Ambulance

An ambulance is a vehicle designated for the transport of sick or injured people. The first ambulances called by that name were horse ambulances used in the American Civil War. The first practical ambulances were created by Dominique Jean Larrey, a French surgeon (1766–1842), for use in the Napoleonic Wars. Modern-day ambulances are typically large automobiles on a van or light truck chassis.

However, an ambulance can be any vehicle, including a bus, helicopter, or even a hospital ship. During the 1960s, station wagons, as well as police cruisers, were used in some American cities (despite their limited space) and can be seen in motion pictures from that period.

In some countries civilian ambulances may use the symbol referred to as the "Star of Life," a blue six point star, originally designed and governed by the U.S. National Highway Traffic Safety Administration (NHTSA). Any unit displaying this star is said to be qualified to render its specific level of emergency care.

Under the laws of war, an ambulance marked by a red cross is not to be fired on and is to be permitted to carry out its duties in spite of the fighting. An ambulance may not mount weapons, although the Israeli EMS has produced a "tankbulance" that combines a Merkava main battle tank with ambulance features.

The word 'AMBULANCE' is spelled backwards on such vehicles. This is a world wide practice to help drivers ahead easily read and identify ambulances using their rear-view mirrors so they may give way.

Ambulances in North America

Ambulance types

1964 police cruiser, which is also fitted to transport patients. This was used before the advent of EMS services.

A typical Type I ambulance. The front of the ambulance is the same as a pickup truck, while the patient-care compartment is in the box-like module. This ambulance used to be run by Palm Beach County Fire-Rescue in Palm Beach County, Florida. It has since been replaced by a Freightliner Heavy-Duty Rescue-Ambulance made by MedicMaster.

A typical Type II ambulance. In contrast to the Type I ambulance shown above and the Type III ambulance shown below, the basic shape of this ambulance is that of a standard full-sized van with a raised roof. This ambulance is operated by American Medical Response, a commercial for-profit company.

A typical Type III Ambulance. The front of the ambulance is a van, while the patient-care compartment is in the box-like module. This ambulance is run by the Harmon, NY volunteer fire department.

A typical "squad truck" design for a fly-car. Fly-cars may also be an automobile or an SUV, or even a retrofitted ambulance, depending on the equipment carried. This fly-car was operated by Good Samaritan Hospital in Suffern, New York, in 1989. The service has since been merged with others in Rockland County to form Rockland Paramedic Services.

Ambulances in both the United States and Canada are defined by KKK-1822E requirements which defines several categories of ambulances.
* Type I Ambulances are based on the chassis-cabs of light duty pickup-trucks,
* Type II "Vanbulance" Ambulances are based in modern passenger/cargo vans,
* Type III Ambulances are based on chassis-cabs of light duty vans,
* Extreme Duty versions of both Type I and Type III are also now authorized based on the chassis-cabs of medium duty truck chassis.Note that Type I's and Type III's are often called boxes by their crews with Type II's being called vanbulances (or jokingly Trauma Twinkies); ambulances are also referred to as buses (common nomenclature in the New York City area, which some EMTs and paramedics from other areas consider to be derogatory), mods or modulars (if type I or III), rigs etc. Type III ambulances with single-wheel rear axles are sometimes referred to as mini-mods, since the "full-size" mods have dual-wheel rear axles.
* There are also fly-cars, which are large cars or SUVs. These units cannot provide patient transport, but are used variously by supervisors or as a source of additional personnel. In some communities the paramedics respond to emergency calls in their fly-car, while a BLS ambulance responds as well to transport the patient.
* Many companies who specialize in non-emergency patient transfers are creating their own vehicles, which are similar to ambulances and carry ambulance type equipment, but lack emergency lights and sirens.

Ambulance Providers

Ambulance service providers come in several types in the USA:

1. Volunteer Ambulance Corps (VAC) or services - function similar to Volunteer Fire Companies. VACs may be community owned or privately owned, but are typically organised as non-profit organizations. VACs may also be part of Volunteer Fire Companies; in some of these cases, EMTs and drivers are also firefighters. Up until recently, Harbor City Volunteer Ambulance Squad (HCVAS) in Melbourne, Florida was the largest volunteer ambulance squad in the United States.

