for example: While men mainly complain of pain in their left upper arm, women have other symptoms. They suffer from pain in the chest, stomach, shoulder, or back; they also feel nauseous and short of breath. When it comes to cancer, men are at a disad-vantage. They suffer more frequently from tumors and are more likely to die from them. The difference may have something to do with the different lifestyles, but it may also be due to many other reasons. Men are also at a disadvantage when it comes to diseases that are typically associated with women, such as osteo-porosis or depression, because they are often diagnosed and treat-ed later. There are also differences with Covid-19, the lung and immune disease caused by the SARS-CoV-2 virus. Current studies show that the mortality risk is twice as high for men as it is for women. Clearly, gender medicine is not just a female subject.

THE SOFTWARE CONSIDERS WOMENThe SmartPilot View from Dräger calculates and predicts the anesthesia on the basis of age, weight, height, and gender. Women were incorporated from the start

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SERGE HEINES is an expert in ventilation at Maastricht University Medical Center. His specialist field is artificial ventilation imaging

40 DRÄGER REVIEW 123 | 1 / 2021

HOSPITAL VENTILATION THERAPIES

t the end of April 2020, an alarming report was cir-culating: “New coronavirus study: Almost 90 percent of venti-lated patients in New York die.” Even though it soon transpired that the figures were incorrect, doubts started to emerge in the course of increasing experience with artificially ventilat-ed Covid-19 patients as to whether everything had been done correctly in the first months of the pandemic.

The general consensus in the beginning was that coronavirus patients exhibiting serious progression of the disease were suf-fering from the clearly defined medical condition ARDS (acute respiratory distress syndrome), but over time it became appar-ent that the patients were exhibiting completely different symp-toms, making it necessary to draw up an individual treatment plan. What has surprised the doctors is the fact that the lungs are often still functioning in cases of Covid-19, although the nec-essary exchange of oxygen and carbon dioxide is impaired to such a considerable extent that they are no longer able to absorb sufficient quantities of oxygen. The patient’s respiratory drive and thus the respiratory rate increasingly rises, and they need to be supported by a ventilator. The likely cause of this is fluid retention in and between the alveoli, which then stick together, thereby hindering gas exchange in the lungs. Doctors are now even considering that the virus SARS-CoV-2 essentially causes a vascular disease rather than a pulmonary disease. Other organs – and especially the heart – are also affected, as a team led by Dr. Zsuzsanne Varga, senior consultant at University Hospital Zurich in Switzerland, has confirmed. The big question remains: Which is the right ventilation strategy for Covid-19 patients?

If the problem consists of the lungs being unable to absorb oxygen, is it then even necessary to supply the lungs with high doses of oxygen by means of artificial ventilation?

The first person to raise doubts in public was the Italian anesthetist Prof. Luciano Gattinoni in various professional jour-nals*. The task force leader who works in the Department of Anesthesiology at the Medical University of Göttingen came to the conclusion from observing patients in Italy that artificial-ly ventilating patients at high pressure is not very promising in many cases. Instead, he recommended ventilating them at low

A SAVING LOOK INTO THE LUNGS

Does artificial ventilation harm Covid-19 patients more than it benefits them? Imaging processes could settle this debate, which has been ongoing

among medical professionals since the start of the year. It also proves that research must still be conducted into certain aspects of SARS-CoV-2.

TEXT RALF GRÖTKER PHOTOS PATRICK OHLIGSCHLÄGER

BESIDES REAL-TIME VISUALIZATION, the machine also works out the extent to which areas of the lungs are overdistended or collapsed

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25


pressure less frequently. The recommendations certainly sparked lively debates among the medical community – since certain aspects of the recommendations put forward by the globally acknowledged expert on respiratory failure actually contradict-ed medical guidelines in some aspects. Yet doctors are increas-ingly recognizing that it shouldn’t be a case of either/or when making therapy decisions, but rather a continuum of variants that must be carefully balanced with each other and individu-ally adapted during the therapy.

EIT (electric impedance tomography) plays a significant role here. “It is usually only possible to observe how the lung vol-ume changes – depending on the ventilator settings,” explains Serge Heines, ventilation expert at Maastricht University Med-ical Center in the Netherlands. Even though the lung volume is an indicator of whether the alveoli are active, increased lung volume can be a sign of a reopening of collapsed regions with imploded alveoli, but it may also be due to dangerous overdis-tension of already opened alveoli. “With EIT we can literally see what is happening in the lungs. We not only obtain an overall picture, but can also examine individual areas more closely – and optimize the therapy accordingly.”

The Covid-19 patients in Heines’ intensive care unit are mostly placed into an artificial coma, intubated, and mechani-cally ventilated in the emergency room. The central parameters

that determine how the ventilator settings are optimized are the air pressure while inhaling and exhaling and the breathing rate. The aim is to use targeted distension maneuvers with high ventilation pressure on an ad hoc basis to make lung regions that have already collapsed accessible for gas exchange once again and subsequently stabilize them by applying lower pres-sure during the exhalation phase. In normal times, Maastricht University Medical Center has four intensive care units with a total of 33 beds. Another ten have been added since March of this year. By late summer, around 150 patients had been admit-ted to the ICU to be ventilated. During the peak period, around 50 were on the unit at the same time. “In normal circum - stances, a nurse will look after two patients who are being mechanically ventilated,” adds Heines. “In 90 percent of the cases, the patients were suffering from an extreme lack of oxygen; some of them also had overly high carbon dioxide levels – so it wasn’t a question of whether or not we should ventilate them. We would otherwise have had to resuscitate them,” says Heines. “We were not able to observe the fact that no high pressure was needed. On the contrary – high pressure was essential during the exhalation phase in most of the cases.”

OFTEN SIMULTANEOUSLY: TOO MUCH AND TOO LITTLE PRESSUREOn the EIT machine (Type: Dräger PulmoVista 500), Heines and his colleagues can monitor what is happening in individual regions of the lungs. If too little pressure is built up through the ventila-tion, the alveoli collapse. They implode like a balloon from which the air is escaping. Too much pressure leads to overdistension and irritation and can even directly trigger cardiac problems. Both phenomena, alveolar overdistension and collapse, can often be simultaneously observed in different lung regions. Doctors and

WHO IS RIGHT: THE GUIDELINES OR AN ITALIAN PROFESSOR?

42 DRÄGER REVIEW 123 | 1 / 2021

nurses can use EIT to track these events more closely and then adjust the ventilator accordingly to the optimal settings. Besides visualizing ventilation distribution in the lungs, the machine also works out the proportion of the lung regions with overdisten-sion or even at risk of collapse. In professional literature it is now considered more or less certain that Covid-19 patients go through two or more phases in the critical stage. These phases manifest themselves in various ways and require different approaches to ventilation therapy. With the help of EIT, the doctors and nurs-ing staff in Maastricht can see when it is necessary to change the ventilator settings. “Most of our patients are ventilated for one to two weeks,” says Heines. “Then there is a turning point: They either gradually start to breathe independently again, or the effects of the virus strikes for a second time.” Then the patients stay on the ventilator for up to 70 days or more. According to the results of a study involving over 10,000 Covid-19 cases treated in German hospitals, 53 percent of all patients who were invasively ventilated died. Among the casualties, patients aged 80 or older were particularly strongly represented, but also dialysis patients, while the risk for patients aged 60 or younger was much reduced. In view of the high risks that appear to be associated with inva-sive artificial ventilation, some doctors in Germany have decid-ed to ventilate their Covid-19 patients using non-invasive meth-ods. Instead, they use nasal masks or other apparatus that do not have to be inserted into the trachea and do not require the patient to be placed in an induced coma. Two establishments in Germa-ny that have taken this path claim to have lost virtually no venti-lated patients thus far. It may well be the case, as in Maastricht, that they haven’t had to treat patients who were already in a very advanced stage of the disease.

For Serge Heines, the non-invasive approach was not an option at that time. “There has been a clear message from the

steering committee in the Netherlands that the risks associated with non-invasive ventilation are simply too high for the clini-cal staff,” says Heines. When using nasal masks or other equip-ment, it is very difficult to prevent the exhaled air, which con-tains viruses, from circulating in the treatment room. The German guidelines also stress these risks. Nonetheless, the guidelines published at the end of April 2020 by the German Respiratory Society state the following: “Fear among medical staff of a Covid-19 infection should […] not be a primary reason for intubation.” In other words, it is not a reason for mechani-cal ventilation that involves placing the patient in an induced coma. Even in Germany, however, relatively few hospitals opt for non-invasive ventilation.

