Ambulance

For other uses, see Ambulance (disambiguation).

An ambulance is an emergency vehicle designated for the transport of anyone who due to disease or injury is in need of medical treatment and/or monitoring throughout transportation. Transportation by ambulance can either be from the site of accident/injury/home to (usually) a hospital, or it can be up, down or sideways in the chain of treatment.Although truck- and van-based ambulances are the type most commonly seen, an ambulance can be any vehicle, including a bus, helicopter, or even a hospital ship.

An ambulance in San Jose Del Cabo, Mexico

HMHS Britannic, a hospital ship

History

Early ambulances bore little resemblance to the modern vehicles now seen in many countries. Perhaps the first ambulances, in the sense of a vehicle built for and dedicated to the transport of injured or ill persons to a treatment center, were the ambulance volantes designed by Dominique Jean Larrey (1766–1842), Napoleon Bonaparte’s chief physician. These were two or four-wheeled horse drawn wagons used to transport fallen soldiers form the battlefield after they had received early treatment in the field. Half a century later, during the United States’ Civil War, military physicians Joseph Barnes and Jonathan Letterman built upon Larrey’s work and designed a prehospital care system for that included transporting wounded soldiers to treatment facilities by railroad. ^[1]

Ford 1916 Model T Field Ambulance. This canvas on wood frame model was used extensively by the British & French as well as the American Expeditionary Force in World War I. Its top speed was 45mph produced by a 4 cylinder water cooled engine.

Cities such as Cincinatti, New York, London, and Paris developed their early ambulance services due to lessons learned from Barnes’ and Letterman’s work. In New York City, for example, Edward Dalton, a former surgeon in the Union army, organized ambulance services to provide faster, more comfortable transportation to the hospital. These ambulances carried medical equipment, such as splints, a stomach pump, morphine, and brandy, reflecting contemporary medicine. By the turn of the century, interns accompanied New York City ambulances, treated patients on scene, and often left them at home. ^[2]

A 1948 Cadillac Miller Meteor ambulance. The resemblence to a hearse is obvious (see text)

At much the same time, the automobile was being developed, and in addition to horse-drawn models, early twentieth century ambulances were powered by steam, gasoline, and electricity, reflecting the competing automotive technologies then in existence. Ambulance services were frequently managed or dispatched by individual hospitals, though in some areas, telegraph and telephone services enabled police departments to handle dispatch duties. ^[3]

The equipment carried by the ambulance was also changing. Traction splints were introduces during World War I, and were found to have a positive effect on the morbidity and mortality of patients with leg fractures. Two-way radios became available shortly after World War I, enabling for more efficient radio dispatch of ambulances in some areas. Shortly before World War II, then, a modern contemporary ambulance carried advanced medical equipment, was staffed by a physician, and was dispatched by radio. ^[4]

A 1963 Cadillac Miller Meteor ambulance belonging to the Dobbs Ferry Volunteer Ambulance Corps. This ambulance resembles a hearse slightly less than the 1948 model pictured above. Volunteers continue to provide ambulance service in many areas.

In the United States, ambulance quality fell sharply during the second world war, as physicians, needed by the armed services, were pulled off of ambulances. In England, during the Battle of Britain, the need for ambulances was so great that service vans were commandeered and pressed into service, often carrying several victims at once. Following the war, physicians would continue to ride ambulances in some countries, but not in others. In the United States, postwar ambulances were often hearses (the only vehicles that could easily accommodate a patient on lying on a stretcher) staffed by poorly trained mortuary workers. ^[5][6]

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

This situation persisted into the 1960s, when several events occurred that led to a redesign of the ambulance and the services it provided: CPR was developed and accepted as the standard of care for out-of-hospital cardiac arrest; defibrillation, based in part on an increased understanding of the pathophysiology of heart arrrythmias, was introduced, as were new pharmaceuticals to be used in cardiac arrest situations; in Ireland, a mobile coronary care ambulance successfully resuscitated patients using these technologies; and well-developed studies demonstrated the need for overhauling ambulance services. In the United States, for example, three years of federally funded research produced a report entitled “Accidental Death and Disability: The Neglected Disease of Modern Society,” (1966) which concluded, in part, that both the public and their government were “insensitive to the magnitude of the problem of accidental death and injury”; that the standards to which ambulance services were held were diverse and “often low”; and that “most ambulances used in this country are unsuitable, have incomplete … equipment, carry inadequate supplies, and are manned by untrained attendants.” ^[7][8]

An early 1970s Cadillac Miller Meteor ambulance. By the early 1970s, the value of patient care during transport had influenced ambulance design, and in comparison to the 1963 model pictured above, this ambulance has a higher roof, and thus more room for the attendents and patient. Nevertheless, this design lacked adequate interior space to meet the ambulance standards that arose in the late 1970s. (see text)

These studies placed pressure on governments to improve emergency care in general, including the care provided by ambulance services. Part of the result was the creation of standards in ambulance construction concerning the internal height of the patient care area (to allow for an attendant to continue to care for the patient during transport), in the equipment (and thus weight) that an ambulance had to carry, and several other factors. Few, or perhaps none of the then-available ambulances could meet these standards. Contemporary ambulances were built on car chasses, which could not accept the weight and other demands of the new standards; van (and later, light truck) chasses would have to be used instead. ^[9]

Israeli EMS's contemporary civilian armored Mobile Intensive Care Unit. Used for response to ongoing terrorist incidents, it is based off a super-duty Ford E-450 chassis.