2. Private Ambulance Service - Normal commercial companies with paid employees, but often still have ties to municipalities. Access to private ambulance service nationwide is available through 1-800-AMBULANCE. The two largest private companies in the United States are AMR (American Medical Response) and Rural/Metro. While many private companies provide inter-facility patient transfer, many communities' emergency medical needs are served by private services.

3. Municipal Third Service - Operate as a third service alongside fire and police departments. These are more likely to be found in areas with a high population density, such as a city or metropolitan area. Municipal third services may be operated directly by the municipality, or by private companies such as AMR or Rural/Metro).

4. Municipal - Usually fire department owned and operated, though some systems are police department owned and operated.

5. Combined - these are full service emergency service agencies such as airport and college public safety offices. Some smaller towns and cities may also have them. Generally all personnel are cross-trained as EMT's/Firefighter/peace officer.

6. Hospital Based - Ambulance service such as ALS, BLS and CCT are offered by profit and non profit hospitals as a service to the community. Often these services do not support themselves and are funded by the hospital. An example of such a service is Enloe Medical Center out of Chico, Ca.

Service Level

The lines between one level of care and the next are becoming increasingly blurred. Skills that were once reserved for physicians are now routinely done by paramedics, and skills once reserved for paramedics, such as defibrillation, are now routinely done by Basic Emergency medical technicians (EMTs). There is also wide country-to-country, state-to-state (or province-to-province), and even county-to-county variation of what types of care providers at different levels are allowed to provide. That said:
*Certified medical First Responder (CFR, or sometimes just FR) - usually consist of personnel in a rural setting in which ambulance transport is delayed due to distance. In these cases, many of whom are volunteers, render very basic first aid to include oxygen administration to patients until a more definitive transport unit arrives.
*Basic Life Support or BLS - usually consists of two EMT-Basics. Provides oxygen therapy, splinting, bleeding control, defibrillation with an AED,and light extrication (eg: removing a victim from a car, but not using the jaws of life.)
*Intermediate Life Support of ILS - usually consists of an EMT-Basic and an EMT-Intermediate. EMT-Intermediates provide BLS care with the addition of IV therapy, and often intubation.
*Advanced Life Support or ALS - usually consists of an EMT-Basic or EMT-Intermediate and an EMT-paramedic. EMT-paramedics provide BLS care and ILS care with the addition of manual defibrillation and advanced electrical therapy including transcutaneous pacing (fitting a temporary pacemaker to the patient's chest) and synchronized cardioversion (an advanced form of defibrillation), intubation, medication administration, pleural (chest) decompression, and more.
*Mobile Intensive Care Unit (MICU) - Some services divide ALS, as described above, into units staffed by Intermediates, which they call "ALS units" and units staffed by paramedics, frequently called "MICUs" or "paramedic units." These usually consist of either an EMT and a paramedic or multiple paramedics, and provide the full range of advanced services to include IV therapy, Cardiac monitoring and drugs, pain killers. etc. In some locations, physicians may ride MICUs for special calls or as a matter of course.
*Critical Care Units - consist of a combination of EMTs/Paramedics/Nurses/Physicians depending on the need and service. They may provide special transports for premature babies, cardiac transfers, etc, although in some services, these are standard ALS units.

Need for Flexibility

There is a continuous flux in terms of types of services due to constant efforts to improve efficiency and effectiveness. Indeed, many fire departments are fire-oriented only in name and are becoming all-purpose emergency services organizations.

Ambulances in the United States are often staffed by at least one EMT driver and one paramedic, but sometimes they are staffed with two EMTs who can request paramedics if needed. Paramedics in the U.S. are professionally trained emergency medical technicians, a healthcare profession distinct from physicians and nurses.

American paramedics called to an emergency will identify and treat anyone needing medical assistance. US ambulances use an operational pattern known as "Scoop and Carry": They stabilize and transport those in need of further medical care to hospitals immediately, calling for additional ambulances as necessary. If the scene is dangerous (because someone is brandishing a gun or a building is on fire) paramedics usually do not enter until police or fire personnel explicitly allow them to do so.

Large American cities like New York and Los Angeles tend to have many distinct ambulance services representing all of the types mentioned above, so pedestrians and drivers must be alert for ambulances of many shapes, sizes, and colors. All ambulances certified for emergency response in the U.S., and many other countries as well, are marked with the Star of Life for ready identification by the public.