BETTER CHANCES OF SURVIVAL WITH EIT?The use of EIT could potentially improve the success rate of invasive mechanical ventilation. Initial observations of patients who have been artificially ventilated while using EIT moni-toring have been described by Serge Heines’ cooperation part-ners at University Medical Center Rotterdam in a professional paper** published in May. “At the present time, we are unable to say whether the survival chances of patients who are inva-sively ventilated are actually any better when the therapy is monitored by EIT,” says Heines. “Many of the patients who we ventilate are problem cases who have been referred to us from other hospitals. They are naturally not representative as a group.” The scientists are currently working on a new study in which the progress of 100 patients who were ventilated using EIT is being evaluated.

It is already possible to say the following: As the various treatment approaches and experiences show, there is proba-bly no single remedy for ventilating Covid-19 patients. The dif-ferent ways in which the disease has progressed and the cir-cumstances in the hospitals treating these patients are simply very diverse. It is also for this reason that EIT could prove to be such a promising technology. The fact that the procedure provides detailed live information about the condition of the lungs means that the ventilation of patients can be individu-ally adjusted – which in turn is a very good prerequisite for promising treatment.

LABOR-INTENSIVE TREATMENT saves lives in critical phases: With the aid of EIT, the Maastricht doctors and nurses can track precisely when it is necessary to change the settings on the ventilator

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HOSPITAL VENTILATION THERAPIES

ALMOST ALL THAT GLITTERS IS GOLD

Medical and safety equipment requires high-performance materials and metals. The Dräger waste management team takes raw materials from decommissioned products and feeds them back into the circular economy.

TEXT CONSTANZE SANDERS PHOTOS PATRICK OHLIGSCHLÄGER


SUSTAINABILITY RECYCLING

NACHHALTIGKEIT RECYCLING

PRECIOUS HARVEST Whether brass (left image), copper, silver, or gold, electronic products are full of metals that can be used again. Right: The separated sensor used for performing alcohol breath tests in the Dräger Interlock (left, above the device) contains platinum, for example

Florian Baer’s job is to think about things starting from the end of their life. Old electronic devices, packaging mate-rial, production waste: Everything that ends up here in the product returns unit has served its purpose. Industrial special-ist Baer is head of waste management at Dräger Gebäude und Service GmbH, which has two sites in Lübeck and is a certified waste disposal facility in accor-dance with Section 56 of Germany’s Cir-cular Economy Act (Kreislaufwirtschafts-

gesetz or KrWG). “We get the best out of the waste and dispose of elements that can-not be recycled, while complying with the legal regulations – to protect the environ-ment,” he says. Baer sees apparent waste as a stream of valuable materials which, together with five colleagues, he diverts in new directions.

The sources for the raw materials are old devices that customers no longer need. “We take back equipment that we manufacture ourselves,” says Dr. Michaela Schatz, envi-ronmental officer at Dräger. The compa-ny has taken responsibility for such prod-ucts very seriously since the 1990s; for the

entire life cycles of its medical and safety equipment and beyond. “We do this volun-tarily with KrWG approval,” says the chem-ist, “and we want to increase understand-ing.” Every year, two technicians dismantle more than 100 tons of medical equipment, measuring technology, sensors, filters, and other consumable materials from de - vices that have been returned by customers. “We are certified as a primary facility for dealing with old equipment in accor-dance with the Electrical and Electronic Equipment Act,” says Florian Baer. Dräger supports the disposal of such equipment with recycling passes and material lists,

DRÄGER REVIEW 123 | 1 / 2021 45

diagrams, and dismantling recommen-dations in line with the WEEE Directive 2012/19/EU (Waste of Electrical and Elec-tronic Equipment). In the trolley of a ven-tilator, around 15 kg of aluminum can be identified and recycled. The employees primarily use their extensive experience to determine what can be separated, but they conduct tests if they are unsure. Fol-lowing the initial rough dismantling pro-cess, steel, copper, and brass remain as alloys in other components. Mixed materi-als, welded and glued parts, device waste, and printed circuit boards are sent to ser-vice providers that can separate and sort such components. “This helps us to make sure that our electrical waste doesn’t end up on illegal dumping sites,” says Baer.

RECOVERING PRECIOUS METALS Tiny amounts of gold and platinum can be found in high-quality sensors: “The elements that glitter like gold are actual-ly gold – mostly in the form of a thin coat-ing that can nonetheless be recovered per-fectly well.” After the sensors have been taken back and dismantled free of charge, they are sent to a metal recycling facility where high-purity gold, silver, and plati-num are recovered. Recyclable amounts of platinum can also be found in the sen-sors fitted in the Alcotest devices, several

thousand of which have been taken back from the French police, for example. All individual parts, testers, sensors, printed circuit boards, and housing elements are fed back into the cycle after being disman-tled. Taking back products from outside Germany is a complex process in accor-dance with European waste laws. “Howev-er, we also want to offer the service to our European customers,” says Dr. Michaela Schatz. Until now, this has always involved complex notification processes and high costs. The European Commission wants to revise the Waste Shipment Regulation (WSR). “We are committed to making it easier for the manufacturer to take respon-sibility for its products,” says Dr. Schatz. Dismantling old equipment is about creat-ing value and eliminating hazardous sub-stances – as in the case of oxygen self-res-cuers, for example, which are used in the mining industry. A technician carefully dis-mantles the product by hand, removes the cartridge that contains a chemical that pro-duces oxygen, and deactivates the starter. The plastics are labeled; these are sorted into their distinct types and then recycled.

With up to eight tons each day, hospi-tals are the fifth-largest producers of waste in Germany. On average, each patient produces around six kilos per day, three times more than a normal, healthy citizen. Dräger begins focusing on the economical

use of materials and their recyclability in the product development stage. Blue and black recycling containers have been set up at hospitals and industrial facilities for years so that equipment can be returned in the correct manner.

Dräger largely remains unrivaled in terms of offering such a service. “We have the experience and the expertise, because we know what the equipment contains,” says Florian Baer. “If required, we can take care of the entire logistics and offer our customers a complete package.” This is made possible by the Dräger Waste Man-agement Association, which was estab-lished around twenty years ago. On behalf of its members, it handles all tasks relat-ing to eco-friendly, legal, and economi-cal waste management. The big Dräger companies in Lübeck and other industrial firms (a total of 26 businesses) send every-thing here that they no longer need. “We separate and sort the goods, keep the nec-essary legal records, and produce reports documenting the amount of waste,” says Baer. Rather than being a disposal busi-ness, Dräger Waste Management is actual-ly a service provider that works on behalf of the association. “We send the materi-al for recycling – or, if this is not possible, for disposal and landfill.”

Dräger sampling tubes are constant-ly being used for the analysis of harmful

EFFICIENT RECYCLER“Our disposal policy protects

the environment and is econom-ically efficient with the maximum

possible recycling rate,” says Florian Baer, head of waste

management at Dräger

TURNING WASTE INTO KEY RESOURCES

46 DRÄGER REVIEW 123 | 1 / 2021

substances. The reagent system contains tiny amounts of different chemicals. Sub-stances that are subject to authorization requirements in accordance with the EU REACH Regulation have already been replaced by less harmful substances in the production process. Used or expired Dräger tubes can be sent to Lübeck for recycling. Dräger also conducts research to determine whether ventilation tubes and filters can be manufactured from bio-plastic or recyclate. “Unfortunately, this is where we are still reaching our lim-its, because the regulations for medical products are very strict,” says Dr. Schatz. There is generally no guarantee that recy-clate meets the same quality requirements as new plastic. And compared to conven-tional plastic, the production of bioplas-tic is expensive.

COMPLEX LEGAL SYSTEMThere are at least 35 overriding local, regional, national, and EU legal provi-

sions, laws, regulations, and directives gov-erning the safe and clean disposal of waste. Opt for recycling over disposal of goods – the Circular Economy Act adds this pre-ferred order to the extensive nomencla-ture. Every new waste code needs its own approval: “Each for a limited period,” says Dr. Schatz, an expert in hazardous sub-stances. “Extensions must be applied for on an individual basis.” The strict and ever-growing legal system in the disposal industry is her specialist field. “We work closely with the City of Lübeck.” In 2019, 3,900 metric tons of waste accrued at Dräger in Lübeck, with a recycling rate of almost 96 percent. “Hazardous waste like solvents and leftover paint and lac-quer go to special incineration plants,” says Baer. “Just a small amount of leftover waste ends up in landfill, such as asbes-tos or insulating materials.” However, at the very top of the five-tier waste hierar-chy of the KrWG (Section 6) is the preven-tion of waste. Since 2009, while sales have

risen, the total amount of waste produced at Dräger has almost halved to a little over two tons of waste per million euros of sales.