Ambulance design therefore underwent major changes in the 1970s. The early van-based ambulances looked very similar to their civilian counterparts, having been given some emergency vehicle equipment (flashing lights, a siren), and the internal (and thus, generally hidden) fittings for carrying medical equipment and a stretcher. As time went on, ambulances matured in parallel to the newly developed EMS, gaining the capacity to carry additional equipment (both portable and permanently installed) as EMTs and paramedics added this equipment to their arsenal. This, coupled with the general trends of vehicle design and improvements in warning equipment (lights, sirens, etc) has led to the ambulance design of the early 21st century, and continues to influence the design of new ambulances. New influences are also being felt, including the need to protect the ambulance and its crew from traffic accidents and terrorist activities.

Design and construction

Ambulances often have two manufacturers. The first is frequently a manufacturer of light trucks (or previously, hearses) such as Mercedes or Ford. The second manufacturer purchases the vehicle (which is sometimes purchased incomplete, having a full chassis and crew compartment, but no body or interior behind the driver's seat) and turns it into an ambulance by adding bodywork and interior fittings.

Modern ambulances are typically powered by internal combustion engines - whether diesel powered or gasoline powered varies from one location to the next. Colder regions may favor gasoline powered engines, and diesels can be difficult to start when they are cold.

Appearance and markings

An Italian ambulance, displaying flashing lights in the roof, above the driver's door, and in the front grill; a siren speaker on its roof, striping; the Star of Life; and the reversed "Ambulance" sign on its hood (see text)

As ambulances may engage in unexpected maneuvers (e.g. disregarding traffic control signs) or park in unexpected locations (e.g. in a high speed traffic lane), they tend to be conspicuously marked with high-contrast striping, chevrons, checker-board patterns, or other devices. Originally, these patterns were painted onto the vehicle, but in many cases, permenant reflective tape is now used instead. Flashing lights, whose colored lenses are frequently visible even if the lights are off, are also used, as are sirens. Older car-based ambulances often used mechanical or electric sirens, which would be mounted on a front fender or on the roof. Many modern ambulances favor electronic sirens, whose speakers can be found on the roof or in or near the vehicle's front grill. Air horns are also seen on some ambulances.

Ambulances often wear additional identifying markings. Originally, this was a red cross, but in some countries, civilian ambulances now 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. It is common to see the word 'AMBULANCE' (or the equivalent) spelled backwards on the front of the vehicle. This helps drivers easily identify ambulances using their rear-view mirrors. Ambulances may also display the name of their owner or operator, and a telephone number which may be used to summon the ambulance.

Under the laws of war, an ambulance marked by one of the Emblems of the Red Cross is not to be fired on, but is to be permitted to carry out its duties in spite of hostilities. More on this subject may be found below, at Ambulance#Military ambulances.

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.

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 emblazoned with the Red Cross

Inside of an ambulance VAB of the French Army.

Military ambulances include both ambulances based on civilian desings and armoured but unarmed ambulances based upon APCs such as the FV104 Samaritan. Civilian based designs may be painted in olive though some may be white — the British Royal Army Medical Corps has a fleet of white ambulances, based on production trucks. 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 armoured fighting vehicles (AFV). Since laws of war demand ambulances marked with one of the Emblems of the Red Cross not to mount any weapon, an ambulance AFV is disarmed. 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 medical personnel from enemy fire —deliberate or accidental. As a result, medics and other medical personnel attached to military ambulances are usually put through basic military training on the assumption that they will have to fire weaponry in a combat zone when not attending to injured personnel. The laws of war also allow non-combatant military personnel to carry individual weapons for protecting themselves and casualties, but not all militaries exercise this right.

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-armoured ambulances are not sufficently protected against anti-tank weapons and improvised explosive devices, it was decided to use the heavily armoured Merkava tank. Its rear door enables the evacuation of critically wounded soldiers. Israel did not remove the Merkava's weaponry, claiming that weapons were more effective protection than emblems since Palestinian militants would fire at ambulances whether emblazoned or not.

Ambulances in North America

Ambulance types

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. At the time this photo was taken, this ambulance was operated by Palm Beach County Fire-Rescue in Palm Beach County, Florida.

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.

Medium duty type ambulance in Montreal Quebec.

Ambulances in the United States are defined by KKK-1822E requirements which defines several categories of ambulances, althought most states have additional requirements that are added to meet their individual meeds. In Canada, each Province and the Canadian Military has its own Ambulance Specifications.