American ambulances usually are fitted with red (and sometimes white, amber and/or blue, depending on local law) flashing lights and a siren that continuously rises and falls, as opposed to the two or three-tone sirens heard in other countries. Air-horns, such as those found on a fire engine, are also becoming more prevalent. When an ambulance turns on its lights and siren, all other drivers are required by law to yield the right of way. In some states, like California, there is an affirmative requirement that all vehicles and pedestrians must also move to the side of the road as much as possible and stop.California Vehicle Code Section 21806.[1]

Ambulances in France

Ambulance in Lausanne (Switzerland)

A SMUR car in Lausanne

In France, the most general term is "vehicle adapted to patient transport", the term "ambulance" only applies for some categories of patient transport vehicles.

The word "ambulance" is reserved to transportation on medical prescription, including oral prescription in case of emergency. It does not apply to first responders vehicles (most of the time firefighters), although they also transport casualties; their vehicles are called VSAV–véhicule de secours et d'assistance aux victimes (casualties' rescue and assistance vehicle), or VPS–véhicules de premiers secours (first responders vehicles) in case of volunteers from associations. The VSAV and VPS are considered as vectors that bring rescue workers and devices onsite, the evacuation being only the logical following of this intervention but not their main duty.

There are therefore two kinds of ambulance providers: hospitals and private companies.

The reglementation classifies the patient transport vehicles in four types:
* A-type : ambulance for rescue and emergency care (ambulance de secours et de soins d'urgence–Assu) : in these ambulances, the personnel can stand; only these vehicles can be used for emergency (sanitary duty and H-MICU, see below) ;
* B-type : rescue and assistance to casualty vehicles (VSAV), i.e. first responders vehicles, very close to the A-type ;
* C-type : ambulance : the personnel cannot stand, it only allows the transport of a lying patient and of a sitting ambulance technician besides ; due to the lack of room, cares cannot be performed during the transport (these vehicles tend to disappear) ;
* D -type: light vehicle (véhicule sanitaire léger–VSL) : normal car without any specific equipment, for patient who can sit.The A, B and C-types are called "specially equipped" vehicles, and must follow the NF EN 1789 standard (December 1999).

First responders vehicles

A VSAV has three professional¹ CFR onboard, a VPS has five volunteer CFR.

The first responders of the VSAV and VPS are called secouristes and have 60 hours of initial education (plus additional continuous education) and perform non-medical, non-invasive acts. They use splints (including cervical collars, long spine boards and vacuum mattresses), oxygen first aid, and make the casualty lifting.

Note# some firefighters are not full-time professionals; they are called "pompiers volontaires", but they are paid for their work, whereas the volunteers from CFR associations (secouristes bénévoles) are not paid.

Hospital ambulances

There are two kind of hospital ambulances:
* internal ambulances, which drive the patients from one building to another; these are sometimes simple vehicles without any medical equipment (if the patient does not require any care enroute). These are always very short transportations.
* the UMH–unité mobile hospitalière (H-MICU–hospital medical intensive care unit) from the SMUR–service mobile d'urgence et de réanimation (mobile emergency resuscitation service) : an ambulance with an MD, a nurse and an ambulance technician that do pre-hospital intervention and interhospital transportation under intensive care.The H-MICU can be an ambulance, but it is often a light rapid-intervention vehicle, i.e. a car carrying the personnel and the material to the casualty; the transport itself is made with a VSAV or a private ambulance equipped with the medical unit.

When a private ambulance, a VSAV or an helicopter is reinforced by the medical team and material of the H-MICU, it "becomes" a H-MICU (i.e. the regulations that are specific to the H-MICU apply to the ambulance/VSAV/helicopter).

Special warning devices and traffic law

The H-MICU (A-type) and VSAV (B-type) have a blue rotating light and a two-tones siren (high-low-high-low-high-low...). When these special warning devices are on and when the emergency of the mission justifies it and as long as they do not endanger the life of other people, the traffic law allow them to disregard certain limitations such as speed limits, direction of driving, priorities and traffic light. In most states, this allows ambulances to travel no more than 5 miles per hour above the posted speed limit. Also, when approaching a red light, the ambulance must first stop, determine the intersection is clear, and then may proceed regardless of what color the light is.

The ambulance of private companies (A- and C-type) have a blue flashing light and a three-tones siren (high-low-high...high-low-high...). When these special warning devices are on and when the emergency of the mission justifies it and as long as they do not endanger the life of other people, traffic laws allow them to disregard certain limitations such as speed limits while respecting lane priorities and traffic lights.