EU directives are increasingly deter-mining what is needed to save resources. The European Commission has calculated that up to 80 percent of the environmental impact of products can be traced back to the design phase. Dräger starts out by consider-ing how new instruments can be recycled properly once they have served their pur-pose, and pursues the long-term C2C (cra-dle-to-cradle) principle, which is commit-ted to cyclical reuse of raw materials rather than linear use. Since 2015, there has been a systematic monitoring program for mate-rials whose legal restriction is foreseeable or under discussion. “Sustainable prod-ucts will be the norm in the future,” says the Lithuanian Virginijus Sinkevičius, EU Commissioner for the Environment. The right to repair set out in the EU’s Circular Economy Blueprint is a fundamental prin-ciple at Dräger. Professional maintenance

COLLECTING RAW MATERIALS

Returned aluminum filters prior to shredding. Right: soda lime

in bulk in the disposal yard



and repairs are carried out worldwide so that customers benefit from machines with a long service life.

Many a material requires a complete solution. A patient is anesthetized for an operation in Germany around 18 million times a year. Each anesthesia machine contains a plastic cartridge with soda lime in order to bind CO2 (carbon diox-ide) from the exhaled air. “Since 2015, the Regional Working Group on Waste (Bund/Länder-Arbeitsgemeinschaft Abfall or LAGA) has classified soda lime as haz-ardous waste,” says chemist Schatz. Sepa-rate collection and appropriate documen-tation have been obligatory ever since. The dry chemical product must be replaced approximately every four weeks, because it gradually loses its absorption ability. Dräger provides a comprehensive collec-tion and recycling concept for soda lime (Type: Drägersorb 800+) and cartridges. Hospitals collect the used containers in recycling drums, which are then well sealed and returned to Dräger as soon as they are full. “The customer can be sure that they have found a clean and legal means of disposal. This saves both time and money,” says Dr. Schatz. An employee in the product returns department removes the used chemical from the carton, which is then shredded and thermally recycled. Due to the large amounts of soda lime

involved, it becomes a bulk material which accumulates in the disposal yard. Once it has been processed, some of it is used in agriculture to improve the soil. The Dräger disposal yard handled several hundred tons of soda lime waste in 2019. Active carbon from mask filters can also be used for a second purpose: Dräger delivers the used granules to the metalworking industry as a reducing agent in smelting furnaces, thereby ensuring that the life cycle of the raw material ends as responsibly as it began. The active carbon is made from the shells of coconuts – a renewable raw material. The aluminum filters are col-lected, shredded, and sent to a recycler as metal shreds.

SUPPLIER OF SECONDARY RAW MATERIALSEven though medical equipment only accounts for around three percent of annu-al global plastic production, high-perfor-mance plastic is leading in terms of inno-vative use – whether for disposable items, implants, or diagnostic aids. “We sort plas-tics in abundance,” says Florian Baer. Only correctly sorted plastic – unpainted, with no plasticizers or adhesions – can be mar-keted well. “There is currently barely a market in Germany for the colorful mix of different polymers.” If there are no takers, the only remaining option is to thermally

recycle them at specialist companies; this amounts to several hundred tons a year at Dräger. Although the energy gain is consid-erable, for Baer it is only the second-best solution. He is interested in the recovery and reuse of materials, whether as pack-aging or in logistics and storage systems, as flower and drinks boxes, film, window frames, or watering cans made from recy-clate. “Our secondary raw materials are dependent on national and international markets and the corresponding prices.” Agreements with the waste generators on the amount paid for quantities of waste are assessed and adjusted on a monthly basis. Since 2019, the German Packaging Act (Verpackungsgesetz) requires a recy-cling rate of 58.5 percent, rising to 63 by 2022. To date, there has been no reliable market for recyclate that would enable the higher rates to feed into a functioning cir-cular economy. In addition, Hamburg Cir-plus was launched in March 2020. This is a freely accessible stock exchange for sec-ondary plastic that already has a volume of 500,000 tons. Plastic in every grade of purity is traded here. A yellow bag can be bought for just one cent. “When it comes to waste management in an industrial firm, it is not about earning money,” stresses Florian Baer. “We want to save money – for our customers too – while protecting the environment.”

SEPARATED FOR THE CIRCULAR ECONOMY

PROFESSIONALLY DISMANTLED

Employee Enrico Schernau takes apart an oxygen self-

rescuer in the product returns unit in Lübeck, northern

Germany. Dräger disposes of damaged, opened, used,

and expired products

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41 Lime products

40 Active

40 Breathing

25 Medical

3 Oxygen self-rescuers

2 Test tubes

PRODUCT RESPONSIBILITYDräger actively takes back almost all of its own products, thereby boosting the circular economy. Due to the exemption granted as per Section 26 KrWG on voluntary returns, the customer is exempt from registration, licensing, and labeling obligations. Medical and measurement equipment and consum-ables are dismantled and separated by material in Lübeck and passed onto disposal specialists.

REUSEThe material is processed for use as

soil improver in agriculture, for example.

INCINERATIONCartridges are sent for

thermal recycling.

DISMANTLINGPlastic cartridges and contents

separated in the product returns unit.

DRÄGER

PRODUCT RETURNS

ANESTHESIA MACHINES

(CUSTOMER)

RETURNSCustomer gives the full recycling drums

back or arranges collection. Dräger supplies drums. Long-term recycling loop.

DELIVERY Dräger supplies the empty

drums on request.

Dräger product returns Based on the example of soda lime: Anesthesia machines contain plastic cartridges filled with soda lime,

which binds CO2 from the exhaled air. Soda lime has been classified as hazardous waste since 2015 and must bedisposed of separately from the cartridges. What’s more, documentation is required. That is the job of

Dräger’s waste management unit. The customer collects the used cartridges in recycling drums.

RAW MATERIAL COLLECTIONSoda lime is sent from the

collection point to the disposal specialist.

AMOUNT RETURNED (tons; 2019)

DRÄGER REVIEW 123 | 1 / 2021 49

FOR THE SAKE OF CLARITY

Sewage doesn’t disappear that easily. It is purified in up to four stages and then fed back into bodies of water. On the way

there, the finest analysis provides detailed information – even about the sociodemographics of the population.

TEXT NILS SCHIFFHAUER PHOTOS PATRICK OHLIGSCHLÄGER


51

been using chemical and microbiological analysis to look beyond the supply and disposal of water in order to gain insights into people’s health and their consumption habits as well as the sociodemographic structure of entire districts.

To this end, the sewage is analyzed using ever finer methods. More recently, these methods have also helped to trace the SARS-CoV-2 virus, which caused the disease known as Covid-19 (“coronavi-rus”). Even before the WHO declared the infection a global pandemic on 11 March 2020, Professor Gertjan Medema, senior microbiologist at the KWR Water Research

ou are what you eat, so they say. And if you think a few hours further ahead, something else can be added to this saying: “... and what you leave behind you.” Urine and feces end up in the toilet, together with toilet paper and other things that don’t actually belong there. This mixture is flushed away with water and ends up in the wastewater treatment plant via the sewer system. Domestic and industrial wastewater mostly accumulates here. For a number of years, scientists have

ALL CLEARThe purifi ed sewage ends upin one of these fi nal clarifi ers

RUBRIKTHEMA


SCIENCESEWAGE

Institute in the Dutch city of Nieuwegein, set to work with his team to prove the pres-ence of the specific residues of the caus-al virus in the sewage: “If the number of infected people increases, the viral pollu-tion in the sewage should also increase,” says the microbiologist, explaining his approach. “As such, corresponding mon-itoring of the sewage can ultimately serve as an early-warning system for the out-break (or recurrence) of Covid-19.” The team pursued a similar concept in 2009. SIGNS IN THE SEWAGEBack then, the scientists were initially looking at the bird flu virus; then they broadened their interest to include causes of diseases such as polio, hepatitis A, and the norovirus, which causes vomiting and diarrhea. Health officials in the Netherlands recorded the first Covid-19 case on February 27, 2020, almost three months after the outbreak of the epidemic in the Chinese city of Wuhan. The microbiologists started taking the first samples just three weeks before the country’s first case. Their aim: to prove the presence of virus-specific nucleic acids excreted in the stools of those who were infected. The scientists traced the geographic progress of the infection over time by taking samples at specific locations agreed in conjunction with the health authorities. Professor Medema’s study in Amersfoort provided an indication of the potential suitability of the concept as an early-warning system – subject to further research. Traces of the virus were found in the sewage before a single case had even been reported to the local health authority.

In Germany, a consortium of Frank-furt-based virologists, ecotoxologists, evo-

lutionary water researchers, and Aachen-based water researchers also showed that the presence of genetic SARS-CoV-2 mate-rial in water treatment plants can also be proved with modern molecular methods. In all nine of the water treatment plants tested in April 2020, analyses recorded between three and 20 genocopies per milliliter of raw sewage, a concentra-tion level also measured in studies in the Netherlands and the USA. “If sensi-tive enough, such analyses could serve as an early-warning system for the authori-ties,” summarize the authors, “to enable them to identify a local rise in cases in the area around a water treatment plant at an early stage.”