• Type I Ambulances are based on the chassis-cabs of light duty pickup-trucks,
• Type II 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 go by several names; see the fly-car page for details), 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.

2. Private Ambulance Service - Normal commercial companies with paid employees, but often still have ties to municipalities. 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.

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 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 (BLS) - usually consists of two EMT-Basics. Provides oxygen therapy, Splint (medicine), 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 (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 (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 two crewmembers. Many areas require that at least one crew member be a certified or licensed EMT, enabling this person to continue to provide medical care while the other crewmember drives the ambulance to transport the patient to the hospital. Ambulance crews called to an emergency will identify and treat anyone needing medical assistance, calling for additional assistance in the field (e.g. additional ambulances, paramedic assistance, police or fire department intervention) as needed.

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. Most ambulances certified for emergency response in the U.S. 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.^[10]

Ambulances in France

Ambulance in Lausanne (Switzerland)

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

1. 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

A SMUR car in Lausanne

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 United Kingdom

Crest of NHS ambulance services in England

Crest of the Scottish Ambulance Service

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. In England there are 29 ambulance 'trusts', 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. In Scotland, the Scottish Ambulance Service serves all of Scotland and is a special trust funded directly by the Health Department of the Scottish Executive. Scotland also has Britain's only publicly funded 'Air Wing', comprising of 2 Eurocopter EC 135 Helicopters (based in Glasgow & Inverness) and 2 Beech King Air 200c fixed wing aircraft (based at Glasgow & Aberdeen).

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

Most trusts offer three levels of personnel for service: ambulance care assistant, ambulance technician and paramedic. Care assistants operate PTS (Patient Transport Services), which is largely concerned with the moving of patients between hospital and home, often in what are essentially minibuses with the only specialist equipment being a wheelchair ramp and no blue lights or provision for bed-ridden patients, although they are still officially considered ambulances. Technicians and paramedics crew the emergency ambulances - usually one of each per vehicle - 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.

Scottish Ambulance Service Helimed 5. - A Eurocopter EC 135.

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.

Two Mercedes Sprinter vehicles of the Scottish Ambulance Service

Ambulance crews work a shift rotations, 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.

St. John Ambulance emergency/multi-purpose ambulance.

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 medical cover at large events; it is uncommon to find an emergency being attended by a non-NHS ambulance, though this difers from trust to trust. 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.

Ambulances in Germany and Austria

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

In Germany and Austria, preclinical care is provided by non-physician staff (Rettungssanitäter or Rettungassistent)and by specially trained emergency physicians (called "Notarzt").

German Air Ambulance

Originally, an ambulance that was sent to a potentially 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 order to better make use of the Notarzt physicians' skills, this system was redesigned into the current "Rendezvous-System", where the emergency physician is driven to the scene by a separate car (NEF = NotarztEinsatzFahrzeug), usually a station wagon, and the paramedics by 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 dispatcher, 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. Additionally, the NEF is equiped with nearly all equipment an ambulance has, except such needed for patient transportation, which enables the emergency physician to treat a patient before the ambulance arrives and also increases the amount of equipment in response to a severe accident.

Air ambulances

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.

Ambulances in Norway

Norwegian ambulances changed their markings in 2005. This is the old appearance

Mercedes Sprinter from Trondheim in the new colours

Ambulances in Norway are operated both by the government (financed through the four regional Hospital Trusts) and private organizations such as the Red Cross and commercial transportation companies. Ambulances are usually staffed by two emergency medicine technicians, who have two years of training at Vocational school followed by two-year internships. Ambulances in Norway have traditionally been manned by EMTs with only 2/3-month courses in acute emergency medicine, but increasing focus on prehospital medicine has phased such courses out in favor of the more comprehensive 2+2 year education. As of 2003, a new national education at college level is offered. This is inspired by American EMS training, and is a one-year degree offered to current EMTs. The degree grants the right to use the title "Paramedic" and is a requirement for working in the ambulance service in most of the Oslo region.

As Norway has a very scattered population with lots of small towns and villages that are located far from hospitals and treatment centers, the ambulances are supplemented with helicopters; these are operated by the Air Force and two private organizations through Norwegian Air Ambulance. At a national level, effort is being made to reduce the number of ambulances staffed by on-call personnel. The national goal is that any citizen should not have to wait more than 12 minutes (in densely populated areas) or 20 minutes (in scarcely populated areas) for emergency services.

See also

• Air ambulance
• Fly-car
• Emergency medical service
• Emergency medical technician
• MEDEVAC
• Rescue squad

• National Health Service
• Paramedic
• Scottish Ambulance Service
• SAMU
• St. John Ambulance
• Stretcher
• Hearse

External links

• Ambulance manufacturers
  • American Emergency Vehicles
  • Demers Ambulances
  • Frazer Ambulances
  • Horton
  • Marque Ambulances
  • Nilsson Special Vehicles
  • UV Modular (UK ambulance manufacturer)
  • American LaFrance

References and Notes

Additional material from

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

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