Ambulances in the UK

An ambulance waiting outside of a hospital in Leeds, United Kingdom.

In the UK, ambulance services are provided under the National Health Service through local ambulance 'trusts'. Each trust is specific to a county or area, and so the country is divided across a number of ambulance trusts, in a similar way to the British Police are. There are 29 ambulance trusts in England but mergers in July 2006 will see the number of trusts fall to 13, with boundaries generally following those of the regional government offices. Interestingly, following a high profile local and national campaign, Staffordshire Ambulance Service has been given a temporary reprieve from reconfiguration; similarly the Isle of Wight will also retain a separate service.

Most trusts offer three levels of personnel for service: care assistants, technicians and paramedics. Care assistants operate PTS (Patient Transport Services), which is largely concerned with the moving of patients between hospital and home. Technicians and paramedics crew the emergency ambulances, providing more urgent transport and also paramedical care of casualties. Occasionally, when not attending emergency incidents, technicians and paramedics may help out with PTS duties. Ambulance Trust's performance is measured. The Governments targets are to reach 75% of Category A (life threatening) calls within 8 minutes. A number of initiatives have been introduced to assist meeting these targets, including Rapid Responders and Community Responders.

The crest of NHS ambulance services in England, United Kingdom.

Ambulance crews work a shift rota, and working nights and public holidays is seen as part of the job. Many people start out in a PTS role to gain experience of patient care, and then progress onto additional technician training at a later date. This has always been the classic method of entry into the ambulance service, although more recently some Universities have started to offer paramedicine degrees, some in association with local Ambulance Trusts, with guaranteed direct entry into the service on completion. These courses are somewhat controversial, with some more experienced ambulance staff arguing that such a fast-track approach misses the experience of PTS where recruits learn vital interpersonal skills. Direct entry to paramedic is becoming more available via the University route. Many trusts receive several hundred applicants per place, and this allows them to be very discriminating.

Technician training in many trusts is a 10 week course, usually residential. The IHCD division of Edexcel provides the qualifications for ambulance technicians and paramedics, and qualifiers become known as "state registered" or "IHCD registered". Without this registration, crewing of emergency vehicles or administration of certain medical techniques is forbidden.

Private ambulance services are becoming more common in the UK, along with the traditional voluntary sectors, such as the Red Cross and St. John Ambulance. However both the voluntary and private services tend to be concerned with PTS, and it is rare (although not unheard of) to find an emergency being attended by a non-NHS ambulance. The relevant UK legislation applies to all ambulances with no discrimination as to who owns or operates them. The majority of UK Private Ambulance Services are members of the British Ambulance Association.

In the UK, a minority of NHS ambulance staff are highly critical of the voluntary and private services, and there may exist an elitist attitude within some trusts. This may stem from hatred incurred during the various ambulance strike actions, where private, voluntary and military ambulance services have stepped in to provide cover, being referred to as "scabs". Most trusts are more positive about the additional services, even welcoming them as a means to reduce their own workload.

Ambulances in Germany and Austria

A German ambulance and the smaller emergency physician car with blue signal lights on.

In the German-speaking countries of Germany and Austria, preclinical care is not only provided by non-physician staff (Rettungssanitäter or Rettungassistent), but also by specially trained emergency physicians (called "Notarzt"). Therefore there are different types of ambulances.A few years ago, an ambulance that was sent to a potential life-threatening situation (e.g. cardiac arrest), was usually staffed with two paramedics and one physician. This system's disadvantage was that if the situation wasn't that life-threatening at all (and therefore no emergency physician would be needed) the ambulance staff had to treat the patient and wasn't therefore able to respond to situations where they really would be needed.In the last few year the so-called "Rendezvous-System" took over, where the emergency physician is driven to the scene by a separate car (usually a SUV) and the paramedics with the ambulance. Therefore, if there is no physician needed, the doctor can leave and let the paramedics take care of the patient or - in the opposite situation - if an ambulance is deployed to a situation which didn't sound that serious to the operator, the paramedics can call for reinforcements and the emergency physician could respond. Also, the driver of the emergency physician's car is usually a trained EMT too, so in case there is a very serious situation (resuscitation, heavy trauma), there are more trained people on the scene.