The project launched in spring 2020 under the aegis of Professor Georg Teutsch from the Helmholtz Center for Environmental Research in Leipzig (“Integral SARS-CoV-2 Sewage Monitoring”) essentially wants to bring clarity to the matter. “By continuously monitoring the sewage, we want to shine a light on the unreported cases, provide a basis for taking decisions, and establish an early-warning system,” says the hydrogeologist. Members of the German Association for Water, Wastewater, and Waste (DWA) – including Cologne’s municipal drainage works (StEB) – are also involved in the project. Many problems have reportedly already been solved, allowing the scientists to identify evaluable signals in the highly diluted samples. The main question now turns to what it all means. “An infected individual,” explains Prof. Teutsch, “does not excrete viruses on the very first day. And the amount of virus excreted differs for each infected person. Since we measure the total content, we don’t

VIRUSES IN THE SEWAGE INDICATE INFECTIONS – INCLUDING COVID-19

SKIMMING Large screws keep the

aquatic plants at bay in the clarifying basins

that obviously feel at home here

know, for example, whether the virus content in the stools changes in one and the same person as the disease progresses or whether the rate differs from one person to the next.” These are questions that make it just as difficult to translate the virus figures from the sewage into the actual number of infected people as it does to establish a clear and reliable early-warning system. We currently have around 20 people working on clarifying this and other issues,” adds Prof. Teutsch. “That’s how science works!”

FINDING THE SOURCEThis is also the starting point for the supply and disposal of water as we know it today. In 1854, the English physician John Snow bent over a map of London and marked every cholera fatality with a dash. Then he focused on the water

52 DRÄGER REVIEW 123 | 1 / 2021

SCIENCE SEWAGE

pumps and marked these with a dot. The geographical link between the two was uncanny: The cholera epidemic of 1854 was clearly caused by polluted water at one of the pumps. This ran counter to the theory popular at the time that this disease was caused by miasmas. Yet this proved to be incorrect. It was a bacterium, which an Italian doctor had discovered in the same year. Even though it would be another 30 years before Robert Koch could prove the hypothesis of microorganisms, John Snow’s discovery had consequences. Particularly in the wake of the sewage scandal of 1858, known as the Great Stink, it led to a fundamental change in the way water was supplied and disposed of in London.

“In a certain way, we are still guided by these insights and methods,” says Dr. Andrea Poppe, head of the StEB’s sewage

“THERE IS A RISE IN THEAMOUNT OF PAINKILLERS”

Dr. Andrea Poppe is the head of the StEB’s sewage institute and is a member of the board at the DWA* – it boasts 30 years’ experience in the sampling and analysis of sewage.

Dr. Poppe, what is the purpose of performing this analysis?With around 30 employees in our laboratory, we keep the population safe by constantly monitoring the quality of the sewage and ensuring compliance with legal regulations. Even if we are not allowed to conduct research ourselves, because sewage charges directly serve our actual purpose, we are, of course, focused on the future. Here we take part in scientific studies like the Helmholtz Center’s coronavirus project.

What has changed over the years in terms of the analysis we know today?It now gives us much more precise and in-depth insights into the substances contained in the sewage. Chemical analysis complements biological methods where changes in the behavior of fish are examined, for example.

What things in the sewage are especially problematic nowadays?We are seeing a rise in the amount of pharmaceutical substances, such as diclofenac, which is contained in painkillers. These are freely available to buy and are clearly taken in large quantities prophylactically. They end up in the water via excrement or as a result of not being disposed of properly. Pain relief ointments also contain this substance, which then ends up in the sewage when showering. X-ray contrast agents from doctor’s surgeries or hospitals are equally problematic. And while toilet paper disintegrates in the process, the same cannot be said of moist wipes, which are increasing being used. They block pipes and pumps and don’t belong in the toilet!

How will the future of analysis develop?It will certainly improve in terms of the quantities and substances it is able to detect. The examination of sewage must keep pace with the changes in the behavior of our customers. Microplastics, for example, are another challenge.* The German Association for Water, Wastewater, and Waste


institute. One of Europe’s biggest and most modern sewage treatment plants runs right along the Rhine in the northeast of the city. The StEB manages its large treatment plant on a site covering 35 hectares. “It is designed for the almost 1.6 million so-called ‘population equivalents,’ which we use to refer to the combined capacity for households and industry,” explains Martin Grudzielanek. According to the head of operations, this is where the purification begins for up to 8.2 cubic meters of water per second – from households and industry. That is the equivalent to a total of almost 80 million cubic meters per year. At the end of a process that takes just 24 hours, during which the main task is to absorb bacteria, around 220 million liters of purified water flow into the Rhine from eight final clarifiers up to 70 meters in diameter.

THEY COME UNANNOUNCEDFor anyone who has stood at the strong-smelling entry point and screening plant, which rakes out the coarsest matter before draining it of water (up to 6,000 tons per year), the result is a minor miracle. That’s because it is not just fecal matter that floats along the sewage system to Stammheim. It is joined by toilet paper, hygiene articles, food waste, dead rats, and other things. Dräger fixed gas detectors (Dräger PIR 3000/7000 and Polytron 3000) raise the alarm as soon as the gas content (such as hydrogen sulfide or methane) exceeds certain values. Sand and suspended matter are filtered out in several stages. The sludge is treated further until it harmlessly burns and can be used for generating energy. From 2030, the city of Cologne plans to completely power its treatment plants using electricity it

has generated itself. The StEB employees regularly check the contents of the sewage system: “As such, I see places that not everybody gets to see that easily,” says Tobias Krebs. The chemistry technician “draws sewage samples,” as they say in the industry. “Including from companies or the airport – wherever the sewage enters the system – and of course unannounced.” Immediately afterwards while still in the car, the fresh suspension is homogenized on a stirrer, divided into smaller vials, documented, and taken to the laboratory in a cool bag for further examination – including a retained sample so that the original sewage can be used at any time in the event of a need to discuss any matters. The Helmholtz researchers also advised Dr. Andrea Poppe’s laboratory on the best places to take samples for proving the presence of the virus. “We are also

An estimated

55%

is the figure by which global water consumption

is expected to rise by 2050

4.5billion people worldwide live

without functioning sewer systems

80%of the world’s sewage is channeled

into the environment untreated

FROM SEWAGE TO CLEAR WATER WITHIN A DAY

PRECISE CHECK Sewage is constantly

being sampled and analyzed at different

locations

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SCIENCE SEWAGE

WHAT MAKES SOCIETY TICK? A new trend involves using sewage to produce sociodemographic data, which could even dispense with the need for a census or at least complement it. How many residents in a city have a school education? What percentage of them are divorced? Saer Samanipour studies this and much more, not just with demographic statistics, but by analyzing the wastewater. The doctor of chemistry and current professor of molecular science used precise sensory analysis to test the sewage of Australian cities for 40 substances from completely different areas: drugs, antidepressants, sweeteners, or food. He used the concentration of substances such as ethanol and amitriptyline as markers for the consumption of alcohol and antidepressants. He linked his findings with sociodemographic data gathered from a census conducted at the same time. This allowed Samanipour to develop a system of equivalents: a kind of yardstick that he could place alongside the results of the chemical analysis in order to btain data about the population’s social structure. From sewage systems of unknown origin to him, he was able to make sometimes accurate assertions about the social structure of the corresponding district.

getting involved in this project by sending samples,” says Dr. Poppe.

There is still no absolute certainty as to whether the coronavirus spreads through the sewage. A study published in Nature in the summer found that excreted viruses can remain active for a few days in the wastewater of a sewer system and in aerosols. It concludes that a risk assessment should be carried out and proposes disinfection with chlorine, treatment with ozone, or processes such as micro- and ultrafiltration with membrane filters. Other scientists dismiss this and point to the high dilution level, the short lifespan, and the fact that just a fraction of the virus material actually contains active viruses in any case. Mankind’s sewage disposal has always been put to good use in the past. Analysis and evaluation continue to write the story in unimagined ways.

FATBERGS CLOG SEWER PIPESTime and again, sewer workers find large quantities of fat in the pipe systems during inspections. Over time, they grow into huge lumps. Such deposits in the sewer system occur when fats and oils are disposed of via washbasins or toilets and end up in the sewage. Objects such as wet wipes, diapers or cotton swabs that do not belong in the toilet also cause these lumps. In 2017, one such “fatberg” blocked London’s sewer system. It was 250 meters long and weighed more than 100 tons. Every year, Thames Water spends more than 13 million euros alone on clearing such deposits in the sewer system of the British capital.

Here is a selection of things that do not belong in the toilet: • Leftover food; kitchen waste • Medication; tablets • Moist wipes, moist toilet paper• Hygiene articles like panty liners, condoms, disposable

diapers, or sticking plasters • Toxic and aggressive substances like some toilet cleaners • Deep-frying fat; cooking oils


UNDERWATER HUNTERS

Their job is not just strenuous, but also explosive: This unit of the German Navy specializes in defusing explosive devices. The lack of new recruits

is due to the training – which is rather demanding.

