Ambulance
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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 and 1970s, station wagons were used in some American cities (despite their limited space) and can be seen in motion pictures from that period.
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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 NHTSB. 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 (see below).
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Ambulances in North America
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Ambulance types
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 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 II are also now authorized based on the chassis-cabs of medium duty truck chassis.
Note that Type I's and Type II's are often called boxes by their crews with Type II's being called vanbulances, ambulances are also referred to as buses, modulars, rigs etc.
Ambulance Providers
Ambulance service providers come in several types in the USA:
1. Volunteer Ambulance Corps or services - like Volunteer Fire Companies, St. John Ambulance are the most common and may be found everywhere, from NYC to the smallest rural community all around the world. May be community owned or privately owned, usually non-profit.
2. Private Ambulance Service - Normal commercial companies of which the largest is AMR or American Medical Response. Most are usually only patient transfer services without an emergency capability although some are dual capable.
3. Municipal Third Service (city and some metropolitan counties) - Operate as a third service alongside fire and police departments.
4. Municipal - Usually fire department owned and operated, rare, or police department owned and operated, very rare. The former exist in only some large cities and the latter are so rare they defy categorization.
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 personal are crosstrained as EMT's/Firefighter/peace officer.
Service Level
- Basic Life Support or BLS - usually consist of two EMTs and can only provide limited aid.
- Advanced Life Support or ALS - usually consists of an EMT and an EMT Intermediate, or and EMT and a paramedic and can provide BLS with th addition of IV therapy.
- Mobile Intensive Care Unit - Usually consists of either an EMT and a paramedic or mutlpile paramedics, and provide the full range of advanced services to include IV therapy, Cardiac monitoring and drugs, pain killers. etc.
- Critical Care Units - Usually consist of a combination of EMTs/Paramedics/Nurses/Physicans depending on the need. They provide special transports for premature babies, cardiac transfers etc.
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 usually staffed by at least one EMT driver and one paramedic. 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. They stabilize and transport those in need of further medical care to hospitals, 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. However, many smaller cities and suburbs are completely dominated by AMR, and AMR vehicles are synonymous with "ambulance" in those areas.
American ambulances usually are fitted with red flashing lights and a siren that continuously rises and falls, as opposed to the two or three-tone sirens heard in other countries. When an ambulance turns on its lights and siren, all other drivers are required by law to pull off to the side of the road and yield the right of way.
Ambulances in France & Europe
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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 times firefighters), although they also transport casualties; their vehicles are called VSAV–véhicule de secours et d'assistance aux victimes (rescue and assistance to casualties 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 a building to the other; these are sometimes simple vehicles without any medical equipment when the transport do not require any care (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 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.
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 get rid of certain limitations such as speed limits, direction of driving, priorities and traffic light.
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 get rid of certain limitations such as speed limits while respecting lane priorities and traffic lights.
Ambulances in the UK
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.
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. When not attending emergency incidents, most technicians and paramedics help out with PTS duties.
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, with guaranteed direct entry into technician status on completion. These courses are somewhat controversial, with many 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 not available, and can only be achieved via the technician 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, often 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, some NHS ambulance staff are highly critical of the voluntary and private services, and there exists an elitist attitude within many trusts. This may stem from hatred incurred during the various ambulance strikes, where private, voluntary and military ambulance services have stepped in to provide cover, earning them the title "scabs" (a northern British slang term for people who break a trade union strike) . Other trusts are more positive about the additional services, even welcoming them as a means to reduce their own workload!
Private ambulance companies
In the United States, private ambulance companies perform non-urgent transportation from home to hospital and back (e.g. regular dialysis, programmed surgical operation, this could be described as a "white taxi") or between hospitals. They also participate to the sanitary duty: they make interventions at home for relative emergencies (their response time is not compatible with "real" emergencies); the crew of a private ambulance is made of an ambulance driver and an ambulance technician, both usually EMT's.
In France, no ambulance drivers are 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 has only one the ambulance driver. In this case, the driver must have the basic first aid diploma.
Military ambulances
Military ambulances include both regular ambulances painted in olive and armed ambulances based upon AFVs. Military helicopters are often function as aerial ambulances, since they are exteremely useful in performing MEDEVAC.
Due to the high level of danger in battle-fields, military ambulances are often armored, or based upon armored fighting vehicles (AFV). Since laws of war demand ambulance not to mount any weapon, an ambulance AFV is disarmed and marked by red cross or other accepted medicine markings.
Recently, Israel have modified some of it Merkava main battle tank with ambulance features in order to allow rescue operation to take place under heavy fire in urban warfare. The modifications where made following a failed rescue attempt in which Palestinian gunmen killed two soldiers, who aided a Palestinian woman in Rafah. Since M-113 APCs and regular up-armored ambulances are not protected enough against anti-tank weapons and IEDs, commonly used by Palestinian militants against both military and civilian Israeli vehicles, it was decided to use the Merkava tank, because it feature heavy armor and a rear door enabling evacuation of critically wounded soldiers. Though ambulances may not carry weapons, Israelis did not remove the Merkava's weaponry since Palestinian militants do not adhere to international law.
See also
- Air ambulance
- emergency medical service
- MEDEVAC
- National Health Service
- paramedic
- Emergency medical technician
- SAMU
- St. John Ambulance
- stretcher
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