Air ambulances

German Air Ambulance

There are many Air Ambulances especially in Austria, but also in Germany, mainly because of the significant number of regions hard to reach by car, mostly around the Alps. These helicopters are all physician-staffed.

Private ambulance companies

In addition to the possibility of being run by a local or regional government (similar to, or even as part of, the local fire department), in the U.S., ambulance services may be provided by a private company. Private companies may be either non-profit charities or for-profit businesses.

In 1967, a privately operated ambulance responds in Portland, Oregon.

In the United States, private companies may contract with local governments to provide emergency or non-emergency services. In this case, their revenue often comes from a combination of user fees for those who can afford to pay for the service, and taxpayer subsidies for those who can't. In some areas private ambulance companies may be the primary or secondary responder for all medical emergency calls. In Portland, Oregon, for example, private ambulance companies are the only agency to transport patients from the scene of an emergency to a hospital, except for extreme circumstances when Fire Department will transport.

Whether or not emergency services are primarily a governmental or private effort, private ambulance companies often perform non-urgent transportation between hospitals or from home to hospital and back (e.g. for regular dialysis or planned medical procedures). This service is sometimes called a "white taxi." In other parts of the U.S., non-emergency transportation is provided by the local public bus service. Many public transit systems provide specialized services for elderly and disabled people who need to be taken to and from medical appointments, often under provisions of the Americans with Disabilities Act of 1990. In some (usually rural) areas, this may be the only form of taxpayer-subsidized public transportation service.

In some areas, private ambulance services also respond to non-emergency home calls, such as "pick up and put back" calls, which are made when a person falls without injury, but needs help getting up. They might also provide "first aid only" services, such as providing bandages (but not a trip to the hospital emergency room) to a child who skinned his/her knees at a playground. In other areas, these calls may be handled by fire departments or other local emergency services.

The size and qualifications of the crew on a private ambulance depends on the kind of service that they are expected to provide. It often includes one or both of whom may be EMT-Basic, EMT-Intermediate, or EMT-paramedics. Other times, especially for routine transport of ambulatory patients, it may be simply a person with a commercial driver's license and perhaps a small amount of first aid training. The same company may provide different levels of service.

In France, ambulance drivers are not legally required to have any first aid training, although most have at least basic first aid training. For simple transport (no care required), private companies also provide light vehicles called VSL–véhicule sanitaire léger, for seated transport. The crew consists of only one: the ambulance driver. In this case, the driver must have a basic first aid diploma.

Military ambulances

A US M997 Ambulance

Inside of an ambulance VAB of the French Army.

Military ambulances include both regular ambulances painted in olive (though some may be white, like civil ones. The British Royal Army Medical Corps has a fleet of white ambulances, based on production trucks) and armoured but not armed ambulances based upon AFVs. Military helicopters often function as aerial ambulances, since they are extremely useful for MEDEVAC.

Due to the high level of danger in battlefields, military ambulances are often armored, or based upon armored fighting vehicles (AFV). Since laws of war demand ambulances not to mount any weapon, an ambulance AFV is disarmed and marked by a red cross or another accepted medical marking. It is a generally accepted practice in most countries to classify the personnel attached to military vehicles marked as ambulances as non-combatants; however, this application does not always exempt medics and medical personnel from enemy fire. As a result, medics and other medical personnel attached to military ambulances are usually cycled through basic military training on the assumption that they will have to fire weaponry in a combat zone when not attending to injury personnel.

Recently, Israel has modified some of its Merkava main battle tanks with ambulance features in order to allow rescue operations to take place under heavy fire in urban warfare. The modifications were made following a failed rescue attempt in which Palestinian gunmen killed two soldiers who aided a Palestinian woman in Rafah. Since M-113 armoured personnel carriers and regular up-armored ambulances are not protected enough against anti-tank weapons and improvised explosive devices, commonly used by Palestinian militants against both military and civilian Israeli vehicles, it was decided to use the Merkava tank, because it features heavy armor and a rear door enabling the evacuation of critically wounded soldiers. Though ambulances may not carry weapons, Israel did not remove the Merkava's weaponry, claiming that Palestinian militants do not adhere to international law by firing on ambulances. Therefore, it becomes necessary to protect troops that come to aid the wounded.

References and Notes

*Meisel, Zachary (Nov. 8, 2005). "Ding-a-Ling-a-Ling". Slate.

Ambulance: Encyclopedia BETA

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