TEXT BJÖRN WÖLKE PHOTOS PATRICK OHLIGSCHLÄGER

MASTER OF THE DEPTHS One of several dozen mine clearance divers in the armed forces in Eckernförde, a coastal town in Schleswig-Holstein – they are trained to defuse explosives at depths as low as 54 meters


oored contact mine or washing machine? For Christian M., whose full name cannot be revealed, this is a seri-ous question. The answer can be a mat-ter of life or death when the 33-year-old dives down into the Baltic Sea. He gener-ally cannot see very much and one false move would have fatal consequences. It is an occupational hazard. His job is one of the toughest the German Navy has to offer: Chris, as his colleagues call him, has been a mine clearance diver for eight years.

TOUGH TRAININGAs such, the native of Saxony is part of the diving elite in the armed forces. The demands in this specialized unit are high. The mine clearance company at the mili-tary base in Eckernförde, Schleswig-Hol-stein, has around 120 posts, although not even half of them are filled. There is an intense search for new recruits. An eight-week selection process prepares the appli-cants for their first milestone: the fitness entrance test. It includes a five-kilometer run in less than 23 minutes, a 1,000-meter swim in no more than 24 minutes, dynam-ic apnea over a distance of 30 meters and static apnea for 60 seconds, six pull-ups,

ten 50-kilo bench presses, and recovering two five-kilo rings from a depth of three meters. Lastly, the candidates must do as many push-ups and sit-ups as they can in two minutes! Those who pass the test here will subsequently embark on a training course lasting up to 42 months, depend - ing on rank and degree of specialization. Most candidates are diving for the first time with apparatus, so they are learn-ing this discipline from scratch. They attend seminars over the course of several weeks in order to familiarize themselves with various kinds of ordnance and booby trap mines, known as IEDs (improvised explosive devices) in military jargon, along with their characteristics and behavior – and also learn how to dispose of ordnance. “The homemade ones are the most dan-gerous, because there are no limits to the imagination,” says mine clearance diver Chris.

“UNDAUNTED BY DIFFICULTIES”The level of training is also high. What kind of ordnance is there? How do the var-ious types differ? How can they be opened with blasting technology? How many explo-sives must be attached and where? What is the best way to blast them? And above all else: How do you manage to ensure that the mind doesn’t play tricks on you in a life-threatening situation? In contrast, the final examination appears to be a breeze – here the soldiers must complete a 20-kilo-meter run wearing a backpack and then swim ten kilometers back. Spending sev-eral hours in the cold Baltic Sea requires physical and mental fitness. Only those who possess both and can regularly push themselves to their limit will live up to the mine clearance divers’ motto: Nec aspera terrent – “Undaunted by difficulties.”

MINES IN THE NORTH SEA AND BALTIC SEASea mines are classified into ground mines and moored contact mines, depending on the way in which they are positioned, and into contact and remote detonation mines, depending on the type of detonator – they can be laid in virtually all water depths. Moored contact mines are anchored on the seabed and float beneath the water surface; their explosive power can sink entire ships. Gigantic mine barriers were laid in the world wars – after which large amounts of unused bombs and grenades were dumped. Old explosives and chemical munitions are a problem. Experts estimate that in the North Sea and Baltic Sea there are still more than 1.5 million tons of them.

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No woman has thus far made it into this male domain. “We attend to anything that can explode underwater, but also many things on land,” says Chris, father of one son, describing his job. “A lot of it plays out in the mind,” says the chief petty offi-cer. You have to be able to keep a cool head when you’re alone with an explo-sive device at a depth of 54 meters. Most are remnants from the Second World War. More than 1.5 million tons of these old munitions are scattered across the North Sea and Baltic Sea. Even 75 years after the war ended, the seabed is still littered with these explosive remains. Nobody has really paid much attention to them for decades. However, there are risks associated with simply leaving the ordnance in the sea. Hazardous substances poison the under-water world, terrorists could recycle the ordnance, and it hinders the construction of wind farms and cable routes. And not all mines are the same. Some are as small as a beer can, while others weigh many tons and are several meters long. They can take the form of torpedoes, spheres, or plates. Chris can generally tell quickly which mod-el he is dealing with. Should this not be the case, he assesses it and makes notes underwater on a plastic board about its shape, length, and position – and then, back on board, he discusses how to pro-ceed further with his commander.

SURPRISES ON THE SEABEDHe has familiarized himself with the dif-ferent types in a hall at the military base in Eckernförde. Hundreds, if not thou-sands, of types of ordnance from all over the world stand, lie, and hang here – all properly sorted. Chris and his colleagues also search for weapons that have been

dumped in the sea – even in crisis regions, by NATO mandate. If nothing else, the weapons present a grave danger to ship-ping traffic. Equipped with special tech-nology, the hunt is conducted in spe-cial boats. If an object is detected using sonar, it is classified as mine-like contact (MILCO). It is then up to the command-er to decide whether to launch a mine clearance diving mission to take a clos-er look at the object. Chris and his col-leagues sometimes come across surpris-es when the “thing” on the seabed turns out to be a domestic appliance, for exam-ple, although this is the exception.

DISRUPTIVE MAGNETIC FIELDSWhen a mine clearance diver approaches a “contact,” he sizes it up before touching it. He carefully runs his fingers over the gen-erally overgrown surface in order to get an idea of what exactly he is dealing with – a washing machine, secretly dumped, or old ordnance? If the latter, is it from France, the UK, the former Soviet Union, or Ger-many? Live or not? In any case, he mustn’t handle the ordnance too firmly, because the detonator is often still fully intact – even after more than three-quarters of a century in the sea – and could cause an explosion if the mine is exposed to strong vibrations. The mine clearance divers perform this exploratory work in special

EVEN 75 YEARS AFTER THE END OF THE WAR, THE SEA IS STILL FULL

OF EXPLOSIVE SURPRISES

A GARDEN FULL OF MINESProspective mine clearance divers cannot avoid this special garden at the naval base in Eckernförde; it is an inte-gral part of the training. In the so-called mine garden, they learn to recognize, detect, and identify explosive devices. Apart from the shallow depth, the condi-tions are realistic. The underwater mines are real, but have been defused. There is a course for underwater military units at depths of between five and ten meters. Is that an overgrown mine or has someone disposed of an old elec-tric appliance? Is there a risk of a dud exploding? Trained mine clearance divers are specialists who operate at depths as deep as 54 meters and can dispose of all kinds of explosive devices.

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WE ARE THE ENGINE! Small muscle-powered boats are a suitable means of attack, plus they can take you almost anywhere. Mine clear-ance divers also secure coastal sections, which they reach by kayak and examine for buried explosive devices with the aid of metal detectors – before other units land


diving suits and are equipped with various devices and tools. They are completely on their own here and sometimes exposed to strong currents. Visibility underwater tends to be poor. Chris can just about see his hand in front of his eyes, otherwise he is virtually blind and has to feel his way around his environment. When he touch-es the seabed, mud swirls up. Then he gen-erally no longer sees anything. The div-ing computer on his wrist shows him the depth and duration of his dive: “Even if I hold it right in front of my eyes, it is like looking into a snowstorm.” Why doesn’t he use a flashlight? “That would be sui-cide – some mines react to changes in the earth’s magnetic field, which can be caused by the electrical circuit of a flash-light, among other things,” explains Chris. It is therefore little wonder that his entire kit is nonmagnetic.

SAWFISH AND MOORED CONTACT MINESEven the smallest breathing noises under-water can cause ordnance to explode. For dives down to depths of 24 meters, the mine clearance divers therefore use a closed-circuit system (Type: Dräger LAR

VII Combi); either front-mounted with oxygen (for shallow diving to depths of seven meters) or including back-mounted apparatus with nitrox B, a NATO mixture composed of 60 percent oxygen and 40 percent nitrogen (for deeper dives between 7 and 24 meters). On this complex system, also known as a rebreather, the exhaled air does not end up in the water, but is puri-fied by soda lime, enriched with oxygen, and fed back to the diver. The job of the soda lime is to bind the carbon dioxide (CO2) from the exhaled air. For a num-ber of years, the Regional Working Group on Waste (Bund/Länder-Arbeitsgemein-schaft Abfall or LAGA) has classified soda lime as hazardous waste. Separate col-lection and appropriate documentation of how it is used and recycled have been obligatory ever since. The dry chemical is replaced at regular intervals, because it loses its absorption ability over time. Dräger offers its customers a comprehen-sive collection and recycling concept for soda lime and cartridges (see page 49). The Dräger equipment used by special units all over the world is not only robust, reliable, and easy to handle, but also demonstrates good breathing behavior and permits dives lasting up to four hours.

When Chris talks about his job, it all sounds very modest. What he does is quite simply his job. He is aware that he is put-ting his life on the line every time. Profes-sionalism and camaraderie form a kind of safety net among mine clearance div-ers. The mood is laid-back and relaxed. Nothing less than chummy. Each of them must spend at least 24 mandatory hours per year underwater – this may not sound

MINE CLEARANCE DIVERS CONSTANTLY RISK THEIR LIVES. PROFESSIONALISM AND CAMARADERIE

HELP THEM FORM A KIND OF SAFETY NET

like much at first, but diving missions on the seabed can soon be tiring. The divers sometimes come across a now rarely seen sawfish there. Together with a moored contact mine, it features on the company insignia of the mine clearance divers. The predatory fish are able to maintain their body temperature a little higher than the ambient temperature. A team of research-ers from the University of Queensland in Australia also discovered that they heat up their eyes in order to be able to see better in cold water. If Chris and his colleagues could do the same, they would no longer need to feel their way around at a depth of 54 meters.

WHEN TWO PEOPLE MEETThose who pass the mine clearance diver training are given a coin with their service number and the image of a sawfish, the symbol of the mine clear-ance divers. This “challenge coin” can soon rouse the play instinct in even the most hardened men, because the coin must be on hand at all times. At a moment’s notice. If a mine clearance diver is caught without this symbol during the “coin check,” they must pay for the next round of drinks. If all the mine clearance divers have their coins with them, the person who challenged them has scored an own goal – andpays for the round.

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PUT TO THE TEST Before each dive, the functionality of the apparatus (here: Dräger LAR VII Combi) must be checked and the equipment must be inspected to make sure that it is complete and ready for use

DRÄGER REVIEW 123 | 1 / 2021 61

Public awareness of climate change went global two years ago with the emergence of the Fridays for Future movement. For good reason, people are trying to improve the earth’s atmo-sphere by cutting emissions. Human activities over the past 50 years have driven greenhouse gases to a higher level than at any time in the last 800,000 years. The environmental footprint in the field of medicine is also big – five to ten percent of emissions in Western countries are attributable to the healthcare sector. Many areas are already being addressed.

The “Green Hospital” concept is a growing trend that has hospitals monitoring waste and energy use to help estab-lish a sustainable healthcare system. Operating rooms can play their part in reducing the carbon footprint. The spot-light is on anesthetic gases, because about a third of a hospi-tal’s greenhouse gas emissions are generated by the use of anesthetic gases.

HALFWAY AROUND THE WORLD – FOR AN ANESTHETICThe American Society of Anesthesiologists (ASA) has launched the “Inhaled Anesthetic 2020 Challenge,” calling for a 50 per-cent reduction in carbon emissions caused by anesthetics. The German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Professional Association of German

A BETTER OPERATING

CLIMATEThe World Medical Association has declared a climate emergency and called for climate neutrality by 2030.

One of the many details that must be addressed is an eco-conscious approach to anesthesia.

The problem lies in the use of anesthetic gases.

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Anesthesiologists (BDA) are also looking at the subject of sus-tainability. They got together in 2020 to form the “Sustain-ability in Anesthesiology” commission and published a paper with specific recommendations. One of the key points referred to the consistent use of low- or minimal-flow anesthesia with volatile anesthetic agents.

Standard forms of anesthesia are characterized by their low fresh gas flow into the machine’s breathing gas system. In the past, the fresh gas flow was generally used in very high con-centrations in order to ensure that the anesthetic was as safe as possible. This is the straightforward approach for anesthe-tists. By using high flow, they can control the anesthetic and therefore don’t have to manage the anesthesia as much. It is a bit like driving an SUV: safe and comfortable, but not real-ly environmentally friendly. The carbon dioxide equivalent of the inhaled anesthetic amounted to around three million tons in 2014. This provides an indication of how much a certain amount of a particular greenhouse gas contributes to global warming compared to the same quantity of carbon dioxide. The volatile anesthetics are halogenated hydrocarbons – high-ly potent greenhouse gases, some of which stand out with par-ticularly high global warming potential (GWP). In the Kyoto Protocol adopted in 1997, it was agreed that there should be a global reduction in the amount of halogenated hydrocarbons; in Kigali in 2016, it was resolved that they should be phased out completely by 2035. However, anesthetics were exempted

INHALED ANESTHETICSStrictly speaking, anesthetics are not gases at all, but volatile agents that evaporate at low temperatures. This evaporation can be controlled in special vapors. Each anesthetic gas has advantages and disadvantages and is chosen and adjusted based on the needs of the patient. The optimal anesthetic gas quickly washes in and takes eff ect within the body. At the same time, it should also be capable of washing out again quickly as soon as the anesthesia has ended. The most common agents are sevofl urane, desfl urane, and isofl urane.


HOSPITALOPERATING ROOM

YOUNGER COLLEAGUES ARE IN FAVOR OF CHANGE – AND FOLLOW THE PRINCIPLE “FLOW AS LOW AS YOU CAN GO!”

because they are medically necessary substances. The problem is that there has been a sharp global increase in the use of vol-atile anesthetics. This is due to improved medical care and an aging patient population that is operated on more frequently.

Minimal- and low-flow anesthesia can cut anesthetic gas emissions by up to 90 percent – while also benefiting the patient and the environment. During low-flow anesthesia the fresh gas flow is reduced to a maximum of 1 l/min, while a maximum of 0.5 l/min is used during minimal-flow anesthesia. By way of example, a seven-hour anesthesia with a fresh gas flow of 0.5 l/min and two percent inhaled anesthetic causes a greenhouse effect roughly comparable to that of a 500-mile car trip. With a conservative fresh gas flow (which uses around 4–8 l/min) this could soon add up to 9,320 miles, depending on the anes-thetic agent. As a preventive measure, a basic requirement for anesthesia with low fresh gas flow is a rebreathing system with absorber, which removes and binds the exhaled carbon dioxide from the breathing cycle. Moreover, unused gases and anesthetic agents from the patient’s exhaled air are also reused. As a gen-eral rule, the lower the fresh gas flow, the higher the rebreath-ing component and thus the smaller the agent consumption and the negative impact on the environment.

THE YOUNGER GENERATION WANTS TO SEE CHANGE“Flow as low as you can go!” says Professor Manuel Wenk, explaining the motto that has guided his work ever since his residency days. After being appointed chief consultant of the Department of Anesthesiology, Intensive Care Medicine, and Pain Management at the Florence Nightingale Hospital run

by the Kaiserswerther Diakonie in Düsseldorf, he switched to using volatile anesthetic agents in the hospital’s operat-ing rooms. Until then, total intravenous anesthesia (TIVA) was almost exclusively used in Germany. Wanting to protect the environment, Wenk committed himself to reducing the waste associated with the disposable products needed for TIVA. “Everybody was surprised at how quickly the impact became evident,” says the doctor. In order to ensure that he wasn’t jumping out of the frying pan into the fire, he opted for low-flow anesthesia from the very beginning. “Our younger col-leagues in particular are pressing for things to be done dif-ferently,” says Wenk, confirming the commitment to change. Since the hospital linked its anesthesia workstations and add-ed the Dräger Connect data analytics application, successes in gas agent reduction can now be evaluated – as a team, of course: “We are not competing with one another. It is more about working in a way that is as efficient and environmen-tally friendly as possible – and Dräger Connect helps here.”

TAKING RESPONSIBILITY WITH THE RIGHT FLOWWhile low- and minimal-flow anesthesia offer compelling ben-efits, the approach has not yet been widely adopted around the world. Dr. Jeffrey Feldman, Professor of Clinical Anesthesiol-ogy at the Children’s Hospital of Philadelphia, located in Phil-adelphia, USA, is an advocate for low- and minimal-flow anes-thesia. In a children’s hospital, persuading colleagues to reduce flows can be especially challenging as sevoflurane is the most commonly used inhaled anesthetic. It is well known that sevo-flurane produces Compound A when used with certain types of carbon dioxide absorbents. Although Compound A can be neph-rotoxic in rats, this risk has never been verified in humans. Fur-thermore, modern carbon dioxide-absorbent formulations do not produce Compound A. Nevertheless, the guidelines from the United States FDA state that flows of less than 1 liter per minute should never be used with sevoflurane and many prac-titioners do not use less than 2 liters per minute. “I naturally try to convince my colleagues of the safety and benefits of low-flow anesthesia,” says the doctor, who is committed to protect-ing the environment and has published professional articles documenting the safety of low-flow anesthesia. “Since anesthe-tists adjust the fresh gas flow, each of them is responsible for the environmental impact of the anesthetic vapors and gases,” he says – and wishes to appeal to his colleagues’ sense of respon-sibility. “Even though the environmental impact of one single case may be small, it is still a good idea to reflect on habits that extend across an entire career.” His appeal is also aimed at the P

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DRÄGER CONNECT Linking medical equipment can provide new options for evaluation and optimization. With Dräger Connect, for example, data from all anesthesia workstations in a hospital can be evaluated and clearly presented as part of a gas consumption analysis. Besides consumption figures, the efficiency level is also displayed – from a brief overview to a detailed analysis of individual operating departments or anesthesia workstations.

manufacturers of volatile anesthetics. “It is time to drop any concerns about low flow rates and ask both the manufacturers and the regulatory authorities to remove all restrictions from their requirements,” he says. “We owe it to society to work on minimizing our carbon footprint.”

FIRST SIGNS OF SUCCESSIn a recent study, the use of low-flow anesthesia in a US hos-pital equipped with 600 beds led to a 64 percent reduction in carbon dioxide, which equates to 2.8 million kg. This is equiva-lent to the annual emissions generated by more than 600 cars. In addition, using low-flow anesthesia cut the cost of volatile anesthetics by $ 25,000 – per month. Some hospitals have made considerable progress in reducing their inhaled anesthetic foot-print, while others are still at the beginning of the process. It is essential to measure the current level of emissions and track the progress made.

Prof. Manuel Wenk and his team are looking forward to the first annual evaluation of their 12 anesthesia workstations with the help of Dräger Connect. One colleague is currently in the process of reviewing the switchover from intravenous to vola-tile anesthesia management – taking into account all param-eters. The fact that the team has stopped using disposable cof-fee cups in the operating area and also rides bicycles around the city cannot be taken into account here – although it is good for their personal carbon footprint.

DATA ANALYSIS The gas consumption values

can be directly assessed via the connected machines

If you have any questions about Dräger Connect or require further information, simply scan the QR code and send us an e-mail.


READY FOR ANY SCENARIO

When the coronavirus pandemic reached Europe in March 2020, the Berlin Senate set an ambitious target: to build a hospital in an exhibition hall in just four weeks. Up to 1,000

beds are available at short notice – although ideally they will never be needed.

TEXT OLIVER DRIESEN PHOTOS PATRICK OHLIGSCHLÄGER


AS FAR AS THE EYE CAN SEE

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HOSPITALCORONAVIRUS PANDEMIC

LIQUID OXYGEN is suppliedby a 50,000-liter tank located outside. A network of pipes distributes it to the respective hospital beds

Pale sunlight falls in diagonal stripes through the sky-lights in Hall 26 on this late summer’s day. It is quiet in here, even quieter than outside on Berlin’s almost deserted exhi-bition grounds beneath the radio tower built in 1926, one of the city’s landmarks. With increasing distance, the deepen-ing shadows being cast appear to play tricks on the eyes – one hospital bed after another is lined up along the aisles marked with green and blue linoleum flooring. There are almost 500 beds here, extending across a hall with a length of 165 meters. All are identical, standing in front of mobile wall supply units*, which supply ventilators with oxygen and compressed medi-cal air. Every single bed is empty. An auxiliary hospital now stands on the same 12,000 square meters of space where thoroughbred horses were exhibited at the start of 2020 as part of International Green Week.

BERLIN WANTED TO BE WELL PREPARED“I am very much hoping that it remains empty,” says Albrecht Broemme. The 67-year-old should know. After all, in his role as general project manager, he oversaw the construction of the auxiliary hospital in record time. When the former chief of Ber-

lin’s Fire Department – who later became president of Germa-ny’s Federal Agency for Technical Relief (commonly known as THW) and is now its honorary president – retired last Decem-ber, little did he know that Berlin’s Health Senate Director Dilek Kalayci would call him out of retirement just a few months lat-er as a disaster management expert. His mission: to construct the Jafféstraße Coronavirus Treatment Center, to give it its offi-cial name. Now, in late summer 2020, the treatment center has been built and is currently in standby mode.

“Jafféstraße is a so-called overflow hospital,” explains the architect Bettina Hufe, who is usually the project mana-ger overseeing the construction of new hospitals for Ger-many’s umbrella association of accident insurance institu-tions for the industrial and public sectors (German Social Accident Insurance or DGUV). Patients are only admitted to overflow hospitals when the regular hospitals are literal-ly overflowing – in this case due to the ongoing coronavi-rus pandemic – and can no longer accommodate the influx of sick patients. And this is precisely what the state of Berlin wanted to be prepared for. Within Broemme’s team, Hufe was responsible for coordinating those involved in the on-site

planning and construction due to her experience in managing hospital development projects.

Nobody had experience of building an improvised pan-demic hospital, however, when those in charge of the project met on March 19, 2020 for the first planning meeting, imme-diately after the start of the nationwide lockdown. There were no regional or national action plans that anyone could consult. And given the pressure caused by the fact that nobody knew how the pandemic would progress, everything had to be orga-nized very quickly, particularly since China had already shown the world how a specialized pandemic hospital could be built within a matter of weeks. Could they pull off a similar feat in Berlin – despite the completely different starting situation and approval procedures (with almost 100 licensing units)?

First of all, planning permission was required, because con-verting an exhibition hall into an auxiliary hospital is clearly clas-sified as a change in use. A neat and clever solution was found, which also complied with building regulations. It still brings a smile to Broemme’s face: “We declared it a civil protection facil-ity, for which there is a special paragraph in most state building codes. This paragraph allowed us to complete the fastest build-ing application in Berlin’s history – I simply had to draft a build-ing notice and then approve the application myself!” Necessity is the mother of invention.

COMPLETED WITHIN WEEKSThe Senate specified, however, that it had to be ready four weeks after construction work began – which necessitated a firm plan in the beginning. “On March 20, we called the plan-ners and asked them whether they wanted to get involved,” recalls architect Hufe. “Just a few days later, the draft was on the table.” The Lübeck-based company Dräger was also on hand from the very start. Not just as the manufacturer of the 111 ventilators for patients who would need mechanical venti-lation, but also as the supplier of the technical infrastructure behind it all – the units that supplied oxygen and compressed medical air for the ventilators. In the fastest time possible, a complex network of pipes and cables was created to supply the

THE SHEER DIMENSIONS SEEM TO

PLAY TRICKS ON THE EYES

MASTERMINDS behind the coronavirus treatment center project, which was built within a matter of weeks: ex-THW President Albrecht Broemme and architect Bettina Hufe

hospital with the different media it needed: gases, water, elec-tricity, data. At the heart of the innovative solution was oxygen, a vital gas for patients infected with Covid-19. “In terms of oxy-gen supply, a conscious decision was made to install one cen-tral tank rather than use individual cylinders,” explains Patrick Bading, key account manager at Dräger. “With 111 ventilators, it would have been necessary to employ an entire team just to regularly replace the oxygen cylinders.” The concept adopted by Dräger involves one 50,000-liter tank filled with liquid oxy-gen and compressors for compressed medical air, all located outside the hall. The gases flow from here along a 6-kilometer- long network of copper pipes to the hospital beds, where they are fed into the supply units. The supply of such medical gases is one of the areas in which the Dräger ANSY busi-ness unit specializes. The planners’ main concern was how they were going to get heavy copper pipes, 110 kilometers of

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HOSPITAL CORONAVIRUS PANDEMIC

KEEPING TRACK OF THE PRESSURE

The gas management system from Dräger monitors the pres-

sure of two important media: oxygen and compressed air for medical applications. Both are supplied to the bedside via a system of pipes installed be-

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electric cables, and 20 kilometers of network cable to where they were needed in an exhibition hall that was not designed for such infrastructure (no load-bearing interior walls). For hygienic and structural reasons, laying the pipes and cables underground was not an option. The solution came from on high. The cluster of pipes and cables was attached to steel ropes hung on transverse beams, which can be lowered from the ceiling and raised up again. “We rented some of the trans-verse beams from the stage show of a comedian,” says project manager Hufe. “He doesn’t need them at the moment, because of the lockdown.”

A SECOND HALL IS BEING PREPARED“We built the hospital from the top down,” says project man-ager Broemme, “because it was statically possible to construct the network of pipes and cables in a quick and neat way using maneuverable transverse beams.” Almost simultaneously, the problem of the hall floor had to be solved. Ultimately, clearly laid-out paths for beds on wheels had to be created on rough concrete. The solution came in the form of green linoleum for the normal care area and blue for the intensive care area. “All of this was only possible,” says Broemme, praising the effort, “because the entire team worked from morning till night with-out thinking about taking time off!” This is confirmed by Toralf Meier, divisional manager at Dräger ANSY GmbH: “Thanks to the hard work of everyone involved, we were able to reach the milestone and keep to the ambitious timetable. On our side, too, all employees from different departments pulled together.” Construction work on the entire treatment center in Hall 26 was completed on May 11, as the first wave of the pandemic had begun to significantly subside. It was officially recognized as a hospital one week later. Yet since the hall could only accommo-date half of the roughly 1,000 beds planned by the Berlin Senate and it remained uncertain how the pandemic would progress, the neighboring Hall 25 is also being prepared as an additional treatment area, initially with another approximately 320 beds. Around 200 beds remain in reserve at Vivantes, the Berlin- based healthcare company that is operating the treatment center. “The infrastructure for Hall 25 will be built with all

If you have any questions about Dräger Medical ANSY GmbH or require further information, simply scan the QR code and send us an e-mail.

MAKING IT ALL POSSIBLE The fact that Dräger Medical ANSY GmbH was involved in the construction of the coronavirus treatment center in Berlin is no coincidence: The Lübeck-based company specializes in medical engineering and construction services in hos-pitals. The main areas of focus lie in installing central gas supply lines and designing medical workspaces together with supply units. The division of the sales operation within four regions of Germany and the decentralized personnel structure guarantee fast reaction times and cus-tomer-oriented service – not only with its own products, but also other systems. A 3D planning tool developed together with the Dräger Work-place Infrastructure Projects (WPI) business unit and the use of Building Information Modeling (BIM) are among the highly developed technolo-gies used to assist hospital planners with design and construction tasks. In addition, there are (currently virtual) customer workshops on work-space design, held at the Dräger Design Center in Lübeck, where all spaces relevant to hospital processes are set up. Equally interesting is the range of services covering risk management in the supply of medical gases. ANSY helps its customers meet their obligations as operators in this field, especially when it comes to complying with the provisions of Germany’s Critical Infra-structure Directive that governs the functional safety of critical infrastructure facilities. Yet the company has also demonstrated its efficiency and flexibility beyond predictable situations and standard projects. When called upon in emer-gencies during floods and other disasters, the company has often helped hospitals avert the threat of having to evacuate patients. Here the crisis management teams benefit from the fact that the Lübeck-based company also keeps key components and compact systems fully prepared and on standby.

THE SOLUTION CAME FROM ON HIGH:

TRANSVERSE BEAMS SECURE THE

CLUSTER OF PIPES AND CABLES



the required connections, although the final phase of the project using public funds will only be implemented if the sit-uation requires it,” explains Broemme. The same goes for the delivery of most of the planned ventilators. “Our company’s strategy has always been to ensure that the hospitals with an acute need for the machines are primarily the ones that get them,” says Dräger key account manager Bading. “Given the current global situation, it would be irresponsible to send even more machines to Berlin when they are needed much more urgently elsewhere.”

Numerous lessons have been learned by everyone involved in the project that was completed in record time. It has become clear, for example, that the highly flexible Berlin model can be reproduced in an extremely flexible approach for future pan-demic scenarios around the world. “There is already a great deal of interest,” says Hufe, “whether from the German Armed Forces Medical Academy, ambassadors, politicians, the trade press, or medical professionals who want to find out more about the auxiliary hospital project.”

CONSIDERABLE FEEDBACKRegardless of the situation, planners can rely on Dräger’s cross-functional experience. Prof. Peter Schmiedtchen, pro-fessor of hazard prevention at Magdeburg-Stendal University of Applied Sciences and head of safety and emergency manage-ment at Dräger, sums up the available package of services in a nutshell: “As a supplier of critical care medical equipment and supply units, infrastructure design, protective equipment such as masks, and medical and safety advisory services, Dräger is uniquely positioned to prepare hospitals for future pandemics.”

WELL PREPARED FOR AN EMERGENCYWhat is the point of a backup hospital if every-thing stalls in the event of an emergency? To prevent this from happening, the Berlin-based healthcare company Vivantes trained for an emergency under real conditions: Actors playing Covid-19 patients were driven to the hospital, registered in reception, and handed over to the clinical staff. Then the doctors, nursing staff, and more than 80 previously trained extras playing patients practiced the initial diagnostic process; among other things, the use of mobile X-ray machines was tested at the bedside. This was followed by routine tasks, such as preparing and serving food. Special situations were also simulated, such as alarm management or the reactions of staff members to problem cases and complications. One of the “patients,” for example, feigned a sudden loss of consciousness. In keeping with the scenario, others turned out to be under 18 or dialysis patients – two patient groups that cannot be treated at Berlin’s Jafféstraße Treat-ment Center and would have to be transferred to other hospitals in the event of an emergency. The outcome of the simulation exercise was that clinicians practiced taking care of patients and the logistics chain was tested. It also proved advantageous for the treatment center to have the clinical staff committed to a con-tract. In the field of healthcare in particular, it would otherwise be difficult to guarantee suffi-cient staffing levels during a pandemic. There was room for improvement in the sanitary con-tainers, for example, which proved not to be wheelchair-accessible, and this was rectified.

Albrecht Broemme, the veteran of disaster management, hopes a sudden ramping up of activities at Jafféstraße won’t be nec-essary. Yet the considerable feedback received has convinced him of the positive effect the mere existence of such a facility can have. “Most people I speak to express how happy they are that the ‘coronavirus hospital’ exists – because we now have a buffer in Berlin that has been sorely missed in places such as New York, Madrid, and Rome.”

FULLY EQUIPPED: This ICU space is already prepared for demonstration purposes (“Berlin model”). A total of 111 of these ventilation units are ready to use in the event of an emergency

72 DRÄGER REVIEW 123 | 1 / 2021


Technology for LifeHere you will find an overview of some of the products featured in this issue.

The QR codes lead to the information for each product. If you have any questions about a particular product or Dräger Review, write to us: [email protected]

X-PLORE 8000 SERIES These powered air-purifying respirators are protected against dust and water according to IP65. A battery supplies power for up to eight hours. Page 28

SMARTPILOT VIEWThis software displays the interaction of hypnotics and opioids in graphic form during anesthesia. Page 38

MOBILE AGILA SYSTEM A special version of the ceiling supply unit for use in emergency hospitals – it provides the technical infrastructure for the treatment units. Page 68

PULMOVISTA 500 This device uses electrical impedance tomography to monitor the distribution of ventilation in the lungs. Page 42

PSS 7000The carrying system of the com-pressed air breathing apparatus made of carbon-fiber-reinforced plastic can be adapted to suit the height of the wearer. Page 34

ABC AND CIVIL PROTECTION FILTERS These special filters protect crews involved in civil protection and disaster management from chemical agent and industrial chemicals. Page 47

HPS 4500*Half-shell helmet with advanced visor concept and ergonomic interior features for a high level of comfort. Page 17 * Successor to the HPS 4300

SERVICE INFORMATION

Dräger Safety AG & Co. KGaA, Lübeck, manufactures the following products: PSS 5000 (p. 15) and PSS 7000 (p. 34), HPS 3500 and HPS 4300 (p. 17), X-plore 8000 (p. 26 ff.), Interlock (p. 45), PIR 3000/7000 and Polytron 3000 (p. 54), LAR VII Combi (p. 60 f.) and LAR 8000 (p. 74). Drägerwerk AG & Co. KGaA, Lübeck/Germany, manufactures the SmartPilot View (p. 38 f.),

PulmoVista 500 (p. 42 ff.), soda lime (Drägersorb; p. 48 f.), Perseus A500 (p. 63), the Connect software (p. 64 f.), Linea and Agila (p. 68 f.) and the gas management systems (p. 70).

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Diving is sometimes a matter of survival in a strange environment that is even more dangerous for mine clearance divers. For up to four hours – a limit set

by the human body rather than the equipment – they use breathing apparatus like the new Dräger LAR 8000.

SECURE GRIP

Upper and lower attachment points ensure a secure grip on the diver’s chest.

GREATER DEPTHS WITH NITROX

With pure oxygen, bubble-free depths of up to six meters can be reached – or even 24 meters when using this rotary switch to change over to mixed gas in a semi-enclosed circuit. Then the nitrogen escapes into the environment in the form of fi ne bubbles, both invisibly and silent-ly, so that mines do not detonate as a result of the acoustic signal.

ABSORBINGSODA LIME

In a closed-circuit breathing system, soda lime binds the CO2from the exhaled air.

OXYGEN CYLINDER

Available in steel or composite material. The latter is, like the entire unit, nonmagnetic, and

thus does not aff ect the earth’s magnetic fi eld – an eff ect to

which mines respond. If just a single paper clip was present

in the apparatus, the speci-fi cations would be exceeded

approximately tenfold.

MINIMAL BREATHING RESISTANCE

A new geometry of mouthpiece and breathing hose and the use of a

separate breathing bag from soft mate-rial for inhaling and exhaling reduce the

breathing resistance by about a third – to such an extent that a frogman testing it immediately returned to the surface

because he thought it was faulty.

REDUCING VALVE

Pressure reducer toreduce the pressure of the

oxygen cylinder.

If you have any questions about the LAR 8000 or require further infor mation, simply scan the QR code and send us an e-mail.

AN HONOR! - Dräger

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